Every finding on record at Smyrna Care Center

Based on American College of Physicians (ACP) article review, facility policy review, Quick Glance Skin Integrity and Wounds procedure form, medical record review, observation, and interview, the facility failed to ensure residents received the necessary treatment and services consistent with professional standards of practice to promote wound healing, prevent new wounds from developing, and complete wound assessments on residents determined to be at risk of skin breakdown for 4 of 5 (Residents #4, #47, #62 and #66) sampled residents reviewed for pressure wounds. Resident #4 was admitted to the facility on [DATE]. On 5/19/2026, a pressure wound was identified as a Stage 3 (pressure wounds are staged from 1 - 4 to measure tissue damage with 4 being the most tissue damage). The facility failed to complete a thorough wound assessment, including wound documentation, or initiate a pressure wound treatment until 5/28/2026, when an inappropriate treatment order was put in place for a Stage 3 pressure wound. On 6/10/2026, Resident #4's wound was assessed as unmeasurable due to necrosis (dead tissue). Resident #47's Stage 2 pressure wound was identified on 5/3/2026. The facility failed to complete a thorough wound assessment and did not follow physician orders for further evaluation and treatment, which resulted in the wound increasing to a Stage 4. Resident #62 returned from the hospital on 6/13/2026 with skin breakdown to her intergluteal cleft (a term used for the deep groove between the buttocks). The facility failed to complete a thorough assessment until 6/24/2026 which resulted in the skin breakdown then being identified as an unmeasurable wound due to necrosis. Resident #66 was admitted to the facility on [DATE] with a Deep Tissue Injury (DTI) noted to the sacrum. The facility failed to complete a thorough assessment until 3/11/2026 and the sacrum DTI increased to a Stage 3 pressure wound. Resident #66 currently had a stage 4 pressure wound. The facility failed to ensure these residents' pressure wounds had thorough assessments performed, with measurements, staging, and treatments consistent with accepted standards of practice. The facility's failure resulted in an Immediate Jeopardy (IJ) for Resident #4, #47, #62 and #66. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and [NAME] President of Clinical Operations (VPOCO) were notified of the Immediate Jeopardy (IJ) for F-686 on 6/24/2026 at 1:55 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-686. The facility was cited Immediate Jeopardy F-686 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy began on 1/8/2026 through 6/25/2026, the IJ was removed on 6/26/2026. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 6/25/2026 at 4:17 PM, and the Removal Plan was validated onsite by the surveyors on 6/26/2026 through policy review, medical record review, review of ongoing staff education records, and facility staff interviews. The facility's non-compliance at F-686 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the ACP Clinical Guideline article titled, Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians, dated 3/3/2015, revealed .Pressure ulcers affect.adults in the United Stated across health care settings.Treatment of pressure ulcers is critical to promote healing and minimize the risk for complications. Treatment interventions include management of conditions that give rise to pressure ulcers (support surfaces and nutritional support, protection and promotions of wound healing (wound dressings; topical applications.).Treatment of pressure ulcers involves multiple methods intended to alleviate the conditions contributing to ulcer development.protection of the wound from contamination and creation of a clean wound environment, promotion of tissue healing (local wound applications, debridement [removal of dead, damaged, or infected tissue from a wound], and wound cleansing).Hydrocolloid dressings [water proof, inner layer of gel-forming agents to absorb wound fluid] were superior to gauze dressings [woven or non-woven cotton to allow air to circulate while absorbing fluids] for reducing wound size and were equivalent to foam dressings [nonadherent dressing used to create a moist healing environment and provide a waterproof barrier] for complete wound healing. 2. Review of the facility policy titled, Charting and Documentation, dated July 2017, revealed All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.treatments or services performed.Documentation in the medical record will be .complete and accurate.Documentation of procedures and treatments will include care-specific details, including.the date and time the procedure/treatment was provided.the assessment data and/or any unusual findings obtained during the procedure/treatment. Review of the facility policy titled, Exceptional Living Centers Skin Integrity and Wound Policy, dated 11/7/2023, revealed Based on the comprehensive assessment of a resident, the facility must ensure that - A resident receives care, consistent with professional standards of practice, to prevent pressure ulcer/injuries and does not develop pressure ulcers/injuries unless the individual's clinical condition demonstrates that they were unavoidable.a resident with pressure ulcers/injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers/injuries from developing.Examples of impaired skin integrity include, but are not limited to, pressure injuries.The staging of pressure injury is consistent with the recommendations of National Pressure Injury Advisory Panel.Pressure Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence.and may be painful.will present as an open ulcer.The injury occurs because of intense and/or prolonged pressure or pressure in the combination with shear.Pressure Injury Staging.Stage 3 Pressure Injury: Full- thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible.Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar.If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed.Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood -filled blister. 3. Review of the undated procedure form titled Quick Glance Skin Integrity and Wounds, revealed .Refer to policy for details as this is not the policy but means to be a quick reference guide.Admission/readmission: Complete the following.a skin evaluation.a licensed nurse will complete another skin evaluation within 24 hours to validate skin condition with documentation on the skin observation tool.Weekly.Complete a Wound Observation Tool for each wound to include pressure.Review wound Progress notes as orders or interventions may be written in the progress notes.a new skin impairment.The Licensed Nurse will initiate and document investigation of the new skin impairment.the date and time wound was observed.other pertinent data as necessary or required. 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Reduced Mobility, Anxiety, and Respiratory Failure. Review of a Skin Check form for Resident #4 dated 5/19/2026, revealed .buttocks - generalized .Pressure ulcer/injury .new wound .Stage 3 Pressure Ulcer / Injury .In-house .Measurements not documented as part of this assessment . Review of the Care Plan for Resident #4 dated 5/19/2026, revealed Resident #4 had .Potential for new Skin Impairment R/T [related to] impaired mobility, incontinence, Parkinsons, Pneumonia. The facility failed to capture Resident #4's actual skin impairment of a Stage 3 pressure wound on the Care Plan dated 5/19/2026. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively intact. Resident #4 had impairment in mobility of the lower extremity on one side, was dependent on staff for all activities of daily living (ADLs) except eating and oral hygiene and was always incontinent of urine and bowel. Resident #4 had one stage 3 pressure ulcer that was present on admission. Review of the Physician's Orders for Resident #4 dated 5/28/2026, revealed .apply zinc to bilateral buttocks, cover open area with dry dressing . The facility was unable to provide documentation of orders for wound treatments to Resident #4's Stage 3 Pressure ulcer from 5/19/2026-5/28/2026. Review of a Progress Note for Resident #4 with a created date of 5/28/2026 at 12:55 PM, written by Licensed Practical Nurse (LPN) B revealed, Effective Date 5/18/2026 at 15:10 [3:10 PM].LATE ENTRY.open area noted to sacrum. Review of a Progress Note for Resident #4 with a created date of 5/28/2026 at 2:21 PM, written by LPN A, revealed Effective Date: 5/19/2026 14:10 [2:10 PM].LATE ENTRY.Skin issues.bilateral buttocks and gluteal cleft issue.new wound. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin.Measurements not documented as part of this assessment. Review of a Progress Note for Resident #4 with a created date of 5/28/2026 at 2:23 PM, written by LPN A, revealed Effective Date: 05/20/2026 14:22 [2:22 PM] Type .Skin Check .LATE ENTRY .Stage 3 Pressure ulcer/injury- full thickness skin loss . Review of a Progress Note for Resident #4 with a created date of 5/28/2026 at 2:23 PM, written by LPN A, revealed Effective Date: 5/27/2026 14:23 [2:23 PM] Type .Skin Check .LATE ENTRY .Pressure ulcer / injury .Stage 3 Pressure ulcer / injury-full thickness skin loss . Review of the Treatment Administration Record (TAR) for Resident #4 dated 5/1/2026 - 5/31/2026, revealed a treatment beginning 5/29/2026 .apply zinc to bilateral buttocks, cover open area with dry dressing every day . Review of the Care Plan for Resident #4 dated 5/29/2026, revealed Resident #4 had .impaired skin integrity.Pressure ulcer to the sacrum.Administer treatments as ordered and observe for effectiveness.Observe wound healing, Measure length, width and depth where possible. Observe status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD [Medical Doctor] . The facility failed to update the Care Plan to reflect Resident #4's Stage 3 pressure ulcer until 5/29/2026, 10 days after the wound was identified. Review of a Progress Note for Resident #4 with a created date of 6/3/2026 at 3:06 PM, written by LPN A, revealed Effective Date: 5/19/2026 1457 [2:57 PM] Type .Skin Issues.LATE ENTRY.Location . buttocks and gluteal cleft.Pressure ulcer staging: Unstageable pressure ulcer.unstageable ulcer due to slough and / or eschar.Length (cm) [centimeters] 2.7 Width (cm) 8.2 Depth (cm) 0.1. The facility failed to complete thorough assessments including measurements, stage and description of Resident #4's wound and document them in the medical record a timely manner. Review of the Physician's Orders for Resident #4 dated 6/3/2026, revealed .sacral wound - clean with wound cleanser, apply leptospermum honey, [a specialized type of honey used in some wounds], cover with calcium alginate,[a natural seaweed -derived polysaccharide (complex carbohydrates) used in wound care] and bordered gauze every day . Review of a (Named Company) Wound Physician Evaluation and (&) Management Summary for Resident #4 dated 6/10/2026, revealed .At the request of the referring provider .UNSTAGEABLE (DUE TO NECROSIS [premature death of cells or tissue]) SACRUM FULL THICKNESS .Estimated Time to Heal 4 - 6 Months .Wound Size (L x W x D) [length times width times depth] 12 x 9 x Not Measurable cm . The facility failed to thoroughly assess a pressure ulcer, failed to document wound assessments in a timely manner, failed to implement treatments for a pressure ulcer for 10 days, and failed to ensure an appropriate treatment was implemented for Resident #4's Stage 3 pressure ulcer. On 6/3/2026, the wound was found to have deteriorated to an unstageable wound due to necrosis. 5. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Scoliosis (sideways curvature of the spine), Liver Disease, Traumatic Brain Injury, Muscle Wasting and Atrophy, and Fracture of the First Thoracic Vertebra. Review of the Comprehensive Care Plan for Resident #47 revised 1/7/2026, revealed .Weekly skin assessment by licensed nurse .Staff will offer assistance with pillow placement to assist with positioning and offloading . Review of the Physician's Progress Note for Resident #47 dated 5/3/2026 at 11:16 AM, revealed .Primary Chief Complaint: Skin: Pressure Wound.Stage 2 pressure ulcer to sacrum noted today. Per nurse area has not been reported to nurse. CNAs [Certified Nursing Assistant] were applying zinc. On exam there are no s/s [signs and symptoms] of infection, there are 2 open areas both appearing to be a stage 2 w/[with] erythema [red or flushed appearing skin] to surrounding tissue.Exam findings per nurse and video observation.SKIN 2 open areas to sacrum, both approx. [approximately] 1.5cm x 1.5cm and about 0.5-0.8 cm depth, no drainage or slough noted, erythema to surrounding tissue.Diagnosis, Assessment/Plan.Pressure ulcer of sacral region, unspecified stage.This is an acute new problem.Condition is worsening.new findings, advised against zinc on open areas. Start Medi honey [used for wound care] to open areas after cleansing gently w/ NS [normal saline]. Cover w/ gauze, change daily and as needed. Wound nurse to eval [evaluate] and treat asap [as soon as possible]. Review of the Physician's Order for Resident #47 dated 5/3/2026, revealed .Cleanse open area to buttocks with NS/wound cleaner and pat dry. Apply medihoney and cover with dry dressing. as needed for soilage/displacement until resolved AND in the morning for wound healing until resolved. Review of the Incident Report for Resident #47 dated 5/3/2026, revealed .While providing care, open wound noted on.[Resident #47] sacrum. On-call provider was notified, and an order was received to cleanse the area, pat dry and apply honey [Medi honey] with gauze every shift until evaluation by wound care nurse. The Wound was cleansed with NS and pat dry, honey applied and gauze applied as ordered. The resident tolerated treatment well. Resident's daughter notified. Supervisor and DON [Director of Nursing] aware.Injury Location.Right buttock. Review of the facility Progress Note for Resident #47 dated 5/3/2026 at 1:46 PM, revealed .New skin Issue. Location: Sacrum. Issue type: Pressure ulcer/injury.new wound. Wound acquired in-house.Measurements not documented as part of this assessment. Review of the SBAR [Situation, Background, Assessment, and Recommendation] Communication Form for Resident #47 dated 5/4/2026, revealed .Skin Evaluation: Wound.Recommendations of Primary Clinicians.Clean open area, apply dressing. Let the wound care nurse evaluate it. Review of the Care Plan for Resident #47 revised 5/4/2026, revealed .Resident is at risk for new altered skin integrity related to Self care deficit .Impaired mobility.Incontinence.Risks for skin breakdown will be minimized through review.Treatment as ordered to sacrum.The resident has altered skin integrity R/T [related to] impaired mobility, incontinence, and fragile skin.pressure ulcer sacrum. Review of the Comprehensive Care Plan for Resident #47 revised 5/5/2026, revealed .Administer treatments as ordered and observe for effectiveness.Observed PRN [as needed] any changes in skin status: appearance, color, wound healing, s/sx [sign and symptoms] of infection, wound size, stage. Observed wound healing. Measure length, width and depth where possible. Observed status of wound perimeter, wound bed and healing progress. Report improvements and decline to the MD [Medical Doctor]. Review of the quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 10 on the BIMS assessment, which indicated she was moderately cognitively impaired. Resident #47 has impaired mobility on one side in her upper and lower extremities, required substantial to dependent assist with ADL care and was always incontinent of urine and bowel. Resident #47 has 1 Stage 2 Pressure Ulcer. Review of the facility Progress Note for Resident #47 dated 5/10/2026 at 10:19 AM, revealed .Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Wound acquired in-house. Review of the facility Progress Note for Resident #47 dated 5/17/2026 at 10:14 AM, revealed Resident #47 .Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Wound acquired in-house.: Review of the Physician's Progress Notes for Resident #47 dated 5/21/2026, revealed .Patient is being seen for a monthly visit.Review of Systems.Skin: No rashes or ulcers. Review of the facility Progress Note for Resident #47 dated 5/22/2026 at 8:36 PM, revealed .Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Wound acquired in-house . Review of the Comprehensive Care Plan for Resident #47 revised 5/23/2026 revealed .Actual skin impairment due to: pressure ulcers to right heel and sacrum. The facility failed to update the Care Plan to reflect Resident #47's wound until 5/23/2026, 20 days after the wound was identified. Review of the facility Progress Note for Resident #47 dated 5/29/2025 at 3:00 PM, revealed .Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Wound acquired in-house. Review of the facility Progress Note for Resident #47 dated 5/30/2026 at 9:16 AM, revealed .Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Wound acquired in-house. Review of the facility Progress Note for Resident #47 with a created date of 6/2/2026 at 2:45 AM, written by Registered Nurse (RN) E revealed Effective Date 5/27/2026 at 11:30 [11:30 AM].LATE ENTRY.Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Wound acquired in-house.: Review of the Physician's Progress Note for Resident #47 dated 6/2/2026, revealed .Pt is seen for med [medication] refill.Review of Systems.Skin/Breast: No rashes or skin breakdown. Review of the Physician's Order for Resident #47 dated 6/2/2026, revealed .Cleanse open area to buttocks with NS/wound cleaner and pat dry. Apply medihoney, calcium alginate, and cover with dry dressing. as [As] needed for soilage/displacement until resolved AND everyday shift for wound healing until resolved. Review of the facility Progress Note for Resident #47 dated 6/7/2026 at 3:00 PM, revealed .Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Wound acquired in-house. Review of the facility Progress Note for Resident #47 with a created date of 6/11/2026 at 12:36 PM, written by LPN A, revealed Effective Date 6/10/2026 at 12:29 [12:29 PM].LATE ENTRY.Skin issue has been evaluated. Location: Sacrum. Issues type: Pressure ulcer/injury.Unstageable pressure ulcer/injury. Unstageable ulcer due to slough and/or eschar. Wound acquired in-house.Length (cm): 5 Width (cm): 6.10% [percent] Exudate amount.wound bed information: 60% necrotic. 20% other, 10% skin.Debridement: Sharp. The facility failed to perform weekly assessments of Resident #47's pressure ulcer from 5/3/2026 until 6/10/2026. The wound deteriorated from a Stage 2 to an Unstageable Pressure Ulcer requiring debridement. Review of a (Named Company) Wound Physicians Initial Wound Evaluation & Management Summary for Resident #47 dated 6/10/2026, revealed .At the request of the referring provider.a thorough wound care assessment and evaluation was performed today.UNSTAGEABLE (DUE TO NECROSIS) SACRUM FULL THICKNESS.Pressure.Unstageable Necrosis.Duration.> [greater than] 7 days.5 x 6 x Not Measurable cm.Depth is unmeasurable due to presence of nonviable [dead tissue lacking blood supply] tissue and necrosis.SURGICAL EXCISIONAL DEBRIDEMENT [a procedure to remove dead, infected, or damaged tissue from a wound] PROCEDURE.Remove Necrotic Tissue and Establish the Margins of Viable Tissue [living tissue with an adequate blood supply].with clean surgical technique, 15 blade, pick-ups were used to surgically excise 9.0cm2 [centimeters squared] of devitalized [dead or dying tissue] and necrotic subcutaneous tissues were removed at a depth of 0.3 cm.Surgical debridement was performed today on this wound. Review of the Physician's Progress Note for Resident #47 date 6/11/2026, revealed .Patient is being seen for monthly visit. Patient continues with wound care to her sacrum.Physical Exam.Skin: Sacral wound covered with protective dressing. Review of the Physician's Order for Resident #47 dated 6/11/2026, revealed .sacrum-cleanse with [a named brand diluted sodium hypochlorite antiseptic used to clean and disinfect wounds, preventing infection and aiding healing], apply leptospermum honey [a premium antibacterial honey], cover with calcium alginate and dry dressing as needed for soilage/displacement until resolved AND every day shift for wound healing until resolved. Review of the Progress Note for Resident #47 dated 6/13/2025 at 7:10 PM, revealed .Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury.Unstageable pressure ulcer/injury. Wound acquired in-house. Review of the facility Progress Note for Resident #47 with a created date of 6/15/2026 at 8:07 AM, written by LPN D, revealed .Effective Date 5/27/2026 at 23:05 [11:05 PM] .LATE ENTRY.Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Unstageable pressure ulcer/injury. Wound acquired in-house. Review of a (Named Company) Wound Physicians Initial Wound Evaluation & Management Summary for Resident #47 dated 6/17/2026, revealed .STAGE 4 WOUND SACRUM FULL THICKNESS.Wound Size (L x W x D).4.9 x 5 8 x Not Measurable cm.15 blade, pick-ups were used to surgically excise [removal of tissue] 5.68 cm2 of devitalized tissue and necrotic muscle level tissues were removed at a depth of 1 cm.Surgical debridement was performed today on this wound. Review the facility Progress Note for Resident #47 dated with a created date of 6/19/2026 at 9:24 AM, written by LPN A, revealed Effective Date 6/17/2026 at 9:17 [9:17 AM].LATE ENTRY.Location: Sacrum.Pressure ulcer/injury.Improving: overall wound characteristics improved.Stage 4 Pressure ulcer/injury - full thickness skin and tissue loss. Wound acquired in-house.Reason measurements not documented as part of this assessment: depth not measured d/t necrosis Length (cm): 4.9 Width (cm): 5.8.wound bed information: 40% necrosis, 10% other, 30% skin.Debridement: Sharp [use of a surgical instrument to debride a wound]. Review of the facility Progress Note for Resident #47 dated 6/24/2026 at 6:30 PM, revealed Resident #47 .Sacrum.Pressure ulcer/injury.Stage 4 Pressure ulcer/injury - full thickness skin and tissue loss. Wound acquired in-house.depth not measured d/t [due to] necrosis Length (cm): 4.5 Width (cm): 5.5 . Review of a (Named Company) Wound Physicians Initial Wound Evaluation & Management Summary for Resident #47 dated 6/24/2026, revealed .STAGE 4 PRESSURE WOUND SACRUM FULL THICKNESS.Wound Size (L x W x D).4.5 x 5.5 x Not measurable cm.Odor, necrosis as source.with clean surgical technique, 15 blade, pick-ups were used to surgically excise 7.42cm2 of devitalized tissue and necrotic muscle level tissue were removed at a depth of 1.2 cm.adherent necrosis remains.Surgical debridement was performed today on this wound. The facility failed to thoroughly assess a pressure wound, failed to document assessments in a timely manner, and failed to obtain a wound care referral for 37 days for Resident #47's pressure wound. The wound increased in size and deteriorated from a Stage 2 on 5/3/2026, to an unstageable wound requiring debridement on 6/10/2026, and then became a Stage 4 wound. 6. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Diabetes, Morbid Obesity, and Muscle Wasting. Review of the Physician's Order dated 4/20/2026, revealed .Zinc Oxide .Apply to coccyx [small triangular bone at the base of the spine] area .for skin breakdown . Review of the annual MDS dated [DATE], revealed Resident #62 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Resident #62 required supervision or partial assist for all ADLs, was frequently incontinent of bowel and bladder and was at risk for pressure injuries. Review of the Care Plan for Resident #62 dated 6/13/2026, revealed .Potential for new Skin Impairment r/t limited mobility, and bowel and bladder incontinence.skin check weekly . Review of the Progress Note for Resident #62 dated 6/13/2026 at 10:51 PM, revealed .Resident arrived .via ambulance .5x5 skin breakdown in the intergluteal region of buttocks .cleaned area and placed a 6x6 dressing to residents [resident's] bottom . Review of the .Admission/re-admission Nursing Evaluation V1.4 for Resident #62 dated 6/14/2026, revealed .Skin Integrity .intergluteal folds .Pressure [Ulcer] .Stage 2 . Review of the Physician's Order for Resident #62 dated 6/14/2026 revealed .Silver sulfADIAZINE External Cream [ a prescription only topical antibiotic used to prevent and treat wound infections] .Apply to intergluteal folds topically two times a day for pressure wound . Review of the Medication Administration Record (MAR) for Resident #62 dated 6/1/2026 - 6/30/2026, revealed a treatment ordered 6/14/2026 for .Silver sulfaDIAZINE .Apply to intergluteal folds topically two times a day for pressure wound . Review of the Physician's Order for Resident #62 dated 6/18/2026, revealed . Cleanse sacral wound with wound cleanser, pat dry, apply calcium alginate, cover with bordered dressing daily until healed . The facility was unable to provide an assessment of Resident #62's wound on 6/18/2026 when the treatment was changed. Review of the TAR for Resident #62 dated 6/1/2026-6/30/2026, revealed a treatment ordered 6/18/2026 for .Cleanse sacral wound with wound cleanser, pat dry, apply calcium alginate, cover with bordered dressing daily until healed . Review of the Skin Check Form for Resident #62 dated 6/24/2026, revealed .NEW ISSUE .right gluteus [muscles that make up the buttocks] extending to left gluteus .Skin Issue .Pressure ulcer/Injury .Pressure ulcer staging .Unstageable .due to .slough [yellowish, soft, and often stringy material that forms in wounds as a result of dead or dying tissue] and/or eschar .Present on admission .Staged by .Health care provider .depth not measures [measured] d/t necrosis .Length (cm) .11.5 .Width (cm) 8.7 .no undermining .no tunneling .Exudate amount .Moderate .Exudate type .Serosanguineous .Dressing saturation .Moderate .Cleansing Solution .Debridement .Sharp .Primary Dressing .Calcium alginate .leptospermum honey, zinc to peri wound [skin surrounding the edge of a wound] .Dry dressing . The facility failed to perform weekly assessments on Resident #62's Pressure Ulcer from 6/14/2026 until 6/24/2026, the wound deteriorated from a Stage 2 to an Unstageable Pressure Ulcer. Review of a (Named Company) Wound Physicians Initial Wound Evaluation & Management Summary for Resident #62 dated 6/24/2026, revealed At the request of the referring provider .a thorough wound care assessment and evaluation was performed today .UNSTAGEABLE (DUE TO NECROSIS) OF THE RIGHT, EXTENDING TO L [LEFT] BUTTOCK .FULL THICKNESS .Noted to be present on admission per staff .Wound Size (L x W x D) .11.5 x 8.7 x Not Measurable cm .Thick adherent [stuck to] devitalized [dead or dying] necrotic tissue .15 blade, pick-ups were used to surgically excise 20.01 cm2 of devitalized tissue and necrotic subcutaneous [deepest layer of skin located below the dermis or middle layer of skin] level tissues were removed at a depth of 0.2 cm .adherent necrosis remains . Review of the facility Dietary Progress Note for Resident #62 dated 6/24/2026 at 3:36 PM, revealed .sacral wound noted to intergluteal folds, stage II [Stage 2] , 6/13/2026 .Recommend .Liquid Protein 30cc [cubic centimeters] BID [two times a day] x 60 days to provide 200kcal/30g [200 kilo-calories/30 grams] to aid in wound healing . Review of a Progress Note for Resident #4 with a created date of 6/25/2026 at 10:16 AM, written by LPN A, revealed Effective Date 6/24/2026 16:01 [4:01PM].LATE ENTRY. New Skin Issue .right gluteus .extending to left gluteus .Pressure Ulcer/injury .new wound .staging .Unstageable pressure ulcer .due to slough and/or eschar .Wound was present on admission .depth not measured d/t necrosis Length (cm): 11.5 Width (cm): 8.7 .90% necrosis .Generic wound cleanser .Debridement .Sharp .Primary Dressing .Calcium Alginate .Leptospermum honey, zinc to peri wound . Review of the Skilled Nursing Evaluation Progress Note dated 6/24/2026 at 11:11 PM, revealed .Skilled nursing evaluation completed .Complex Wound Care/Treatment for Stage 3 / 4 Pressure Ulcer .recent hospital stay .Sacral wound noted to intergluteal folds, stage II 6/13/26 .Recommend .Liquid Protein [aids in healing] . Review of the TAR dated 6/26/2026, revealed .Cleanse sacral wound with wound cleanser, pat dry, apply leptospermum honey, cover with calcium alginate and bordered dressing daily until healed . The facility failed to thoroughly assess a pressure wound, failed to document assessments in a timely manner, and failed to notify the Wound Care Consultant of Resident #62's wound for 11 days. The wound which had been identified as a Stage 2 on 6/14/2026, increased in size and deteriorated to an Unstageable due to necrosis on 6/24/2026. 7. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Heart Failure, Pain, Chronic Obstructive Pulmonary Disease,

Based on review of the Performance Improvement Plan (PIP), job description review, observation, and interview, the Quality Assurance and Performance Improvement (QAPI) failed to ensure the QAPI processes was implemented and effective related to identifying, implementing, and monitoring pressure ulcers. The findings include: Review of the April 2026 PIP sent to the facility by the [NAME] President of Clinical Operations (VPOCO) revealed, .Opportunity exists for improvement in the area of skin/wound prevention/ wound status/ skin evaluations not being completed per protocol to identify and prevent pressure wounds/injuries .ADON [Assistant Director of Nursing]/Unit Manager will do all wounds once weekly on same day and will do the treatment, measurements, weekly wound report, weekly individual skin sheets, notification of documenting all above information in nurse's notes . Review of the Job Title: Executive Director, dated 11/3/2025, signed by the current Executive Director, revealed .Directs and performs quality assessment and assurance functions, including but not limited to: regulatory compliance rounds to monitor performance and to continuously improve quality. Implementation of programs to gather and analyze data for trends and to institute actions to resolve problems promptly. Reports and makes recommendations to appropriate committee. During an interview on 6/26/2026 at 8:36 AM, in the Conference Room, the Executive Director had stated they had identified an issue with the wounds in April prior to this IJ. The Executive Director was asked what did you put into place. The Executive Director stated, We had identified a rounding problem, Certified Nursing Aides (CNA) not checking, turning, and changing patients.we just noticed there was an increase in wounds, we should have had an AD HOC [report created to provide immediate insight for a particular situation or question] it, but I failed to do that.we discussed it in an IDT [Interdisciplinary Team] group. The Executive Director was asked if the Director of Nursing (DON) involved in that initial problem. The Executive Director stated, Yes, she was. The Executive Director was asked at that point was there a more increased look into those wounds. The Executive Director stated, I don't think we changed any processes or procedures significantly enough. During an interview on 6/26/2026 at 10:52 AM, the DON was asked did the facility have a PIP in place related to wounds. The DON stated, .Only PIP in place was about weight loss.that was yesterday.we did one on blood sugars.no others. During an interview on 6/26/2026 at 11:45 AM, in facility hallway the VPOCO was asked if a PIP had been done related to wounds. The VPOCO stated, .Yes it was done in April [2026] and sent to the facility, but the facility did not implement it.

Based on facility policy review, observation, and interview the facility failed to ensure food items were stored under sanitary conditions in the kitchen and failed to properly label and date items in 1 of 3 (500 hall) nourishment room refrigerators reviewed. The facility census was 91 with 90 residents receiving meal trays. The findings include: 1. Review of the facility policy titled, Environment, dated 6/2025, revealed .All food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. Review of the facility policy titled, Ice, dated 10/2022, revealed .Ice will be prepared and distributed in a safe and sanitary manner. Review of the facility policy titled, Food Storage: Cold Foods, dated 2/2026, revealed .All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.All food items will be stored 6 inches above the floor.All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy titled, Food Storage: Dry Goods, dated 2/2023, revealed .All dry goods will be appropriately stored in accordance with the FDA [Food and Drug Administration] Food Code.All items will be stored on shelves at least 6 inches above the floor. 2. Observation in the kitchen on 6/22/2026 at 10:05 AM, revealed a white plastic bin 3/4 (three fourths) full of brown sugar with an uncontained large clear plastic scoop stuck down into the brown sugar. During an observation and interview in the kitchen on 6/22/2026 at 10:09 AM, revealed a large clear personal plastic cup with lid and uncovered straw full of a bluish green liquid placed inside the ice in the front left corner of the ice machine. Dietary Aide G was asked if the unlabeled, undated, uncontained plastic cup full of unknown liquid should be sitting inside the ice machine. Dietary Aide G stated, No. During an observation and interview in the walk-in cooler on 6/22/2026 at 10:11 AM, revealed 4 unlabeled and undated cucumbers with only the bottom wrapped in plastic, the top half of the cucumbers were not covered or contained and 1 cucumber had a large hole in the middle of it with a white fuzzy substance covering the entire middle portion of the cucumber lying on top of a covered metal quarter pan. Dietary Aide G was asked if the cucumbers should be unlabeled, undated, uncontained and have a white fuzzy substance on 1 of them. Dietary Aide G stated, No. A full box of (Named Company) nutritional shake containing 75 4 fluid ounce cartons sitting on the floor. Dietary Aide G was asked if the cartons should be sitting on the floor. Dietary Aide G stated, No. During an observation and interview in the food dry storage area of the kitchen on 6/22/2026 at 10:14 AM, revealed 9 7.25-ounce cans of chicken noodle soup sitting on the floor. Dietary Aide G was asked if the cans of soup should be sitting on the floor. Dietary Aide G stated, No. During an observation and interview in the kitchen on 6/22/2026 at 4:26 PM, revealed a white plastic bin 3/4 (three fourths) full of brown sugar with an uncontained large clear plastic scoop stuck down into the brown sugar. The Certified Dietary Manager (CDM) was asked if an uncontained plastic scoop should be stuck down into the brown sugar. The CDM stated, Nope. The CDM was asked if a personal plastic cup with an uncovered straw containing unknown liquid substance should be sitting inside the ice machine. The CDM stated, No.he said he just forgot to take it out of there as he was leaving, he was trying to hurry up and get out of there since it was Father's Day [6/21/2026]. The CDM was asked if unlabeled, uncontained, undated cucumbers with a white fuzzy substance should be in the walk-in cooler. The CDM stated, No. The CDM was asked if food items should be sitting on the floor. The CDM stated, No. During an observation and interview in the nourishment refrigerator on the 500 hall on 6/25/2026 at 10:29 AM, revealed the following items unlabeled and undated: a. a 5.3 ounce container full of cottage cheese b. a 10 ounce glass jar 2/3 (two thirds) full of sweet relish c. a 15 ounce plastic bottle almost empty of blue cheese dressing d. a 12 ounce glass bottle 1/2 (half) full of hot sauce e. a 20 ounce plastic bottle almost full of mustard f. 1 plastic food container in a plastic bag full of unknown contents g. a large clear plastic container 1/2 full of pineapple chunks h. 1 brown paper bag with unknown contents i. 3 (three) 16.9 ounce bottles of water; 1 1/2 full and 2 3/4 full. Licensed Practical Nurse (LPN) H was asked if she knew who any of those items belonged to. LPN H stated, No, we don't and we should throw them away. During an observation and interview on 6/25/2026 at 10:42 AM, at the 500 hall nourishment refrigerator, the Director of Nursing (DON) was shown the unlabeled and undated items and was asked if the items should be inside the refrigerator. The DON stated, No. The DON was asked if the items should have been labeled and dated. The DON stated, Yes. The DON was asked if there should be employee food or drink inside the refrigerator. The DON stated, No.

Based on medical record review, observation, and interview, the facility failed to assess and monitor the resident's skin under an immobilizer for 1 of 1 (Resident #100) residents reviewed for immobilizers.The findings include: Review of the medical record review revealed Resident #100 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis Right Shoulder, Diabetes, Epilepsy, and Depression. Review of the Care plan dated 6/17/2026, revealed .Potential Skin Impairment r/t [related to] mobility. sling right shoulder. Review of the Physician's Order dated 6/24/2026, revealed .Monitor skin integrity and capillary refill. Ensure R [right] shoulder sling intact one time a day . Observation in Resident #100's room on 6/22/2026 at 10:01 AM, 12:45 PM, and 3:52 PM, 6/23/2026 at 10:10 AM, and 6/24/2026 at 7:35 AM, and 4:00 PM, revealed Resident #100 wearing an immobilizer on her right arm/shoulder. The facility failed to obtain a Physician's order for care and services for the usage of the right arm immobilizer until 6/24/2026, including assessing and monitoring the skin while immobilizer is in use. During an interview on 6/24/2026 at 10:44 AM, Licensed Practical Nurse (LPN) B was asked why Resident #100 was admitted to the facility. LPN B stated, Right shoulder replacement surgery.here for therapy. LPN B was asked about the immobilizer to right arm. LPN B stated, It's kind of like a sling, for support and [to be] elevated at all times. It can come off and [be] reapplied after shower. LPN B was asked if the area (skin) should have been monitored. LPN B stated, I don't see it [a physician order to monitor the right arm]. LPN B was asked if she would have expected to see some monitoring. LPN B stated, Yes. LPN B was asked if the immobilizer should have been monitored. LPN B stated, Yes, it should have been monitored for skin issues. LPN B was asked if there was a physician's order to monitor the immobilizer. LPN B stated, No, I don't see anything for that either. During an interview on 6/25/2025 at 10:00 AM, the [NAME] President of Clinical Operations (VPOCO) was asked if there was a facility policy related to immobilizers. The VPOCO stated, I do not have a nursing policy. The VPOCO was asked how the floor nurse is supposed to know what to do when a resident is admitted with an immobilizer. The VPOCO stated, When a resident with any type of assistive device related to sling or immobilizer, they should come in with orders to treat, and our nurses should write orders to monitor and remove per physician orders. The VPOCO was asked if Resident #100 came in with any orders for the immobilizer. The VPOCO stated, .it was missed. The VPOCO was asked if an order should have been put in when Resident #100 was admitted . The VPOCO stated, Yes ma'am.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow physician orders for tracheostomy (opening in the neck to facilitate breathing) care in 1 of 1 (Resident #6) residents and the facility failed to obtain a Physician's order for oxygen administration for 1 of 1 (Resident #11) sampled residents reviewed for respiratory care. The findings include: 1.Review of the undated facility policy titled, Tracheostomy Care, revealed .The purpose of this procedure is to guide tracheostomy care and the cleaning of the reusable tracheostomy cannulas [a tube that can be inserted into the body] .Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies .Document the following in the residents record .The procedure .The condition of the stoma [surgically created opening on the outside of the body] and surrounding skin .The resident's tolerance of the procedure .Any provider notification of unexpected or abnormal findings . Review of the undated facility policy titled, Oxygen Administration, revealed .The purpose of the procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Review the resident's care plan to assess for any special needs of the resident . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Larynx, Chronic Obstructive Pulmonary Disease (COPD), Acquired Absence of Larynx, and Dysphagia. Review of the resident's care plan dated 1/8/2026, revealed .The resident has a tracheostomy r/t [related to] larynx mass. Placement between dates of 12/7/25-12/15/25 [12/7/2025-12/15/2025] .The resident will have no abnormal drainage around trach site through the review date .Change trach collar daily .Deep suctioning per MD order .Enhanced barrier precautions due to respiratory status .The resident has throat surgical site .Administer medications and treatments as ordered . Review of the Physician's Order dated 1/21/2026, revealed .clean around stoma with mild soap and water then wipe dry BID [two times a day] .two times a day .Clean stoma site BID & PRN [as needed] w/ [with] sterile H20 [water] .two times a day for stoma cleaning AND as needed . Review of the document titled, SMS [Specialized Medical Services] Respiratory Notes, dated 1/29/2026, revealed .PT [patient] instructed on [NAME] Tube [flexible silicone tube used to maintain the airway] Care today and used Aseptic Technique. This patient is capable of cleaning his own [NAME] tube with nursing staff supervision . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated he was cognitively intact. Resident #6 was a set-up or clean-up assistance with eating, supervision or touching assistance with toileting and bathing, and independent of all other ADLs, experience episodes of shortness of breath and received suctioning and tracheostomy care. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2026, revealed missed documentation for tracheostomy care on the following dates: 4/6/2026, 4/8/2026, 4/9/2026, 4/13/2026, 4/15/2026, 4/16/2026, 4/22/2026, 4/23/2026, 4/27/2026, 4/29/2026, 4/30/2026. Review of the MAR and TAR for April 2026, revealed missed documentation for tracheostomy care on the following dates: 5/5/2026, 5/7/2026, 5/13/2026, 5/14/2026, 5/15/2026, 5/16/2026, 5/20/2026, 5/27/2026, 5/31/2026. Review of the MAR and TAR for April 2026, revealed missed documentation for tracheostomy care on the following dates: 6/8/2026, 6/15/2026, 6/18/2026. During an interview on 6/23/2026 at 2:00 PM, Registered Nurse (RN) T was asked who completes the tracheostomy (trach) care for Resident #6. RN T stated, We do it and he does it. When he does it [trach care] we watch him and make sure he is doing it right. RN T was asked, when he does his trach care do the nurses sign off that they completed the care. RN T stated, I sign off that it has been completed and I put a progress note in that I observed it. Review of the medical record revealed there were no progress notes that the nurses observed tracheostomy care. During an interview on 6/24/2026 at 11:04 AM, Resident #6 was asked if staff ever supervised him doing his tracheostomy care. Resident #6 stated, No. Resident #6 was asked if staff ever does his trach care for him. Resident #6 stated, No. During an interview on 6/24/2026 at 11:04 AM, the DON was asked Should there be blanks on the MAR or TAR for tracheostomy care. The DON stated, No. The DON was asked why there would be a blank on the MAR and TAR charts. The DON stated, Either there is a refusal of care but then it should be charted as refused, out at an appointment, or it wasn't completed. The DON was asked should staff be supervising Resident #6 provide his tracheostomy care. The DON stated, Yes. The DON was asked where staff would chart that they supervised Resident #6 completing his tracheostomy care. The DON stated, They could write a progress note. The DON was asked if she was able find a progress note or any documentation of nursing staff supervising Resident #6 providing his own tracheostomy care. The DON stated, I was not able to find any progress notes showing nursing staff supervised tracheostomy care on Resident #6. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD) and Atrial Fibrillation. Review of the admission MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the BIMS assessment which indicated he was cognitively intact. Resident #11 was dependent on staff for all care and oxygen therapy was coded. Observation in the resident's room on 6/22/2026 at 10:00 AM and 12:15 PM, revealed, Resident #11 wearing oxygen set at 4 liters (L). Review of Resident #11's Pysician's Orders on 6/22/2026, revealed there was no order for oxygen administration. During an interview on 6/22/2026 at 12:24 PM, RN U was asked what Resident #11's order was for oxygen administration was. RN U stated, I don't see any orders for oxygen. RN U was asked if there should be an order for oxygen administration if it is being administered. RN U stated, Yes. During an interview on 6/22/2026 at 3:20 PM, the Assistant Director of Nursing (ADON) was asked, when oxygen is being administered, should there be an order. The ADON stated, Yes. The ADON was asked to look at Resident #11's chart and see if there was a signed physician order for oxygen administration. The ADON stated, An order was put in at 12:31PM today [6/22/2026], but has not been verified.

Based on policy review, facility procedure form review, medical record review, observation, and interview, the facility failed to identify and eliminate all known and foreseeable accident hazards in the resident's environment for 1 of 12 (Resident #7) sampled residents reviewed for smoking.The findings include: 1. Review of the facility policy titled, Smoking, Resident, dated 7/9/2024, revealed .provide safety for resident, visitors, and employees. These smoking regulations shall be explained to the residents .upon admission to the facility, and is provided to residents . 2. Review of the facility procedure form titled, Resident Smoking .Quick Glance, revealed .All smoking materials are to be maintained in a designated location by facility staff. Residents may not maintain their own smoking materials/equipment . 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Diabetes, Muscle Wasting and Atrophy, Depression, and Absence of Left/Right Leg Above Knee Amputation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which, indicated he was cognitively intact and was coded for smoking. Review of the quarterly MDS assessment dated [DATE], revealed Resident #7 scored a 15 on the BIMS assessment which indicated he was cognitively intact. Review of the Smoking Evaluation dated 5/12/2026, revealed the facility is to store lighters and cigarettes. Review of the Care Plan revised on 6/12/2026, revealed .smoking materials are stored according to Center recommendations. Observation in Resident #7's room on 6/24/2026 at 8:39 AM, revealed 1 lighter on the over bed table. During an observation and interview in Resident #7's room on 6/24/2026 at 8:48 AM, the lighter was not on the over bed table. Resident #7 was asked where the lighter was. Resident #7 stated, In the drawer and pointed to a white storage container with clear plastic drawers. The Executive Director asked if he could go in the drawer to retrieve the lighter. The Resident gave him permission. In the drawer was 1 pack of opened cigarettes, 1 unopened pack of cigarettes and 7 lighters. The Executive Director was asked if the Resident should have smoking items in his room. The Executive Director stated, Absolutely not .

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse was disposed of properly. The facility census was 91. The findings include: 1. Review of the facility policy titled, Environment, dated 6/2025, revealed .All trash will be properly disposed of in external receptables (dumpsters), and the surrounding area will be free of debris. Observation of the dumpster area and grease trap outside of the facility on 6/24/2026 at 3:12 PM, revealed 2 mattresses on the ground with decomposed cardboard lying underneath and around them, large box filed with white hard foam on the ground, a large black garbage bag on the ground and filled and not tied with the top opened and cardboard coming out of the top of the bag, a grey rolling bin overflowing with cardboard and bagged garbage on the ground sitting behind and in between two dumpsters. The grease trap door was open with thick black, brown and yellow substance on the trap screen with the middle portion of the screen covered with waded up clear plastic and yellow tinted paper and brown dried flakes laying on top of the plastic and paper. During an observation and interview at the dumpster area and grease trap on 6/24/2026 at 4:46 PM, the Certified Dietary Manager (CDM) was asked what all the garbage was around the dumpsters. The CDM stated, Well, maintenance left the mattresses and stuff. The grey bin is supposed to be for cardboard but it looks like the CNAs [Certified Nursing Assistants] are throwing their garbage on top of it, that looks like pee in that bag [pointing to a clear plastic bag hanging partially off the top of the cardboard in the grey bin with a clear yellow liquid in the corner of the bag]. The CDM was asked who is responsible for making sure there isn't garbage lying around the dumpsters. The District Dietary Manager stated, At the end of the day it's a kitchen tag. The CDM and District Dietary Manager were asked if the dumpsters should have garbage lying around them. The CDM stated, No. The CDM was asked while standing in front of the grease trap if the grease trap lid should be left open. The CDM stated, No. The CDM was asked what was lying on the top of the trap screen. The CDM stated. Well, they just dump it over that.I guess people just throw stuff in there. The CDM was asked if those items should be sitting on top of the trap screen. The CDM stated, No. During an interview on 6/25/2026 at 9:31 AM, the Executive Director was asked how the dumpsters and surrounding area should look. The Executive Director stated, I expect it to be clean, and the doors closed and nothing on the ground.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain accurate medical records related to treatment administration for 1 of 26 (Resident #43) residents reviewed for treatment administration. The findings include: 1. Review of the Charting and Documentation policy, with a revision date of July 2017, revealed All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record .Policy Interpretation and Implementation .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . 2. Review of medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Fall, Traumatic Brain Injury, Bipolar, and Fracture of Left Clavicle. Review of the X-Ray report dated 4/10/2026, revealed Clavicle shaft fracture with modest displacement. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident # 43 was moderately cognitively impaired. Review of the Care Plan dated 4/23/2026, revealed .Actual/Potential for Pain.Lt [Left] shoulder fracture-4/10.Provide sling as ordered to Lt shoulder. Review of the Physician's Order dated 4/24/2026, revealed .apply sling to left arm for fracture. Check placement and skin integrity each shift. Review of the Progress Note dated 5/12/2026 at 11:30 AM, revealed .Skin Check.Late Entry.Resident does not have an external device . Review of the Progress Note dated 5/19/2026 at 11:32 AM, revealed .Skin Check.Late Entry.Resident does not have an external device . Review of the Progress Note dated 5/26/2026 at 11:33 AM, revealed .Skin Check.Late Entry.Resident does not have an external device . Review of Medication Administration Record/Treatment Administration Record (MAR/TAR) for 5/2026, revealed order to apply sling to left arm for fracture documented as completed AM and PM shift for the month of May. Review of the Progress Note dated 6/2/2026 at 10:24 AM, revealed .Skin Check.Late Entry.Resident does not have an external device . Review of the Progress Note dated 6/8/2026 at 9:51 AM, revealed .Default PN [Progress Note] Type for eMAR [electronic Medication Administration Record] Note Text: apply sling to left arm for fracture. Check placement and skin integrity each shift. every day and night shift for monitioring [monitoring] cannot find. Review of the Progress Note dated 6/9/2026 at 9:45 AM, revealed .Skin Check.Late Entry.Resident does not have an external device . Review of the Progress Note dated 6/15/2026 at 11:50 AM, revealed .Default PN [Progress Note] Type for eMAR [electronic Medication Administration Record] Note Text: apply sling to left arm for fracture. Check placement and skin integrity each shift. every day and night shift for monitioring [monitoring] cannot find. Review of the Progress Note dated 6/16/2026 at 9:36 AM, revealed .Skin Check.Late Entry.Resident does not have an external device. Review of eMAR for 6/2026, revealed, order to apply sling to left arm for fracture. Check placement and skin integrity each shift. every day and night shift for monitoring-Start Date 04/24/2026 11:00 PM Documented as completed AM and PM shift with the exception of 6/1/2026 AM shift due to (d/t) not in room. On 6/8/2026 AM d/t cannot find. 6/15/2026 AM shift d/t cannot find. The facility failed to maintain accurate documentation in Resident #43's medical record. Observation in Resident #43's room on 6/22/2026 at 10:37 AM, 12:58 PM, and 3:12 PM, 6/23/2026 at 7:51 AM, 1:22 PM, and 5:09 PM, 6/24/2026 at 7:34 AM and 4:36 PM, and 6/25/2026 at 8:00 AM, revealed Resident #43 was not wearing a left arm sling. During an interview on 6/25/2026 at 8:00 AM, Registered Nurse (RN) F was asked if Resident #43 was supposed to wear a sling to his left arm. RN F stated, Yes, well I don't think he is now. RN F was asked if there was a Physician's Order for Resident #43 to wear a left arm sling. RN F stated, Yes, it is still in there .but he does take it off. RN F was asked if there was documentation that Resident #43 would take the left arm sling off. RN F stated, I have not put one in for today. During an interview on 6/25/2026 at 2:12 PM, the Director of Nursing (DON) was asked if Resident #43 had an order to wear a left arm sling. The DON stated, He did but she [Nurse Practitioner (NP)] d/c'd [discontinued] it [the left arm sling] about a month ago.but it was still active in the system until we d/c'd it today. The DON was asked if the NP documented about discontinuing the left arm sling. The DON stated, No, I looked [in Resident #43's medical record] and there is not. The DON was asked how long Resident #43 had not been wearing the left arm sling. The DON stated, For a while now. The DON was asked if she expected staff to document that Resident #43 was wearing the left arm sling if he was not wearing the left arm sling. The DON stated, No, I would not.

Based on facility policy review, Center for Disease Control and Prevention (CDC) sign review, medical record review, observation, and interview, the facility failed to implement isolation precautions for 3 of 3 (Resident #13, #46, and #47) residents reviewed for isolation precautions. The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions Policy, dated 3/2024, revealed .Enhanced Barrier Precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.Gloves and gown are applied prior to performing the high contact resident care activity.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.device care or use.feeding tube.wound care.EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.Wounds generally include chronic wounds.pressure ulcers.Indwelling medical devices include.feeding tubes.Signs are posted in [on] the door or wall outside the resident room indicating the type of precautions and PPE [personal protective equipment] required. Review of the facility policy titled, Contact Isolation Policy, dated 9/24/2025, revealed .The purpose of this policy is to establish requirements for implementing Contact Isolation precautions to reduce the risk of transmission of infectious agents through direct or indirect contact. Contact Isolation shall be used in addition to Standard Precautions for patients or residents who are known or suspected to be infected or colonized with organisms that pose an increased risk for contact transmission.Staff shall follow required hand hygiene, personal protective equipment.to protect patients, residents, visitors, and healthcare personnel.This policy applies to all facility personnel.Contact Isolation.Precautions used for patients or residents with known or suspected infection or colonization with organisms that may spread through direct contact with the individual or indirect contact with contaminated surfaced, equipment, or the immediate care environment.Wear gloves and a gown for interactions that may involve contact with the patient or resident or the immediate care environment.Don [put on] PPE before room entry or before contact with the patient or resident environment.Perform hand hygiene before entering and after leaving the room or care area. Review of the facility policy titled, Handwashing/Hand Hygiene, dated 10/5/2025, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections.Use an alcohol-based hand rub containing at least 62% [percent] alcohol.for the following situations.Before and after entering isolation precaution settings. Review of the undated CDC sign titled ENHANCED BARRIER PRECAUTIONS, revealed .PROVIDERS AND STAFF MUST ALSO.Wear gloves and a gown for the following High-Contact Resident Care Activities.Device care or use.feeding tube.Wound care.any skin opening requiring a dressing. Review of the undated CDC sign titled CONTACT PRECAUTIONS, revealed EVERYONE MUST.Clean their hands, including before entering and when leaving the room.PROVIDERS AND STAFF MUST ALSO.Put on gloves before room entry.Put on gown before room entry. 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Severe Protein-Calorie Malnutrition, Cognitive Communication Deficit, Muscle Weakness, Hypovolemia, and Need for Assistance with Personal Care. Review of the Physician's Order dated 3/21/2025, revealed .Potassium Chloride Oral Solution 20 [milliequivalent]/15ML [milliliter] .Give 20 ml via [by way of] PEG-Tube [Percutaneous Endoscopic Gastrostomy tube is a feeding tube surgically placed through your abdomen into your stomach in the morning for hypovolemia .Enhanced Barrier Precautions related to: PEG tube . Review of the Comprehensive Care Plan, revised 2/23/2026, revealed .requires tube feeding to meet all of her nutrition needs due to dysphagia and inability to swallow oral fluids/foods .Enhanced barrier precautions r/t [related to] Peg Tube placement . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. She had no swallowing disorder and had a feeding tube and mechanically altered diet in nutritional approaches. Observation outside Resident #13's room on 6/22/2026 at 10:42 AM, revealed sign titled, Enhanced Barrier Precautions, attached to Resident #13's room door. Observation in Resident #13's room on 6/24/2026 at 8:16 AM, revealed Registered Nurse (RN) F performed hand hygiene, placed a clean barrier on the cart, put on gloves, checked Resident #13's order for potassium chloride 20 meq /15 mL, verified order was 20 mL, poured 20 mL in small cup, put bottle of medication back in the med cart, doffed gloves and used hand sanitizer, grabbed new gloves and med cup with medication in it and entered into Resident #13's room. RN F placed barrier on the table and placed med cup with medication in cup on the barrier. RN F then positioned Resident #13 for medication administration. RN F aspirated for placement and then flushed tube with 30 ML of water. RN F then administered the potassium chloride prepared and then flushed with 30 ml of water. RN F then exited room and charted medication given in Resident #13's medical record. RN F failed to put on a gown prior to administering medications per PEG tube. During an interview on 6/24/2026 at 8:33 AM, RN F was asked if Resident #13 was on Enhanced Barrier Precautions. RN F stated, No. RN F was asked what the sign (Enhanced Barrier Precautions) on Resident #13's door was for. RN F stated, Oh, they just put those on some of the resident's doors. RN F was asked if Resident #13 had an order for Enhanced Barrier Precautions. RN F looked at Resident #13's Physician Orders and stated, Yes, there is an order for Enhanced Barrier Precautions. RN F was asked what staff should wear with Enhanced Barrier Precautions. RN F stated, I put on gloves. RN F was shown the EBPs sign on Resident #13's door and was asked what staff should wear when a resident has EBPs. RN F stated, Gloves and a gown. RN F was asked if she used the proper PPE while administering Resident #13's medication. RN F stated, No. During an interview on 6/25/2026 at 4:55 PM, the Director of Nursing (DON) was asked if she expected staff to know what EBPs were. The DON stated, Yes. The DON was asked what staff should know about providing peg care to a resident with a peg tube. The DON stated, Follow Enhanced Barrier Precaution practices and be wearing gloves and a gown. 3. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Neuromuscular Dysfunction of Bladder, Hemiplegia, and Urinary Tract Infection (UTI). Review of the annual MDS assessment dated [DATE], revealed Resident #46 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Resident #46 was coded for frequent incontinence of bladder and bowel. Review of the Physician's Order dated 6/19/2026, revealed .Resident is on contact precautions d/t [due to] ESBL [Extended-Spectrum Beta-Lactamase- refers to a group of enzymes produced by certain bacteria that make the bacteria resistant to many standard antibiotics] and MRSA [methicillin-resistant Staphylococcus aureus- a type of staph bacteria that is highly resistant to many common antibiotics] every shift for contact precaution. Review of the Comprehensive Care Plan, revised 6/19/2026, revealed, .The resident has UTI, ESBL/MRSA in urine. NP [Nurse Practitioner] notified. Date Initiated.6/19/2026 .CONTACT PRECAUTIONS DUE TO ESBL/MRSA: WEAR GLOVES AND GOWN WHEN GIVING CARE TO RESIDENT WITH STRICT HAND WASHING. Date Initiated.6/19/2026 . Observation outside Resident #46's door on 6/22/2026 at 10:32 AM, revealed a sign titled CONTACT PRECAUTIONS, attached to the middle of the door at eye level. Observation in Resident #46's room on 6/22/2026 at 3:17 PM, revealed the Admissions Coordinator entered Resident #46's room, she walked up to the side of the bed while the resident was laying in the bed, she leaned the left side of her body against Resident #46's bed, and placed the palm of her left hand onto Resident #46's bed and bedding. The Admissions Coordinator failed to perform hand hygiene and put on a gown and gloves prior to entering with Resident #46 and failed to perform hand hygiene after leaving Resident #46's room. During an interview on 6/22/2026 at 3:46 PM, Resident #46 was asked if staff assisted him with hand hygiene. Resident #46 stated, No. Resident #46 was asked if staff wears a gown when assisting him. Resident #46 stated, No. During an interview on 6/25/2026 at 9:42 AM, the Infection Control Preventionist (ICP) was asked if a resident had contact isolation precautions should staff lean against that resident's bed and place their hand on the bedding while the resident in laying in the bed without wearing a gown, gloves or completing any type of hand hygiene. The ICP stated, Absolutely not. During an interview on 6/25/2026 at 3:15 PM, the Admissions Coordinator was asked if she knew what isolation precautions were. The Admissions Coordinator stated, Yes.depending on what [which isolation precaution] depends on what PPE you wear. I will look at the sign on the door. The Admissions Coordinator was asked if staff should wear a gown and gloves when interacting or touching a residents bedding that is on contact isolation. The Admissions Coordinator stated, Absolutely. The Admissions Coordinator was asked if Resident #46 was on any kind of isolation. The Admissions Coordinator stated, He came back from the hospital [Resident #46 returned from the hospital on 6/18/2026] on isolation. The Admissions Coordinator was asked if staff should enter Resident #46's room without following contact isolation precautions. The Admissions Coordinator stated, No, that's my fault for not paying attention. During an interview on 6/25/2026 at 3:24 PM, the DON was asked if a resident is on contact isolation precautions should all staff follow those precautions. The DON stated, Yes. The DON was asked if a staff member entered a resident room that was on contact isolation precautions and that staff member leaned against the resident's bed and placed their hand on the bed and bedding should that staff member wear a gown and gloves even if they are not providing direct resident care. The DON stated, Yes. 4. Review of medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Scoliosis (sideways curvature of the spine), Liver Disease, Traumatic Brain Injury, Muscle Wasting and Atrophy and Fracture of the First Thoracic Vertebra. Review of the quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 10 on the BIMS assessment which indicated she was moderately cognitively impaired. Review of the Comprehensive Care Plan dated 5/4/2026, revealed there was no plan that included EBP for wound care. Review of the Physician's Order dated 6/11/2026, revealed .sacrum - cleanse with dakins [wound cleaner], apply leptospermum honey [used for wound healing], cover with calcium alginate [used for wound healing] and dry dressing every day shift for wound healing until resolved AND as needed for soilage/displacement until resolved. The facility failed to obtain a Physician's Order for EBPs related to Resident #47's wound and failed to revise the resident's care plan to address EBP. Observation outside Resident #47's room on 6/22/2026 at 10:17 AM, 12:38 PM, and 3:09 PM, 6/23/2026 at 7:53 AM, 1:17 PM, and 5:09 PM, 6/24/2026 at 7:35 AM, revealed no EBP sign on the door or on wall beside door. The facility failed to post a sign on the door or wall outside of Resident #47's room indicating the type of precautions and PPE required. During an observation and interview of wound care in Resident #47's room on 6/24/2026 at 10:01 AM, revealed the Assistant Director of Nursing (ADON) and RN F entered the Resident's room, performed hand hygiene and applied gloves, removed Resident #47's old wound dressing, RN F removed her soiled gloves, performed hand hygiene, applied clean gloves, and performed wound care per Physician's orders. The ADON and RN F failed to wear a gown while providing wound care. The ADON was asked if Resident #47 was in any type of isolation or precautions. The ADON stated, No, she isn't. The ADON was asked if Resident #47 should be in Enhanced Barrier Precautions. The ADON stated, No, since she does not share a room with anyone. The ADON was asked when should a resident be placed in Enhanced Barrier Precautions. The ADON stated, .When they have a trach, feeding tube, some kinds of oxygen, things of that nature .that is what the impression I got was. The ADON was asked to review a copy of the Enhanced Barrier Precaution signage and was asked if according to the facilities Enhanced Barrier Precaution signage should Resident #47 be in Enhanced Barrier Precaution. The ADON stated, .According to the sign, yes she should be . During an interview on 6/25/2026 at 8:09 AM, the ICP was asked what things you would implement isolation precautions for. The ICP stated, .EBP on all residents with any indwelling device or any opening that they are not born with. The ICP was asked how staff know which residents have isolation precautions. The ICP stated, .put up signage [CDC sign related to which type of isolation precautions] and inform [staff] of the type of PPE they need to wear. During an interview on 6/25/2026 at 4:54 PM, the DON was asked if staff should know what Enhanced Barrier Precautions were. The DON stated, Yes. The DON was asked if staff should know when to implement EBPs. The DON stated, Yes. The DON was asked when EBPs should be used. The DON stated, Basically with anything you are not born with.

Based on the Certified Nursing Assistant (CNA) Inservice Training Hours review and interview, the facility failed to ensure 11 of 18 CNAs (CNAs I, J, K, L, M, N, O, P, Q, R, and S) who had been employed for a full year received at least 12 hours of in-service training. The findings include: 1. Review of the CNA Inservice Training Hours revealed: a. CNA I had a hire date of 10/23/2024, and the facility was unable to provide documentation for more than 10.26 in-service hours from 10/23/2024 -10/23/2025. b. CNA J had a hire date of 7/24/2024, and the facility was unable to provide documentation for more than 5.49 in-service hours from 7/24/2024 -7/24/2025. c. CNA K had a hire date of 3/26/2025, and the facility was unable to provide documentation for more than 10.29 in-service hours from 3/26/2025-3/26/2026. d. CNA L had a hire date of 8/23/2023, and the facility was unable to provide documentation for more than 8.2 in-service hours from 8/23/2024 -8/23/2025. e. CNA M had a hire date of 12/24/2024, the facility was unable to provide documentation for any completed in-service hours from 12/24/2024 -12/24/2025. f. CNA N had a hire date of 5/7/2025, and the facility was unable to provide documentation for more than 10.54 in-service hours from 5/7/2025 to 5/7/2026. g. CNA O had a hire date of 3/26/2025, and the facility was unable to provide documentation for more than 10.3 in-service hours from 3/26/2025-3/26/2026. h. CNA P had a hire date of 9/6/2023, and the facility was unable to provide documentation for more than 5.44 in-service hours from 9/6/2024-9/6/2025. i. CNA Q had a hire date of 7/1/2023, and the facility was unable to provide documentation for any completed in-service hours from 7/1/2025-7/1/2026. j. CNA R had a hire date of 9/28/2023, and the facility was unable to provide documentation for more than 8.51 in-service hours from 9/28/2024-9/28/2025. k. CNA S had a hire date of 10/23/2024, and the facility was unable to provide documentation for any completed in-service hours from 10/23/2024-10/23/2025. 2. During an interview on 6/25/2026 at 3:33 PM, the Staffing Educator was asked if he could provide more CNA inservice hours for the staff. The Staffing Educator stated .We don't have access to anything with the old company we used to use. I have contacted corporate to see if they can get the past education record before we swapped over .I have put everything on there that I have . During an interview on 6/26/2026 at 10:26 AM, the Senior [NAME] President/Chief Nursing Officer (SVP/CNO) was asked if the facility had a policy regarding CNA training hours. The SVP/CNO stated, .We don't have a policy for that. We just go by the Regulations. It says we have to have 12 in-service hours a year so that's what we do. The facility was unable to provide documentation that all CNA's had received at least 12 in-service training hours within a one year time period.

Based on facility policy review, medical record review, and interview, the facility failed to conduct a quarterly care plan conference for 1 of 26 (Resident #47) sampled residents reviewed.The findings include: 1.Review of the undated facility policy titled, Care Plans, Comprehensive Person-Centered, revealed .The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment . Review of the facility policy titled, Care Plan Conferences Policy and Procedure, dated 10/2025, revealed .Care plan meetings will be conducted timely, involve the resident and/or responsible party .At least quarterly .Upon resident or family request .Responsible parties/legal representative must be notified in advance .Documentation of communication for care plan conferences will be maintained . 2. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Traumatic Brain Injury, Anxiety, and Fracture of First Thoracic Vertebra. Review of the facility Care Plan Conference Summary dated 1/15/2026, revealed Resident #47 had a care plan meeting with the resident and resident representative in attendance. Review of the quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 10 on the Brief Interview for Medical Status (BIMS) assessment, which indicated she was moderately cognitively impaired. The facility was unable to provide documentation that a Care Plan Conference was conducted on a quarterly basis. During a phone interview with Resident #47's daughter on 6/22/2025 at 4:08 PM, Resident #47's daughter stated, They have had only 1 care plan meeting since Resident #47 admission. During an interview with the Social Services Director (SSD) on 6/25/2026 at 8:30 AM, the SSD was asked how often does the facility schedule care plan meetings. The SSD stated .try to do every 90 days or as needed. The SSD was asked if Resident #47 had a care plan meeting on 1/15/2026 should Resident #47 have had another care plan meeting. The SSD stated .She was supposed to have had one 3 months after that, but it didn't happen .with me being the only social worker there was a lot going on and to be honest I had to put it off . During an interview with the Director of Nursing (DON) on 6/25/2026 at 2:33 PM, the DON was asked when should care plan meetings be conducted. The DON stated .They should be done upon admission and then quarterly .

Based on facility policy review, Emergency Transfers from Facility Ombudsman form, facility email thread, medical record review, and interview, the facility failed to provide the long-term care (LTC) Ombudsman with a timely and accurate notice of transfer list for 1 of 2 (Resident #101) residents reviewed for hospitalization. The findings include: Review of the facility policy titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, revealed .Notice of Transfer or Discharge (Emergent or Therapeutic Leave).When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers.Notice of Transfer is provided to the resident and representative as soon as possible before the transfer and to the long-term care (LTC) ombudsman when practicable (.in a monthly list of residents that includes all notice content requirements). Review of a blank undated Tennessee LTC Ombudsman form titled, Emergency Transfers from Facility, revealed Facility Name.Month/Year.Name of Resident.Skilled or LTC Resident.Place Resident Transferred to.Date of Transfer.Date of Transfer Notice/Bed Hold Policy Given.Date of Return.Reason for Transfer. Review of the medical record revealed Resident #101 was admitted to the facility on [DATE], with diagnoses including Hypertension, Neuromuscular Dysfunction of Bladder, and Diabetes. Review of the significant change Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #101 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Review of the Physician's Order dated 5/10/2026, revealed .Transfer to ED [Emergency Department]. Review of the Progress Note dated 5/10/2026 at 5:24 PM, revealed .daughter was notified at 3:48 pm [PM] and daughter stated she wanted patient [Resident #101] sent out to hospital for evaluation r/t [related to] un-witnessed fall and patient complaint of neck pain. 911 was call at 3:50 pm and arrived at 3:58 pm. patient left facility at 4:05 pm . Review of the Progress Note dated 5/15/2026 at 5:12 PM, revealed .patient [Resident #101] arrived back to facility from [named] hospital at 5:10 pm. Review of an email from the Social Services Director (SSD) to the Ombudsman with the subject title .Discharge Transfer April 2026.Discharge Transfer May 2026., dated 6/23/2026 at 1:35 PM, revealed an admission/discharge report dated 4/1/2026-4/30/2026 and an admission/discharge report dated 5/1/2026-5/31/2026. The facility failed to send an accurate discharge/transfer list for 4/2026 and 5/2026 in a timely manner. The report failed to include any discharges or transfers from the facility. During an interview on 6/24/2026 at 11:15 AM, the SSD was shown the copy of the email and asked if the discharge lists included were correct with no discharges. The SSD stated .That's the wrong print out. The SSD provided a facility report titled .Admission/Discharge To/From Report The report was not included in the email to the LTC Ombudsman. Review of the facility report titled .Admission/Discharge To/From Report., dated 6/24/2026 at 11:19 AM, revealed 21 total discharges during 4/2026. The report did not include date of return or reason for transfer. Review of the facility report titled .Admission/Discharge To/From Report., dated 6/24/2026 at 11:21 AM, revealed 20 total discharges during 5/2026. The report did not include Resident #101's hospitalization, date of return or reason for transfer. During an interview on 6/25/2026 at 8:42 AM, the LTC Ombudsman was asked what the facility sent to her regarding transfer notifications. The LTC Ombudsman stated, .I just see a paragraph with no one's names on it. The LTC ombudsman was asked what was expected to be sent. The LTC Ombudsman stated, There is a form and they typically write it out and it shows where each person went, when they left and when they returned. Some facilities send me a report, but they include the details that are required. During an interview on 6/25/2026 at 2:09 PM, the SSD was asked if the discharge/transfer report for 4/2026 and 5/2026 included the date of return and reason for transfer for the residents transferred during that time frame. The SSD stated, No. The SSD was asked if the discharge/transfer report should include date of return and reason for transfer. The SSD stated, Based on my previous experience at another facility I did, we had a certain form, but here I didn't have that form . The SSD was asked if the additional discharge report dated 5/2026 included Resident #101's hospitalization. The SSD stated, She's not on here. The SSD was asked if that report would be an accurate discharge/transfer report since Resident #101 was not included. The SSD stated Well no, cause she's not on here [the discharge report] and she went out [hospitalized ] at that time.No, it's not correct. The SSD was asked if there was a current list of discharges/transfers for 6/2026. The SSD stated, No, I always just print off this report. During an interview on 6/25/2026 at 3:24 PM, the Director of Nursing (DON) was asked if the ombudsman should receive an accurate list of transfers and discharges. The DON stated, Oh, yes.

Based on facility policy review, medical record review, and interview the facility failed to ensure timely Advanced Beneficiary Notice (ABN) was given regarding Medicare eligibility and coverage for 3 of 3 (Residents #62, #102 and #103) sampled residents reviewed for ABN. The findings include: 1.Review of the facility policy titled, Notice of Medicare Non-coverage, dated 12/18/2023, revealed .for residents receiving services under their skilled Medicare Part A and Medicare Part B, at a minimum of 2 calendar days prior to skilled services ending, a notice of Medicare Non-coverage .must be issued to the resident or family member .to notify of the intent to end skilled services . 2. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Diabetes, Muscle Wasting, and Metabolic Encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Review of the facility's Notice of Medicare Non-Coverage form revealed Resident #62's Medicare service end date was 5/19/2026, and Resident #76 signed the form on 5/18/2026. 3. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE] with diagnoses including Effusion, Pain in Right Shoulder, Repeated Falls and Diabetes. Review of the admission MDS assessment dated [DATE], revealed Resdeint #102 scored a 12 on the BIMS assessment, which indicated he was moderately cognitively intact. Review of the facility's Notice of Medicare Non-Coverage form revealed Resident #102's Medicare service end date was 3/2/2026, and Resident #102 signed the form on 3/1/2026. 4. Review of the medical record revealed Resident # 103 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Anxiety, Pneumonia and Bipolar Disorder. Review of the admission MDS assessment dated [DATE], revealed Resident #103 scored a 5 on the BIMS assessment, which indicated he was severely cognitively impaired. Review of the facility's Notice of Medicare Non-Coverage form revealed Resident #103's Medicare service end date was 4/23/2026, and Resident #103 signed the form on 4/22/2026. 5. During an interview on 6/25/2026 at 2:33 PM, the Business Office Manager (BOM) was asked how much notice a family should be given that Medicare Part A coverage or skilled services were ending. The BOM stated, They need to know benefit is ending 48-72 hours prior to ending. The BOM was asked if they (Residents #62, #102 and #103) were given notice timely. The BOM stated, No.

Based on facility policy review, Resident Rights review, medical record review, observation and interview, the facility failed to treat residents with respect and dignity for 1 of 25 (Resident #41) residents reviewed for Resident Rights. The findings include: Review of the facility policy titled, Resident Rights Policy, dated 8/1/2025, revealed .The resident has a right to be treated with respect and dignity. Review of the undated facility document titled, Resident Rights, revealed .Dignity .The facility will treat you with dignity and respect in full recognition of your individuality . Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, and Parkinson's Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Resident #41 was coded to receive insulin injections for 7 of 7 days. Review of the Physician's order dated 5/15/2026, revealed .Carbidopa-Levodopa Oral Tablet 25-100 MG [milligram] [medication used to treat motor symptoms such as muscle stiffness, tremors and slowness of movement] .Give 2 tablet by mouth every 6 hours. Review of the Physician's order dated 5/18/2026, revealed .Insulin Lispro-aabc [rapid-acting mealtime insulin used to control blood sugar spikes] Injection Solution 100 UNIT/ML [milliliter].Inject 3 unit subcutaneously [under the skin] three times a day for diabetes hold for bg [blood glucose] less [than] 80. Review of the care plan dated 5/26/2026, revealed .Resident has risk of fluctuations in blood glucose levels R/T [related to] DM [Diabetes Mellitus] .Obtain blood sugars as ordered . During a random observation in the dining room on 6/22/2026 at 12:11 PM, Licensed Practical Nurse (LPN) B entered the dining room, walked up to Resident #41, placed her supplies on the dining room table and put on gloves. LPN B raised Resident #41's hand, without acknowledgement of Resident #41, stuck Resident #41's finger to obtain his blood glucose reading with other residents sitting at the table with him and returned Resident #41's hand to his lap. LPN B then spoon fed Resident #41's medication mixed in applesauce and failed to acknowledge Resident #41 by name or speak with him. LPN B left the dining room. LPN B failed to speak to Resident #41, introduce herself, explain what she was doing, and remove the resident from the dining room to a private area during medication administration. LPN B failed to treat Resident #41 with respect and dignity. During an interview on 6/25/2026 at 2:25 PM, LPN B was asked if Resident #41 had an order to obtain blood glucose level at lunch time. LPN B stated, Yes. LPN B was asked if Resident #41 received any other medications at lunchtime. LPN B stated, Carbidopa [Carbidopa-Levodopa]. LPN B was asked how Resident #41 took his medications. LPN B stated, Crushed in applesauce. LPN B was asked if she entered the dining room on 6/22/2026 to obtain Resident #41's blood glucose level and administer medication. LPN B stated, Yes, I should have taken him [Resident #41] to his room. During an interview on 6/25/2026 at 3:24 PM, the Director of Nursing (DON) was asked how should staff administer medications and obtain blood glucose levels. The DON stated, Always in the privacy of their room, not in common areas or in the dining room.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when medications were found unattended and unsecured at the bedside for 2 of 91 (Resident #71 and #85) residents. The findings include: 1.Review of the facility policy titled, Storage of Medications, dated November 2020, revealed .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.stored in locked compartments. 2. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #71 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Review of the Care Plan dated 2/26/2026 revealed .Resident requires the safety of residing on a secured unit dementia, impaired safety decisions. 3. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnoses including Dementia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #85 scored a 3 on the BIMS assessment, which indicated she was severely cognitively impaired. Resident #85 used a walker or a wheelchair and required supervision to walk at least 10 feet. 4. Observation in the shared room of Resident #71 and #85's room on 6/22/2025 at 10:45 AM and 3:51 PM, revealed a bottle of pain-relieving cream sitting on the dresser, and in the shared bathroom counter there was a box containing an over-the-counter vaginal itch relieving cream, a bottle of pain-relieving cream, and a jar of topical antitussive (cough relieving) and analgesic (pain relieving) ointment. During an observation and interview in Resident #71 and #85's room on 6/22/2026 at 4:16 PM, Licensed Practical Nurse (LPN) H was asked if over the counter medications should be left unsecured and unattended in the resident's room or bathroom. LPN H stated, They should not.We would have to have an order for all of that. LPN H was asked where over-the-counter medications should be kept and she stated, .Locked up in the med [medication]cart. During an interview on 6/25/2026 PM at 4:46 PM, the Director of Nursing (DON) was asked if over the counter medications should be left unattended and unsecured in a resident's room or bathroom. The DON stated, .No ma'am.they should be locked in the med cart.

Based on facility policy review, MedicineNet.com article titled, Normal Blood Sugar Levels in Adults with Diabetes, American Diabetic Association (ADA) factsheet Understanding A1C Test (Glycated Hemoglobin-Blood test that measures average blood glucose levels over the past 2 to 3 months) review, medical record review, and interview, the facility failed to ensure the provider was contacted following Blood Glucose (BG) readings that fell outside of the parameters for notification for 5 of 7 (Resident #1, #2, #3, #6 and #7) sampled residents reviewed for medication administration. The facility's failure to ensure staff followed the facility policy and physician's orders to notify the physician of BG levels that fell outside of the listed parameters placed Resident #1 at the likelihood of developing adverse effects and complications related to uncontrolled blood glucose levels. The facility's failure to ensure Resident #1 received care and services to maintain blood glucose levels within a safe range resulted in Immediate Jeopardy to the resident. Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident. The Director of Nursing (DON) was notified of the Immediate Jeopardy for F-684 (J) on 4/13/2026 at 11:16 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-684 at a scope and severity of J, which is Substandard Quality of Care. A partial-extended survey was conducted on 4/13/2026 through 4/15/2026. An acceptable removal plan, which removed the immediacy of the Jeopardy, was received on 4/14/2026 at 5:15 PM and validated on 4/15/2026 through policy review, record review, review of education, audits, and interviews. The F-684 Immediate Jeopardy began on 1/1/2026 and was removed on 4/16/2026. The facility's noncompliance at F-684 continues at a scope and severity of D for monitoring of the effectiveness of the correction actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled Exceptional Living Centers Glucose Monitoring Policy, dated 3/12/2024, revealed .To assist the resident with glucose monitoring by obtaining a quantitative blood glucose level as ordered by the physician/provider.'hypoglycemia'.refers to a glucose concentration below 70mg/dl.Hyperglycemia refers to glucose concentration greater than 125 mg/dL (milligrams per deciliter) while fasting and greater than 180 mg/dL 2 hours postprandial [after a meal].'Ketoacidosis' refers to a life threatening condition and needs immediate treatment. Blood glucose is typically over 250, with other lab abnormalities.'Hyperosmolar Hyperglycemic Nonketotic Syndrome' refers to a condition that arises from complication of diabetes mellitus and occurs mostly in type 2 diabetes. Symptoms include very high blood sugar levels (over 600). Review of the facility policy titled Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, revealed .To provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. For further diabetes education and guidelines, refer to the provider orders and instructions as well as the American Diabetes Association, Standards of Medical Care in Diabetes. Symptoms Associated with Diabetes .Hyperglycemia. Uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia.Diabetic Ketoacidosis (DKA) .when hyperglycemia is untreated and the cells begin to metabolize fat for energy .is a life-threatening emergency that needs immediate medical attention .Hyperglycemia .can lead to cardiovascular and cerebrovascular disease, including heart disease and stroke .Hypoglycemia can lead to .cognitive impairment .functional impairment .falls .The provider will order the frequency of glucose monitoring .Manage hypoglycemia according to protocols and provider orders .Call provider immediately if resident is hypoglycemic (< [less than] 70 mg/dl .Call as soon as possible when: .blood glucose values are > [greater than] 250 mg/dl more than once with a 24-hr [hour] period .blood glucose values are >300 mg/dl more than once over 2 consecutive days .the reading is too high for the glucometer [a device used to measure blood glucose (BG) levels] .the resident is vomiting, has symptomatic hyperglycemia, or poor oral intake . Review of the facility policy Management of Hypoglycemia dated November 2020, revealed .Purpose To provide guidelines for managing hypoglycemia secondary to insulin therapy or therapy with oral hypoglycemic agents .in the diabetic resident .For Level 1 hypoglycemia (<70 mg/dl) .Give the resident an oral form of rapidly absorbed glucose .Notify the provider immediately .For level 2 hypoglycemia (<54 mg/dl) .Administer glucagon (a medication used to treat severe hypoglycemia) .Notify the provider immediately . 2. Review of the Medicine.Net.com article titled, Normal Blood Sugar Levels in Adults with Diabetes, dated 1/24/2025, revealed .Diabetes is defined as a disease in which the body has an impaired ability to either produce or respond to the hormone insulin .People with type 2 diabetes have cells in the body that are resistant to insulin or have a pancreas that slows or stops producing adequate insulin levels .If a person's diabetes is not well controlled, the person may have much higher glucose ranges (for example, 200-400 mg/dl .high blood sugar levels can be dangerous .over time these high blood sugar levels can cause .Kidney and eye damage .A higher risk of heart attack .A higher risk of stroke .Very high blood sugar levels (for example, 1000 or more mg/dl) can cause diabetic ketoacidosis (life-threatening, emergency complication of diabetes which can develop rapidly and requires immediate medical attention) . Review of the undated ADA factsheet titled Understanding A1C Test revealed The A1C test can be used to diagnose diabetes or help you know how your treatment plan is working by giving you a picture of your average blood glucose (blood sugar) over the past two to three months .The higher the levels, the greater your risk of developing diabetes complications .The goal for most adults with diabetes is an A1C that is less than 7 % [percent] . 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes, Acute Kidney Failure, Depression, and Anxiety Disorder. Review of the Comprehensive Care Plan dated 11/14/2025, revealed Resident #1 .has risk of fluctuations in blood glucose levels R/T [related to] Diabetes Mellitus.observe for any s/sx [signs and symptoms] of hyperglycemia.hypoglycemia.has Diabetes Mellitus. Review of the lab results dated 11/21/2025, revealed Resident #1 had a Hemoglobin A1C of 9.2 mg/dl. Review of the Physician's Order dated 11/25/2025, revealed Consistent Carbohydrate diet [designed to keep their carbohydrate (carb) consumption at a steady level, through every meal and snack] Dysphagia Advanced texture [ foods that are moist, tender, and bite-sized, avoiding hard, sticky or crunchy items to ensure safe swallowing], Thin Liquids consistency, Fortified foods and large portions for all meals . Review of the Physician's Order dated 12/15/2025, revealed Accuchecks (a blood sugar test that measures blood glucose levels) were ordered before meals and at bedtime for Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #1 was severely cognitively impaired. Resident #1 required Insulin injections on 7 days of the 7-day look back period and required the physician to change insulin orders on 2 days during the 7-day look back period. Review of the Medication Administration Record (MAR) dated January 2026, revealed a Physician's order dated 12/23/2025 for Insulin Lispro Injection Solution sliding scale subcutaneously (SQ) before meals for Diabetes with the following parameters: For a BG of 180 - 200 mg/dl give 4 units For a BG of 201 - 250 mg/dl give 6 units For a BG of 251 - 300 give 8 units For a BG of 301 - 350 give 12 units For a BG of 351 - 400 give 16 units and notify the physician or NP (Nurse Practitioner) For a BG of 401 - 450 give 20 units and notify physician or NP For a BG of 451 - 500 give 24 units and notify the physician or NP Review of the MAR dated January 2026, revealed Physician's Orders dated 1/10/2026 for Glutose (a form of Glucose medication used to treat hypoglycemia) 15 Gel 40% and to give 1 application orally as needed for a low blood sugar less than 70 mg/dl and an order for Glucagon 1 mg intramuscularly (IM) as needed for a low blood sugar less than 70 mg/dl. Review of Resident #1's Weights and Vitals Summary report for January 2026 revealed the following hypoglycemic and hyperglycemic blood glucose levels, which were not reported to Resident #1's physician or NP. 1/2/2026 11:29 AM 398 mg/dL 1/2/2026 8:35 PM 364 mg/dL 1/3/2026 7:36 AM 498 mg/dL 1/3/2026 9:04 PM 499 mg/dL 1/5/2026 9:49 AM 376 mg/dL 1/6/2026 5:35 PM 66 mg/dL. There was no documentation the Resident received Glutose or Glucagon (a medication to increase the blood glucose in the blood) for the low blood glucose). 1/7/2026 3:54 PM 400 mg/dL 1/8/2026 11:06 AM 363 mg/dL 1/9/2026 7:30 AM 361 mg/dL 1/11/2026 7:33 AM 42 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 1/14/2026 4:38 PM 367 mg/dL 1/15/2026 8:35 PM 533 mg/dL 1/16/2026 12:20 PM 500 mg/dL 1/17/2026 12:07 PM 377 mg/dL 1/19/2026 1:58 PM 365 mg/dL 1/23/2026 9:18 PM 407 mg/dL 1/26/2026 9:48 AM 384 mg/dL 1/27/2026 12:36 PM 431 mg/dL 1/29/2026 11:31 AM 62 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 1/29/2026 4:41 PM 422 mg/dL 1/30/2026 7:56 AM 369 mg/dL 1/31/2026 7:15 AM 458 mg/dL 1/31/2026 4:15 PM 500 mg/dL Review of the Care Plan Conference Summary dated 1/22/2026, revealed an Interdisciplinary Team (IDT) meeting was conducted and Family Member (FM) Q attended by phone and discussed Resident #1's diabetic diet and glucose levels. FM Q agreed to have Resident #1 referred out to an Endocrinologist (a specialized doctor who diagnoses and treats hormonal imbalances and glandular diseases, such as diabetes). Review of Resident #1's Weights and Vitals Summary report for February 2026, revealed the following hypoglycemic and hyperglycemic blood glucose levels which were not reported to Resident #1's physician or NP. 2/2/2026 9:08 PM 402 mg/dL 2/3/2026 11:58 AM 392 mg/dL 2/6/2026 10:39 AM 412 mg/dL 2/6/2026 3:26 PM 460 mg/dL 2/6/2026 9:00 PM 497 mg/dL 2/7/2026 7:40 AM 54 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 2/8/2026 12:25 PM 475 mg/dL 2/9/2026 1:28 PM 365 mg/dL 2/10/2026 1:47 PM 389 mg/dL 2/12/2026 10:46 AM 379 mg/dL 2/13/2026 12:23 PM 496 mg/dL 2/14/2026 7:37 AM 62 mg//dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 2/14/2026 8:14 PM 359 mg/dL 2/15/2026 11:32 AM 350 mg/dL Blood glucose values over 250 more than once over a 24- hr period. (see above) 2/16/2026 1:28 PM 546 mg/dL 2/17/2026 12:44 PM 353 mg/dL 2/19/2026 4:31 PM 399 mg/dL 2/19/20126 8:40 PM 66 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 2/21/2026 11:23 AM 417 mg/dL Review of the medical record revealed Physician Order for the use of the Insulin Lispro Sliding Scale was discontinued on 2/24/2025, and the facility followed the facility's policy to call the physician for blood glucose values > (greater than) 250mg/dL more than once within a 24 hour period and for blood glucose values > 300mg/dL more than once over 2 consecutive days from 2/25/2025 to 4/2025. Review of Resident #1's Weights and Vitals Summary report for February 2026, revealed the following hypoglycemic and hyperglycemic blood glucose levels which were not reported to Resident #1's physician or NP. 2/25/2026 10:24 AM 437 mg/dL BG value > 250mg/dl more than once over a 24-hr period. (2/24/2026 at 12:51PM--530 mg/dL) 2/25/2026 4:52 PM 407 mg/dL 2/26/2026 9:11 AM 575 mg/dL 2/26/026 4:55 PM 497 mg/dL 2/27/2026 8:20 AM 426 mg/dL 2/27/2026 9:04 PM 402 mg/dL Review of Resident #1's Weights and Vitals Summary report for March 2026, revealed the following hypoglycemic and hyperglycemic blood glucose levels which were not reported to Resident #1's physician or NP. 3/1/2026 4:18 PM 421 mg/dL BG value over 250 more than once in a 24-hr period. (3/1/2026 at 7:43 AM--303 mg/dL) 3/1/2026 9:54 PM 360 mg/d 3/4/2026 8:38 PM 472 mg/dL BG value over 250 more than once in a 24-hr period. (3/4/2026 at 12:54 PM--320 mg/dL) 3/5/2026 8:02 AM 380 mg/dL 3/5/2026 9:28 PM 69 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 3/6/2026 7:24 AM 447 mg/dL 3/6/2026 11:17 AM 374 mg/dL 3/7/2026 7:15 AM 433 mg/dL 3/9/2026 5:13 PM 351 mg/dL BG value over 250 more than once over a 24- hr period. (3/9/2026 at 7:27 AM--310 mg/dL) 3/10/2026 9:30 AM 442 mg/dL 3/10/2026 6:37 PM 453 mg/dL 3/12/2026 8:53 PM 373 mg/dL BG greater than 300 more than once over 2 consecutive days. (3/11/2026 at 5:32 PM--332 mg/dL) 3/14/2026 9:26 AM 500 mg/dL BG value over 250 more than once within a 24-hr period. (3/13/2026 at 12:16 PM--382 mg/dL) 3/15/2026 8:21 AM 355 mg/dl Review of the Progress Note for Resident #1 dated 3/16/2026 at 2:13 PM, revealed .Evaluation are/were: Altered mental status Functional decline (worsening function and/or mobility) Unresponsiveness .At the time of evaluation resident/patient Blood Pressure: BP 83/42 .Pulse: P 106 .Regular RR: R 18 .Temp: T 96.1 .Pulse Oximetry: O2 [oxygen saturation] 97 % .Blood Glucose: BS (blood sugar) 600.0 . Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Decreased mobility .Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Nursing observations, evaluation, and recommendations Send out to the ED [Emergency Department] . Review of the hospital Computerized Tomography (CT) scan (a type of imaging that uses X-ray techniques to create detailed images of the body) for Resident #1 dated 3/16/2026 at 8:15 AM, revealed .No acute intracranial abnormality .Prominent, stable ventricular (fluid filled cavities containing fluid to cushion the brain) and sulcal spaces (grooves along the brains surface) . Review of the hospital Assessment and Plan for Resident #1 dated 3/17/2026 at 11:24 AM, revealed Resident #1 .presented to the ED on 3/16/2026 after she was found to be, reportedly gradually worsening over the past 2-3 days. Upon presentation noted to be hypoxic [low, inadequate oxygen levels] requiring 4L [liters] nasal cannula [oxygen delivered by a tube to the nose].Work up revealed blood glucose of 1025.Pt [patient] was then started on insulin drip and admitted to ICU [intensive care unit] for management. Review of the hospital therapy assessment for Resident #1 dated 3/17/2026, revealed the Resident with a history of Diabetic Ketoacidosis, hyperglycemia with BG of 1000 plus (+), Acute Kidney Injury (AKI), Urinary Tract Infection (UTI), acute toxic metabolic encephalopathy (a rapid-onset, reversible or progressive dysfunction of the brain caused by systemic issues), and hypotension (low blood pressure). Resident #1 was an unreliable historian due to cognitive status and had general weakness. Resident #1 was able to take 4-5 steps and was able to follow very simple commands. She was able to sit in a recliner and was pleasantly confused. Review of the facility Nurse's Note for Resident #1 dated 3/21/2026, revealed .Resident returned 09:39 [9:39 AM] back from [Named hospital] .she is alert and oriented to self and place. Denies pain or discomfort. Skin clean, dry, and intact no bruising, redness, observed at this time. Vs [vital signs] 141/67, Hr [heart rate] 75, O2 sat [saturation] 98% RA [room air], BS 274. Resident was admitted to hospital DKA and received insulin drip per EMS [Emergency Medical Services]. On-call physician made aware . Review of Resident #1's Weights and Vitals Summary Report for March 2026, revealed the following hypoglycemic and hyperglycemic blood glucose levels which were not reported to Resident #1's physician or NP. 3/21/2026 4:12 PM 67 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. Review of the Nurse's Note dated 3/23/2026 at 1:39 PM, revealed the nurse was notified by the therapist that Resident #1 was uncomfortable and weak. Resident #1 was assessed, her vital signs were within normal range and her left arm and eye were drooping, while she continued to move her left leg. The NP was notified and gave an order to send her out to the emergency room for further evaluation. Review of the hospital CT scan for Resident #1 dated 3/23/2026 at 12:11 PM, revealed Large acute [sudden onset] to subacute [not a sudden onset, but not chronic] infarct [localized area of tissue death resulting from decreased blood supply] involving the right parietal [upper middle part of the brain] and occipital [back part of the brain] lobes with cytotoxic edema [accumulated fluid in the brain] and mass effect on the right lateral [outer side] ventricle. Review of the hospital Consultation note dated 3/23/2026 at 3:40 PM, revealed Resident #1 was treated in the emergency room for Chief Complaint of Stroke on CT scan. Pt [Resident #1] was discovered this morning w/LT [with left] hemiparesis [weakness stiffness or loss of control on the affected side]and VFD [Visual Field Deficit] .CT brain done today [3/23/2026] showed large acute/subacute .infarct . Review of the Emergency Department Note for Resident #1 dated 3/23/2026 at 11:35 PM, revealed .L [left] sided weakness and facial droop .The pt [patient] recently discharged to the facility after an admission [to the hospital] for DKA with DC [discharge] on 03/21/26 [3/21/2026] . Review of the Nurse's Note dated 3/26/2026 at 1:06 PM, revealed Resident arrived to the facility .[12:08 PM from hospital] .where she was admitted d/t [due to] DKA. Per report received .was found to have some infarct . Review of the Physician's Order dated 3/27/2026, revealed Consistent Carbohydrate diet Dysphagia Mechanical Soft texture [foods that are soft moist and require minimal chewing], Thin Liquids consistency, Fortified foods and large portions for all meals. Review of Resident #1's Weights and Vitals Summary report for March 2026, revealed the following hypoglycemic and hyperglycemic blood glucose levels which were not reported to Resident #1's physician or NP. 3/26/2026 6:13 PM 68 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 3/27/2026 12:46 PM 69 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 3/28/2026 5:01 PM 533 mg/dL BG greater than 300 more than once over 2 consecutive days. (3/27/2026 at 8:38 AM--308 mg/dL) 3/29/2026 8:51 AM 388 mg/dL 3/29/2026 11:16 AM 397 mg/dL 3/30/2026 5:23 PM 548 mg/dL Review of the Care Conference Summary dated 3/26/2026, revealed FM Q attended and voiced concerns about Resident #1's glucose levels. FM Q wanted Resident #1 to eat high protein and vegetables. Review of the physician's order dated 3/26/2026, revealed Accuchecks-FBS (fasting blood sugar), before each meal . Review of Resident #1's Weights and Vitals Summary Report for April 2026 revealed the following hypoglycemic and hyperglycemic blood glucose levels which were not reported to Resident #1's physician or NP. 4/1/2026 4:55 PM 54 mg/dL. There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 4/2/2026 9:31 AM 373 mg/dL BG value over 250 more than once in a 24-hr period. (4/1/2026 at 1:52 PM--256 mg/dL) 4/4/2026 5:23 PM 351 mg/dL 4/5/2026 7:44 AM 358 mg/dL 4/5/2026 11:57 AM 378 mg/dL 4/6/2026 7:40 AM 354 mg/dL 4/7/2026 9:49 AM 422 mg/dL 4/7/2026 1:19 PM 600 mg/dL 4/7/2026 4:34 PM 555 mg/dl Review of facility Lab Results Report for Resident #1 dated 4/3/2026, revealed a blood glucose level of 81mg/dl and Hemoglobin AIC level at 10.8 (normal being 4.1-6.0) which indicated uncontrolled Diabetes. Resident #1's A1c increased 1.6 mg/dL from 9.2 in November 2025 to 10.8 in April 2026. During an interview on 4/7/2026 at 11:30 AM, the Nurse Practitioner (NP) was asked when she was at the facility and the NP stated, .I am at the facility on Monday through Friday The NP was asked how the staff communicated the abnormal glucose readings to her, the NP stated, .The staff usually makes me aware when the residents have abnormal blood glucose readings . When the NP was asked about Resident #1's blood glucose readings. The NP stated, [Resident #1] was a brittle diabetic. The NP said she has had to make several changes to Resident #1's medication orders, and stated Resident #1 wandered around the unit and had been known to eat other residents' snacks which may have been some of the reason for her irregular blood glucose readings. During an interview on 4/7/2026 at 3:25 PM, Registered Nurse (RN) G said that if the BG was lower than 70 mg/dl, Glucagon should be given and the abnormal blood glucose reading should be documented in the progress notes, documented on the Medication Administration Record and the provider [MD or NP] should be contacted. When asked what should be done when there was an abnormally high or low blood glucose reading, RN G said the Nurse Practitioner (NP) should be given a verbal report when the NP was on duty (in the facility) and there should also be a progress note written. RN G said she was Resident #1's nurse on (316/2026) the day Resident #1 was transferred to the ED and stated .[Named Resident #] was not acting right, was lethargic and had a decreased appetite.They served her favorite meal that day and she [Resident #1] didn't want it.[Named Resident #1's] blood sugar remained elevated even though she did not eat. RN G also said on 3/16/2026, Resident #1's blood glucose reading was 600 mg/dL, and she was drowsy but easily aroused prior to being transported to the hospital. The NP was notified and she recommended Resident #1 be transported to the ED (emergency department). During an interview on 4/7/2026 at 3:40 PM, Licensed Practical Nurse (LPN) C was asked what should be done when a resident's blood glucose was less than 70 mg/dl. LPN C said that she would provide either juice or glutose to bring the blood glucose up and recheck the blood glucose in an hour. LPN C said if it was at breakfast time then she would feed the meal and then recheck the blood glucose. When asked where staff documented hypoglycemic and hyperglycemic episodes, LPN C said staff documented in the nursing notes and would notify the Nurse Practitioner. LPN C said an on-call company can be contacted on the weekend and if the NP was on vacation, there would be someone to replace her. LPN C said the NP was supposed to be notified if the blood glucose was greater than 400mg/dl or less than 70 mg/dl which was mentioned in the sliding scale order. LPN C said the family was notified when Resident #1 was sent to the ER [DATE]) and when there was a change in the Resident's condition. During an interview on 4/7/2026 at 3:57 PM, LPN D said when there were abnormal blood glucose readings a note should be made and the physician or NP should be contacted. When asked what should be done for low blood glucose, LPN D said they would administer a Glucagon shot and if the resident was alert, they may give juice. LPN D stated the facility NP was verbally informed of abnormal blood glucose values when she was in-house and the facility NP was on-call until 7:00 PM. After 7:00 PM, the on-call service physician or NP was contacted. LPN D said that the orders should specify when to contact the NP or Medical Director (MD) and should be in place for all Diabetic residents who receive insulin. LPN D said that all of the Nursing Notes should be reviewed every morning and discussed in the daily Clinical Meeting Monday through Friday. During an interview on 4/9/2026 at 4:00 PM, the Social Service Director (SSD) was asked what was discussed during the care conference meeting on 3/26/2026. The SSD said the Interdisciplinary Team had concerns related to Resident #1's BG and FM Q wanted Resident #1 to have no carbohydrates and increased protein/vegetables. FM Q was requested to provide the facility with the name of an endocrinologist for Resident #1 to see, but FM Q has yet to do so and the facility had plans to find a new endocrinologist if one is not provided by FM Q. During an interview on 4/15/2026 at 2:30 PM, the [NAME] President of Operation was asked how the facility will track whether the provider (physician or NP) was being accurately notified according to the current policy. The VPO said she would review the policy and make the appropriate changes to ensure there was no confusion. The VPO then presented the surveyor with a revised undated copy of the facility policy Nursing Care of the Older Adult with Diabetes Mellitus without the section titled Glycemic Targets which listed the parameters for notifying the provider. These parameters were in place at the beginning of the survey. The facility failed to follow Physician's Orders and facility policy for notification of the physician or NP of Resident #1's episodes of severe hypoglycemia and hyperglycemia. 4. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dysphagia, Presence of Insulin Pump and Chronic Kidney Disease. Review of the Care Plan for Resident #2 dated 12/9/2025, revealed .Nutritional Risk r/t NPO [nothing by mouth] status, uncontrolled T1DM [Type 1 DM].dependence on enteral feeds [method of delivering nutrients directly into the stomach or small intestine for individuals who cannot eat or drink enough by mouth].requires tube feeding r/t [related to] Dysphagia [difficulty swallowing].has Diabetes Mellitus.Implanted insulin pump [a surgically implanted device that delivers insulin directly into the abdominal cavity]. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score was not assessed. Resident #2 was assessed as having short and long-term memory problems which indicated severely impaired cognition, required Insulin injections on 7 days of the 7-day look back period and required insulin order changes on 6 of the 7-day look back period. Review of Resident #2's Order Summary Report dated 3/1/2026, revealed .Observe resident for signs and symptoms of hypoglycemia/hyperglycemia.Glucagon Kit 1 MG, Inject 1MG intramuscularly as needed for Low blood sugar.blood sugar less than 70 and unresponsive.Glutose 15 Gel 40%, Give 1 application orally as needed for low blood sugar.Humulin N [an intermediate-acting, man-made insulin used to control high blood sugar] Kwikpen [a multidose, prefilled syringe] 100 Unit/ML, Inject 20 unit subcutaneously at bedtime for hyperglycemia.Inject 20 unit subcutaneously in the afternoon.Inject 25 unit subcutaneously in the morning.Lantus [a long-acting man-made insulin] Solostar subcutaneous Solution Pen-injector 100 Unit/ML, Inject 30 unit sq at bedtime for Diabetes Hold if glucose level is 150. Review of the Medication Administration Record (MAR) dated March 2026, revealed an order for Humalog [a rapid acting injection to lower blood glucose] Kwikpen [multi-dose, prefilled, injection pen] 100 UNIT/ML (milliliter) Solution subcutaneously five times a day for diabetes adjusted by sliding scale [dosages based on blood glucose level] as follows: a. For a BG of 150-200 give 3 units b. For a BG of 201-250 give 6 units c. For a BG of 251-300 give 9 units d. For a BG of 301-350 give 12 units e. For a BG of 351-400 give 15 units and notify provider f. For a BG of 451-500 give 18 units and notify provider g. For a BG of 501-550 give 25 units and notify provider Review of the Weights and Vitals Summary Report for Resident #2 for March 2026, revealed the following hypoglycemic and hyperglycemic Blood Glucose (BG) results were not reported to the physician or NP: 3/4/2026 1:35 PM 376 mg/dL 3/10/2026 1:57 PM 51 mg/dL There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 3/10/2026 6:08 PM 402 mg/dL 3/13/2026 10:10 AM 440 mg/dL 3/13/2026 8:32 PM 43 mg/dL There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 3/14/2026 10:32 AM 478 mg/dL 3/24/2026 9:37 AM 49 mg/dL There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 3/24/2026 12:59 PM 386 mg/dL Review of Resident #2's medical record showed the order for Humalog Kwikpen sliding scale insulin was discontinued on 3/26/2026, and the facility followed the facility's policy to call the physician for blood glucose values > (greater than) 250mg/dl more than once within a 24 hour period and for blood glucose values > 300mg/dl more than once over 2 consecutive days from 3/26/2026-4/13/2026. Review of the Weights and Vitals Summary Report for Resident #2 for March 2026, revealed the following hypoglycemic and hyperglycemic Blood Glucose (BG) results were not reported to the physician or NP: 3/29/2026 10:16 PM 408 mg/dL BG greater than 300 more than once over 2 consecutive days. (3/28/2026 at 8:30 PM--377 mg/dL) 3/30/2026 5:55 PM 43 mg/dL Medication treatment was given Review of the Weights and Vital Signs Summary Report for Resident #2 for April 2026, revealed the following hypoglycemic and hyperglycemic BG results were not reported to the Resident's physician or NP. 4/1/2026 4:55 PM 54 mg/dL There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 4/5/2026 7:44 AM 58 mg/dL There was no documentation the Resident received Glutose or Glucagon for the low blood glucose. 4/5/2026 11:57 AM 378 mg/dL BG value over 250 more than once in a 24-hr period. (4/4/2026 at 5:23 PM--351 mg/dL) 4/5/2026 4:35 PM 453 mg/dL 4/6/2026 7:40 AM 354 mg/dL 4/7/2026 9:49 AM 422 mg/dL 4/7/2026 1:19 PM 600 mg/dL 4/7/2026 4:34 PM 555 mg/dL 4/11/2026 6:29 PM 410 mg/dL 4/12/2026 12:22 PM 350 mg/dL 4/12/2026 4:49 PM 383 mg/dL 4/13/2026 8:02 AM 386 mg/dL 5. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertension, and Disruption of External Operation Wound. Review of the Care Plan for Resident #3 dated 2/13/2026, revealed .risk of fluctuations [continuing changes] in blood glucose levels R/T DM. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #3 was cognitively intact. Resident #3 required insulin injections on 5 days of the 7-day look back period. Review of Resident #[TRUNCATED

Based on facility policy review, Facility Reported Incident (FRI) review, medical record review, interviews, and observations, the facility's Quality Assurance Performance Improvement (QAPI) failed to identify the root cause of an avoidable accident, and failed to implement a plan of action interventions for an elopement. The facility's QAPI Committee also failed to recognize unsafe smoking practices and storage of igniting materials.The facility's failure to identify the root cause of an avoidable accident and implement plan of action interventions, and failure to recognize and prevent unsafe smoking and storage of igniting materials, placed all 92 residents residing in the facility in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) at a scope and severity level of L. The Administrator and Director of Nursing Services (DNS) were notified of the Immediate Jeopardy on 11/4/2022 at 12:25 PM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-867. The facility was cited at F-867 at a scope and severity of L. The Immediate Jeopardy was removed onsite and was effective from 8/22/2022 to 11/4/2022 at 6:50 PM. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/4/2022 at 6:25 PM. The corrective actions were validated onsite by the surveyors on 11/4/2022 at 6:50 PM. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, QAPI Center Plan, revealed, .Quality Assurance and Performance Improvement (QAPI) .Develop and implement an improvement or corrective plan; And continuously monitor the effectiveness of our interventions .QAPI program accomplishes this by ensuring our data collection tools and monitoring systems are in place and are consistent thus allowing for retrospective responsive review, proactive analysis, system failure analysis, and corrective action .Action plans are implemented as needed to prevent recurrence . Review of the QAPI Meeting minutes, voluntarily provided to the surveyors by the Administrator, dated 8/22/2022, revealed, .On 8/22/2022 around 5:30 PM [Named Resident] .was inadvertently let out of the center .All residents with an assessment reflecting a high risk for elopement considered higher risk-the DNS completed an audit to ensure compliance with the elopement guidelines: .Wander guards verified in place and operable on 2 residents .6 Residents total at risk for elopement via the elopement assessment and DNS review .Care plans reviewed to ensure elopement prevention/approaches are in place and UTD [up to date] .Elopement books reviewed to ensure UTD .In compliance 8/23/2022 . Continued review revealed the meeting was attended by the Administrator, DNS, Medical Director, Director of Clinical Operations [DCO], Unit Manager 1, Unit Manager 2, Assistant Director of Nursing (ADON), Memory Care Director (MCD) Maintenance Director, and a representative from nursing staff. Accidents: Failure to ensure adequate supervision for 1 of 14 sampled residents (Resident #4), which resulted in an elopement. Failure to ensure safe smoking/tobacco use for 12 of 16 sampled resdents (Resident #5, Resident 8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18) reviewed for smoking/tobacco use. Failure to secure igniting materials (lighters/matches) for 3 of 17 sampled residents (Residents #8, Resident #9, and Resident #10) which placed all 92 residents in the facility at risk. Refer to F689. Care Plans: Failure to ensure care plans were developed 3 of 14 sampled residents (Residents #5, Resident #6, and Resident #7) reviewed for elopement. The facility failed to implement 2 of 16 sampled residents (Resident #9 and Resident #18) reviewed for safe smoking/tobacco use. The facility failed to implement interventions for care plans on 3 of 16 sampled residents (Resident #5, Resident #10, and Resident #12) reviewed for safe smoking. Refer to F656. Observation and interview on 11/1/2022 at 4:55 PM, revealed the Administrator reviewed the elopement books with the surveyors. The elopement books were noted to have numerous resident face sheets and elopement assessments that revealed numerous residents were not at risk for elopement. During the interview the Administrator confirmed she had decided to make a book for identification purposes and the elopement books did not contain only the residents at risk for elopement. The Administrator confirmed the elopement books contained information for residents that were no longer in the facility, she confirmed the elopement books were not up to date related to the plan of correction noted in the QAPI meeting documentation completed on 8/23/2022. Observation and interview on 11/1/2022 at 5:03 PM and 5:52 PM, revealed the DNS confirmed elopement assessments should be completed upon admission, readmission and a significant change in status. She confirmed residents with a cognitive impairment that were admitted to the Secure Unit were at risk for elopement. She confirmed there were 14 residents in the Secured Unit on 8/23/2022. The DNS reviewed the elopement books on 11/1/2022 at 5:52 PM and confirmed the elopement books were not up to date. She stated, I done the elopement evaluations in the computer system, and I only found 6 residents that were at risk for elopement, only those residents at risk for elopement should have been placed in the book. She confirmed the QAPI plan of action included review of the care plans for those at risk for elopement to ensure facility compliance. She confirmed any time there was a positive risk assessment she expected the care plan to be updated to reflect the outcome of the assessment. The surveyors verified the acceptable Imedicate Action Removal Plan on 11/4/2022 at 6:50 PM by: 1. On 11/4/2022 the surveyors verified the Regional [NAME] President and Director of Clinical Operations conducted training with the Administrator and DON regarding the following topics utilizing resources from CMS Appendix PP, Quality Initiative Organizations and Diversicare policy: a. CMS AQPI Training 8/22 Alliant QIO Fishbone Diagram Worksheet b. QAPI Center Plan: Diversicare of Smyrna Policy c. Elopement- Diversicare of Smyrna Policy d. CMS Resident Rights Training 8/22 e. Diversicare Safe Tobacco Use Policy f. TN Elopement and Prevention Training 8/22 g. Phase III ROP F689-Accidents, Hazards, Supervision h. Phase III ROP F656- Care Plan i. Phase III ROP F835- Administrator j. Phase III ROP F867-QAPI 2. An Ad hoc QAPI meeting was held 11/4/2022 with the Administrator, Director of Nursing, Social Services Director, Nurse Assessment Coordinator, Activities Director, Maintenance Director, Housekeeping/Laundry Director, DCO, Sales/Marketing Director, ADNS, Staffing/Workforce Manager, Director of Care Coordination, Human Resources, Memory Care Director, Business Office Manager, and 2 Unit Managers. 3. The meeting included discussing F867 and the overall impact that QAPI can have when discussing issues that arise in the facility. Administrator explained that when the elopement occurred on 8/22/2022, the facility failed to properly identify the root cause analysis of the elopement which resulted in continued risk of elopement with the potential of serious harm. Administrator and Director of Clinical Operations discussed the need for the whole QAPI committee to be involved in finding root causes of incidents so that it is a collaborative effort. Ad hoc QAPI meetings will be held in the future when an incident arises or safety concerns are identified so that the whole committee can be involved. 4. Oversight and monitoring-The Regional [NAME] President, Director of Clinical Operations or a Diversicare Support Center Leadership team member will provide on-site oversight including review of process compliance, monitoring audits and any current investigations regarding accidents/hazards/supervision a minimum of 2 days per week x 4 weeks, then weekly for 2 weeks then monthly x 3 months. Members of the oversight team will participate in the weekly adHoc QAPI meetings each week via zoom or phone until Jeopardy is cleared. 44724

Based on the job description review and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well being of the residents. Administration failed to provide oversight, ensure a safe environment, complete a thorough investigation of resident elopement, and conduct an ad hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting that identified the appropriate root cause of an elopement to implement appropriate interventions. Administration failed to ensure Elopement Books were updated, failed to educate all staff on elopement risks, failed to update the care plans, which placed 3 of 14 sampled residents (Resident #5, Resident #6, and Resident #7) in Immediate Jeopardy (IJ) when a resident (Resident #4,) a cognitively impaired resident with wandering and exit seeking history and behaviors, exited the facility and was located across a busy street walking along the roadside. Administration also failed to ensure resident care plans and interventions for safe smoking were implemented, Safe Smoking Evaluations were accurately completed, and supervision was provided to residents who smoke for 6 of 17 sampled residents (Residents #5, Resident #8, Resident #9, Resident #10, Resident #12, and Resident #18), who use tobacco products, and 3 of 17 residents (Residents #8, Resident #9, and Resident #10) who use igniting materials (lighters/matches) were secured in a safe manner, which placed all 92 residents residing in the facility in IJ, at a severity level of L, which had the potential to result in serious injury, harm, impairment, or death. The Administrator was notified of the Immediate Jeopardy on 11/4/2022 at 12:25 PM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-835 at a scope and severity of L. The Immediate Jeopardy was removed onsite and was effective from 8/22/2022 to 11/4/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 11/4/2022 at 11:25 AM. The corrective actions were validated onsite by surveyors on 11/4/2022 at 7:40 PM. The facility's noncompliance at F-835 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The findings include: Review of the Job Description for the Administrator revealed, .Directs, oversees and manages the 24/7 day to day operations of the [Named Company] post-acute care center .Key Responsibilities Ensure the patient and resident is the center of every decision; Serve as the center abuse coordinator. Strives to ensure the safety of all residents within the center; ensures education and understanding of all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect, or misappropriation by protecting, investing and making any required reporting; .Ensure adoption of [Named Company]'s policies, guidelines and standards; .Ensure that quality care and services is provided to all patients, residents and that it meets the satisfaction of the patient, resident, family, physicians and other partners; .Lead an effective Quality Assurance and Process Improvement (QAPI) Program; . Accidents: Failure to ensure adequate supervision for 1 of 14 sampled residents (Resident #4), which resulted in an elopement. Failure to ensure safe smoking/tobacco use for 12 of 16 sampled resdents (Resident #5, Resident 8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18) reviewed for smoking/tobacco use. Failure to secure igniting materials (lighters/matches) for 3 of 17 sampled residents (Residents #8, Resident #9, and Resident #10) which placed all 92 residents in the facility at risk. Refer to F689. Care Plans: Failure to ensure care plans were developed 3 of 14 sampled residents (Residents #5, Resident #6, and Resident #7) reviewed for elopement. The facility failed to implement 2 of 16 sampled residents (Resident #9 and Resident #18) reviewed for safe smoking/tobacco use. The facility failed to implement interventions for care plans on 3 of 16 sampled residents (Resident #5, Resident #10, and Resident #12) reviewed for safe smoking. Refer to F656. QAPI: Failure to identify the root cause of an avoidable accident. Failed to implement plan of action interventions for an elopement. Refer to F867 During an interview on 11/1/2022 at 1:28 PM, the Administrator confirmed the investigation did not determine exactly how Resident #4 eloped from the Secure Unit on 8/22/2022. The Administrator voluntarily provided the surveyors the QAPI Committee Meetin minutes. She confirmed she did not measure the exact distance to where Resident #4 was found. She accepted the distance measurement to where Resident #4 was located from Licensed Practical Nurse #2. Continued interview the Administrator confirmed she could not recall exactly where Resident #4 had been located after eloping from the facility. She stated she did not recall being aware of Resident #4 crossing the street. She stated she trusted LPN #2 and believed she was honest in making any statements about where she located Resident #4 after the elopement. The Administrator did not correctly identify the root cause of the elopement, and failed to implement interventions/actions discussed in the plan of action. During an interview on 11/1/2022 at 3:00 PM, a Dietary Chef confirmed he had not been in-serviced on elopement by the facility or his agency. Observation and interview on 11/1/2022 at 4:55 PM, revealed the Administrator reviewed the elopement books with the surveyors. The elopement books were noted to have numerous resident face sheets and elopement assessments that revealed numerous residents who were not at risk for elopement. During interview the Administrator stated, I decided to make a book for identification purposes, and she confirmed that the elopement book did not contain only the residents at risk for elopement. The Administrator confirmed that the elopement books were not up to date related to the plan of correction noted in the QAPI meeting documentation completed on 8/23/2022. During an interview on 11/3/2022 at 8:55 AM, the Administrator confirmed, The smoking assessments should say whether the resident wears a smoking apron or not. Observation and interview on 11/3/2022 at 8:57 AM, the Administrator stated, The smoking aprons should be hanging on the wall as you go out to the patio where residents smoke or in the cabinets in the Sun Room. The Administrator confirmed no smoking aprons were hanging on the wall or in the cabinets in the Sun Room. The Administrator stated, I ordered 6 yesterday, I promise the aprons are usually hanging here on the wall. During an interview on 11/3/2022 at 9:32 AM, the Administrator confirmed the employees should know what type of receptacle they should be using to put cigarette butts in when the residents smoke. The surveyors verified acceptable Immediate Action Removal Plan on 11/4/2022 at 7:40 PM by: 1. On 11/4/2022 the surveyors verified the Regional [NAME] President and DCO conducted training with the Administrator and DON regarding the following topics utilizing resources from CMS Appendix PP, Quality Initiative Organizations and Diversicare policy: a. CMS AQPI Training 8/22 Alliant QIO Fishbone Diagram Worksheet b. QAPI Center Plan: Diversicare of Smyrna Policy c. Elopement- Diversicare of Smyrna Policy d. CMS Resident Rights Training 8/22 e. Diversicare Safe Tobacco Use Policy f. TN Elopement and Prevention Training 8/22 g. Phase III ROP F689-Accidents, Hazards, Supervision h. Phase III ROP F656- Care Plan i. Phase III ROP F835- Administrator j. Phase III ROP F867-QAPI 2. An Ad hoc QAPI meeting was held 11/4/2022 with the Administrator, Director of Nursing, Social Services Director, Nurse Assessment Coordinator, Activities Director, Maintenance Director, Housekeeping/Laundry Director, DCO, Sales/Marketing Director, ADNS, Staffing/Workforce Manager, Director of Care Coordination, Human Resources, Memory Care Director, Business Office Manager, and 2 Unit Managers. 44447

Based on facility policy review, Facility Reported Incident (FRI) review, medical record review, observation, and interview, the facility failed to ensure 1 of 14 sampled residents (Resident #4) received adequate supervision to prevent an avoidable accident. The facility failed to ensure safe smoking for 6 of 17 sampled residents (Resident #5, Resident #8, Resident #9, Resident #10, Resident #12, and Resident #18) reviewed for tobacco product use. The facility failed to ensure igniting materials (lighters/matches) were secured in a safe manner for 3 of 17 sampled residents (Resident #8, Resident #9, and Resident #10) reviewed for smoking. The facility's failure to provide adequate supervision resulted in Resident #4's elopement, and failure to supervise residents who smoke, and failure to store igniting materials in a safe manner, placed the residents in Immediate Jeopardy, (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator and Director of Nursing Services (DNS) were notified of the Immediate Jeopardy on 11/3/2022 at 11:55 AM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of L, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 8/22/2022 to 11/4/2022 at 1:15 AM. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/4/2022 at 12:55 AM. The corrective actions were validated onsite by the surveyors on 11/4/2022 at 1:15 AM. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Safe Smoking, dated 11/1/2016, revealed .To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents .to assess the ability to smoke safely and determine any measures needed to protect residents from possible self-inflicted injury due to smoking .any resident who identifies themselves as desiring to smoke or use an electronic nicotine delivery system [ENDS] will be assessed for safety related to smoking. This assessment will be reviewed and updated with any change of condition .staff members will monitor or obtain fire igniting materials [matches/lighters] for the benefit of smokers at the nurses' station or other designated location. Other electronic nicotine delivery systems [vaporizers, e-cigatettes] will be treated the same way as fire igniting materials and maintained at the nurses' station or other designated location . Review of the facility's policy titled, Safe Tobacco Use, revised on 11/3/2022, revealed .Tobacco materials (cigarettes/cigars/chewing tobacco/snuff) themselves, in addition to fire igniting materials, may be controlled if smoking policy violations have occurred or as a general policy for all residents . Review of the facility's policy titled, Accidents and Supervision, dated 10/2022, revealed, .The resident environment will remain as free of accident hazards as is possible .Each resident will receive adequate supervision and assistive devices to prevent accidents .Implementing interventions to reduce hazard(s) and risk(s) .Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accident . Review of the medical record revealed Resident #5 (who resides on the Secured Unit) was admitted to the facility on [DATE] with diagnoses which included Dementia, Nicotine Dependence, and Other Symptoms and Signs involving Cognitive Functions and Awareness. Review of the Quarterly MDS assessment for Resident #5 dated 8/27/2022 revealed a BIMS score 7, which indicated severe cognitive impairment. Continued review revealed Resident #5 required supervision with transfers, walk in room, walk in corridor, and locomotion on unit. Review of the undated Care Plan for Resident #5 revealed a focus for, .At risk for smoking related injury . Interventions included, .Assist to and from Designated Smoking area .Assure smoking material is extinguished prior to patient leaving smoking area .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Place patient in position to assure visualization of ashtray . Review of Resident #5's (who was severly cognitively impaired) Smoking assessment dated [DATE], revealed Resident #5 exhibited signs of confusion but was able to understand living center's times and place to smoke. Review of the medical record for Resident #8 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia, Cognitive Communication Deficit, and Tobacco Use. Review of the Quarterly MDS assessment for Resident #8 dated 9/17/2022 revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed he required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Continued review revealed he was total dependence for bathing. Review of the undated Care Plan for Resident #8 revealed a focus for, .[Named resident] is a smoker . Interventions included, .Instruct resident about smoking risks and hazards and about smoking cessation aids that are available .Instruct resident about the facility policy on smoking: locations, times, safety concerns .Notify charge nurse immediately if it is suspected resident has violated facility smoking policy .Observe clothing and skin for signs of cigarette burns .The resident requires a smoking apron while smoking . Review of Resident #8's Smoking assessment dated [DATE], revealed Resident #8 currently smokes. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction, Muscle Weakness, and Tobacco Use. Review of the Quarterly MDS assessment for Resident #9 dated 9/20/2022 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Continued review revealed she required extensive assistance for bed mobility, transfer, dressing, and personal hygiene. Review of the Care Plan for Resident #9 revealed she had no focus for smoking. Review of Resident #9's clinical assessments revealed no smoking assessment. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Tobacco Use. Review of the Annual MDS assessment for Resident #10 revealed a BIMS score of 14, which indicated no cognitive impairment. Continued review revealed he required extensive assistance with bed mobility, dressing, and personal hygiene. Review of the undated Care Plan for Resident #10 revealed a focus for .[Named resident] is at risk for smoking related injury . Interventions included, .Assist resident to and from designated smoking area .Assure smoking material is extinguished prior to leaving smoking area .Provide resident a smoking apron while smoking .Resident not to have smoking materials on person .Storage of smoking materials per facility policy . Review of Resident #10's Clinical Health Status Evaluation dated 7/27/2022, revealed a smoking evaluation completed. The Smoking Assessment for Resident #10 was not completed quarterly, according to the facility's assessment schedule. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Dysphagia, and Gastroparesis. Review of the Quarterly MDS assessment for Resident #11, dated 10/13/2022, revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Continued review revealed she was dependent with transfers and bathing. Review of the undated Care Plan revealed Resident #11 had a focus for .at risk for smoking related injury related to: Limited mobility . Interventions included, .Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Patient not to have cigarettes or smoking material on person .Place patient in position to assure visualization of ashtray .Provide smoking apron while smoking .Review smoking policy with patient and or family . Review of Resident #11's Smoking assessment dated [DATE], revealed she exhibited signs of confusion and no answer for understanding of the living center's smoking policy. The Smoking Assessment for Resident #11 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Nontraumatic Intracranial Hemorrhage, Cognitive Communication Deficit, and Tobacco Use. Review of the Admission MDS assessment for Resident #12 dated 8/11/2022 revealed a BIMS score of 5, which indicated severe cognitive impairment. Continued review revealed she required supervision with bed mobility, transfers, walking, dressing, and eating. Continued review revealed she required extensive assistance with toilet use and bathing. Review of the undated Care Plan revealed Resident #12 had a focus for .at risk for smoking related injury . Interventions included, .supervise resident while smoking and Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Patient not to have cigarettes or smoking material on person .Provide smoking apron while smoking .Review smoking policy with patient and or family . Review of Resident #12's Clinical Health Status Evaluation completed on 8/4/2022, revealed no smoking assessment. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Hemiplegia and Hemiparesis, Iron Deficiency Anemia, and Hypokalemia. Review of the Quarterly MDS assessment for Resident #13 dated 9/22/2022 revealed a BIMS assessment was not done because resident is rarely or never understood and has long and short term memory problems. Continued review revealed she required extensive assistance of 2 or more people for bed mobility, transfer, dressing, toilet use, personal hygiene, and total dependence for bathing. Review of the undated Care Plan revealed Resident #13 had a focus for .at risk for smoking related injuries . Interventions included, .Complete smoking safety assessment .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Provide smoking apron while smoking .Provide smoking assistive device .Storage of smoking materials per Center policy . Review of Resident #13's Smoking assessment dated [DATE], revealed she currently smokes, has quit smoking recently, and resident does not wish to quit smoking. The Smoking Assessment for Resident #13 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses which included Cognitive Communication Deficit, Tobacco Use, and Muscle Weakness. Review of the Quarterly MDS assessment for Resident #14 dated 11/3/2022 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Review of the undated Care Plan for Resident #14, revealed, .has the potential for injury r/t [related to] being a smoker. He has a hx [history] of noncompliance with smoking policy. Gets cigarettes from other residents . Interventions included, .keep all smoking materials at nursing station .observe for burn holes on his skin, on his clothing or bed linen and report concerns .observe for safety when he is smoking .redirect when he is inappropriate in smoking habits .Resident to smoke in designated areas only .to wear smoking apron while smoking for safety . Review of Resident #14's Smoking assessment dated [DATE], revealed he currently smokes. The Smoking Assessment for Resident #14 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Peripheral Vascular Disease, Dysphagia, and Tobacco Use. Review of the Quarterly MDS assessment for Resident #15 dated 9/28/2022 revealed a BIMS score of 11, which indicated moderate cognitive impairment. Review of the undated Care Plan for Resident #15 revealed a focus for, .At risk for smoking related injury related to: Cigarette holes burn in clothing . Interventions included, .Complete smoking assessment per Center policy .Patient not to have cigarettes or smoking material on person .Review smoking policy with patient and or family .Storage of smoking materials per Center policy . Review of Resident #15's Smoking assessment dated [DATE], revealed he currently smokes. The Smoking Assessment for Resident #15 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Unspecified Convulsions, Tobacco Use, and Personal History of Traumatic Brain Injury. Review of the Quarterly MDS assessment for Resident #16 dated 10/20/2022, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Continued review revealed he required extensive assistance for bed mobility, transfers, toilet use, and personal hygiene. Continued review revealed total dependent with bathing. Review of the undated Care Plan for Resident #16 revealed a focus for, .[Named resident] is at risk for smoking related injuries . Interventions included, .Assist to and from Designated Smoking area .Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Place patient in position to assure visualization of ashtray .Provide smoking apron while smoking .Storage of smoking materials per Center policy . Review of Resident #16's Smoking assessment dated [DATE], revealed he exhibits signs of confusion but able to understand the living center's smoking policy. Continued review of the Smoking Assessment revealed, The resident untilizes a burn free bib and is with a staff member when he is outside smoking. The Smoking Assessment for Resident #16 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Chronic Pain Syndrome, and Aphasia. Review of the Quarterly MDS assessment for Resident #17 dated 8/23/2022 revealed a BIMS score of 10, which indicated moderate cognitive impairment. Continued review revealed he required limited assistance with bed mobility, transfers, dressing and personal hygiene. Review of the undated Care Plan for Resident #17 revealed a focus for, .is at risk for smoking related injury . Interventions included, .Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Provide smoking apron while smoking .Review smoking policy with patient and or family .Storage of smoking materials per Center policy . Review of Resident #17's Smoking assessment dated [DATE], revealed resident currently smokes. The Smoking Assessment for Resident #17 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Dependence on Oxygen, and Anxiety. Review of the Quarterly MDS assessment for Resident #18 dated 8/6/2022 revealed a BIMS score of 14, which indicated no cognitive impairment. Continued review revealed he required limited assistance with bed mobility, supervision for transfer, limited assistance with dressing and supervision for toileting and hygiene. Review of the undated Care Plan for Resident #18 revealed no focus for tobacco use. Review of Resident #18's Smoking assessment dated [DATE] revealed Resident #18 does not smoke. The assessment does not mention the fact that he uses smokeless tobacco. Review of Resident #18's Clinical Health Status Evaluation dated 11/17/2021, revealed a diminished awareness of safety and confusion with memory problem. Observation and interview on 11/2/2022 at 12:10 PM, revealed Resident #8 (Resident Council President), Resident #9, and Resident #10 outside of the Sun Room, smoking with no supervision, no smoking aprons, or staff present on the patio. Continued observation revealed Resident #8 had his cigarettes and a lighter, Resident #9 had a cigarette pouch with a lighter in the side of the pouch, and Resident #10 had a pack of cigarettes in his electric wheel chair with a lighter in his hand. Resident #8, Resident #9 and Resident #10 stated they can come out and smoke whenever they want to smoke. Continued observation of the patio revealed no smoking aprons available for resident. Observation and interviews on the Secured Unit on 11/2/2022 at 12:40 PM, revealed CNA #3 sitting at a table in the Day Room with 9 cognitively impaired residents sitting around her. The Day Room opens to the outside patio. Continued observation revealed 2 residents (Resident #5 and Resident #12) outside smoking on the patio with Resident #12 sitting with her back to the glass panel, which prevented visualization of the resident smoking, and Resident # 5 sitting at the patio table. Neither residents were wearing a smoking apron and no staff members were outside supervising the 2 residents. Continued observation of the secured unit revealed 2 other residents pacing the hall. CNA #3 confirmed Resident #5 and Resident #12 were outside smoking. CNA #3 stated, We watch them from the inside [referring to watching the residents from the inside Secured Day Room through the glass panel to patio]. Observation and interview on 11/2/2022 at 2:52 PM revealed Resident #8, Resident #9 and Resident #10 outside smoking on the patio that exits from the Sun Room. All 3 residents were unsupervised and not wearing a smoking apron. Resident #9 had her cigarette pouch with the lighter in the side of pouch and she was smoking. Resident #10 was sitting in his electric wheel chair brought out his cigarette from his bag hanging on the side of the wheel chair and pulled out his lighter to light his cigarette and began smoking. Resident #18 was sitting outside and revealed he had a tobacco pouch in his mouth and showed this surveyor his tobacco can that was in his pocket. Resident #18 confirmed he keeps his tobacco in his pocket and doesn't leave it at nurses station. Observation and interview on 11/2/2022 at 4:30 PM revealed Resident #8 and Resident #9 outside smoking. Resident #9 was asked if she ever wears a smoking apron and she stated, The aprons are just worn out and we don't have enough. Today when staff brought another resident out to smoke they pulled off my apron and gave it to them. Observation and interview in Resident #10's room on 11/2/2022 at 5:45 PM, it was noted an electronic nicotine delivering system (vaporizer) was lying on the overbed table. The Administrator confirmed the electronic nicotine delivering system was on the overbed table. Resident #10 confirmed his cigarettes and lighter were in the bag hanging on his electronic wheel chair. Continued interview with the Administrator outside of Resident #10's room, she stated, We try to keep stuff out of the room. During an interview on 11/3/2022 at 8:20 AM, the DNS printed the smoking assessments completed over the last year and confirmed the smoking assessments were not completed quarterly, and some questions on the assessments are not completed for the following residents: Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, and Resident #17. During an observation and interview on 11/3/2022 at 8:50 AM, LPN #6 confirmed the Secured Unit has one smoking apron that has a tear in it. LPN #6 stated, We do the best we can. Observation and interview on 11/3/2022 at 8:57 AM, the Administrator stated, The smoking aprons should be hanging on the wall as you go out to the patio where residents smoke or in the cabinets in the Sun Room. The Administrator confirmed no smoking aprons were hanging on the wall or in the cabinets in the Sun Room. The Administrator stated, I ordered 6 yesterday, I promise the aprons are usually hanging here on the wall. During an observation and interview in the smoking area of patio that exits from the Sun Room on 11/3/2022 at 9:15 AM, the Maintenance Director confirmed candy wrappers and paper were in the cigarette receptacle where the residents drop their cigarette butts. Continued observation and interview on the Secured Unit outside smoking area on 11/3/2022 at 9:20 AM, the Maintenance Director confirmed cigarette butts were in a terra [NAME] pot and no other cigarette butt receptacle was present. The Maintenance Director confirmed the fire extenquisher hanging outside on the patio has not been checked since 2020. The Maintenance Director stated, I will be honest with you. I didn't even know that the fire extenquisher was out here. During an interview on 11/3/2022 at 8:55 AM, the Administrator stated, The smoking assessments should say whether the resident wears a smoking apron or not. During an interview on 11/3/2022 at 9:32 AM, the Administrator confirmed the employees should know what type of receptacle they should be using to put cigarette butts in when the residents smoke. During an interview on 11/3/2022 at 12:00 PM, Resident #8 stated, I understand the smoking is a safety issue. It should have been dealt with before. During an interview on 11/3/2022 at 4:50 PM, CDO (Clinical Director of Operations) confirmed a resident with confusion would not be a safe smoker. The CDO stated, We need to fix that smoking assessment to require supervision if the resident exhibits confusion. She stated, I will contact the Senior [NAME] President of Clinical Operations to request the Smoking Assessment to reflect a confused resident should automatically be supervised. The CDO confirmed the facility did not have a policy to address smokeless tobacco use. The surveyors verified acceptable Immediate Action Removal Plan on 11/4/2022 at 1:15 AM by: 1. On 11/2/2022, the Assessment Nurses and the Nurse Manager spoke to each known tobacco user regarding the smoking policy and ensured residents did not have smoking materials on their person or in their room. During the process, the team found 5 of 16 residents had cigarettes, lighters, and vaping materials on their person. 2. The Administrator met with the Administration Team on 11/2/2022 and educated them on the smoking policy and in-serviced them that supervised smokers can only smoke with a staff member present in the smoking area. Tobacco users were re-educated regarding the Smoking policy by the Social Services Director and the Activities Director. 3. The facility placed all smoking materials in a ziplock bag and labeled them with the resident's name and safe smoking information and secured them at nurse's station. 4. A list of residents who smoke was placed on the wall in the laundry room, which is directly off the smoking area. 5. Designated supervised smoking times will begin 11/4/2022 for those residents who require supervision. 6. On 11/3/2022, Director of Clinical Education in-serviced all available staff members regarding tobacco policy, designated supervised smoking times, signing out smoking materials for residents, and will continue to provide education. All staff must receive the in-service before they work another shift. 7. All smoking assessments were updated for all residents who smoke by the DNS and the ADON on 11/3/2022. Also care plans and Kardex were updated by the members of the nursing managment team on 11/3/2022. 8. All new admits, re-admits, and upon change of status residents will have a new Safe Smoking Assessment. 9. The IDT team will conduct random observations of the smoking area 7 times a day for 30 days to validate adherence to the Tobacco/Smoking policy. 10. The corporate office updated the Safe Smoking Policy to Safe Tobacco Policy to reflect the addition of oral tobacco products. 11. On 11/3/2022 the Senior [NAME] President of Clinical Operations submitted a request to (Named Electronic Medical Record Company) representative to revise the Smoking/Tobacco Assessment. 12. All nurses were educated on the change to the Smoking/Tobacco Assessment. 13. The Administator will hold an ad hoc QAPI meeting 11/4/2022 to discuss the revised Tobacco policy and the procedures for designated supervised smoking times. Any issues with complaince identified will be immediately corrected and reported to the Administrator and the QAPI team. Review of the facility's policy titled, Elopement, dated 4/2017, revealed, .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements .Newly admitted or readmitted residents are assessed for elopement risk .If an elopement risk is determined an individualized plan is established and intervention is initiated to mitigate that risk . Review of the facility's policy titled, Accidents and Supervision, dated 10/2022, revealed, .The resident environment will remain as free of accident hazards as is possible .Each resident will receive adequate supervision and assistive devices to prevent accidents .Implementing interventions to reduce hazard(s) and risk(s) .Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accident . Review of the facility's policy titled, Policy and Procedure, Dementia, Family Questionnaire, dated 5/2021, revealed, .To assess appropriate diagnosis and placement possibilities in The Memory Care Unit .To serve as a guide to the resident's initial care plan and overall approach assisting the resident to a positive adjustment to placement in The Memory Care Unit .families continue to be an integral part of the resident's life .family members are included, if possible, in the assessment and reassessment of .Elopement risk assessment . Review of the FRI #202282221816 revealed the facility reported the elopement of Resident #4 to the State Agency and the local police department. The investigation states Resident #4 eloped from the Secure Unit on 8/22/2022 at approximately 5:30 PM. Continued review revealed the investigation alleges Resident #4 set off an alarm on the back door of the Secured Unit and then was able to push on the entrance door until the alarm sounded and the doors opened. The investigation alleges staff responded to the alarming doors. The investigation alleges Resident #4 was let out of the facility by a staff member that works as needed and then walked approximately 1200 feet from the front door. The investigation alleges the nearest busy street was 1584 feet and the next busy street was 2112 feet. There were statements provided by staff, in-services provided to all disciplines, except dietary. Elopement drills were provided to all shifts and Quality Assurance Performance Improvement (QAPI) meeting minutes were copied and provided. Confirmation received from Administrator for QAPI meeting minutes provided to surveyor voluntarily for removal from the facility. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Other Symptoms and Signs Involving Cognitive Functions and Awareness, Unspecified Dementia, Alzheimer's Disease, and Other Specified Personal Risk Factors, Not elsewhere Classified. Review of the Special Care Unit Criteria Review (facility document used during preadmission review) for Resident #4 dated 8/18/2022, revealed, .Describe resident's special concerns .Wanders, Sleepwalks, Exit Seeking . Continued review revealed the review was signed by the Memory Care Director (MCD), DNS, and the Administrator. Review of Resident #4's Clinical Health Status Evaluation dated 8/22/2022 at 11:35 AM, revealed questions answered as yes which included the resident was physically able to leave the building on her own, she was cognitively impaired, she made repetitive statements about going home, there was a history of wandering or elopement, the resident wandered aimlessly about the facility and/or exhibited night wandering. Continued review revealed resident was at risk for elopement and was placed on the secured unit. Review of the Progress Notes for Resident #4 revealed, .8/22/2022 20:15 [8:15 PM] .this evening around dinner time, [Named CNA (Certified Nursing Assistant)], asked me if I had seen [Named Resident] #4 .[Named CNA] stated that the resident went to the bathroom during dinner trays being passed and staff told pt [patient] to return to dinning [dining] area to eat .the alarm was not heard during this elopement, if so, actions would have been taken more promptly then [than] they were . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a BIMS score of 3, which indicated severe cognitive impairment. Observation of (Named Street) on 11/4/2022 at 5:20 PM to 5:40 PM, revealed 153 total vehicles, an average of 7.65 vehicles per minute passed the area where Resident #4 crossed the street and was walking along the side of the road. Included in the total of 153 vehicles were 5 postal delivery semi-trucks and 3 ambulances. Continued observation revealed 26 small postal delivery trucks parked in back of the post office. During an interview on 10/31/2022 at 3:20 PM, the MCD stated on 8/22/2022 at the time of Resident #4's elopement there was 1 LPN (Licensed Practical Nurse) and 1 CNA assigned on the secured unit. She stated after investigation she felt Resident #4 had eloped, from the secure unit by following someone out the entrance doors. She stated the evening meal trays were brought in through the side door and the tray cart blocked the entrance/exit door to the hallway preventing Resident #4 from exiting through the door. She stated the evening meal cart is delivered between 5:00 PM and 5:15 PM. She stated it was after 5:15 PM when the elopement occurred because the CNA had already passed the trays to residents in the dining area. During an interview on 10/31/2022 at 3:49 PM, CNA #1 stated she was in the dining room/day room assisting residents with the evening meal when she heard the back door alarm. She stated she checked t[TRUNCATED]

44447 Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement a care plan for risk of elopement for 3 of 14 sampled residents (Resident #5, Resident #6, and Resident #7) reviewed for elopement. The facility also failed to implement a care plan for 2 of 16 sampled residents (Resident #9 and Resident #18) reviewed for safe smoking/tobacco use, and failed to implement interventions on care plans for 3 of 16 sampled residents (Resident #5, Resident #10, and Resident #12) reviewed for safe smoking. The facility's failure to implement the care plans and interventions for Resident #5, Resident #6, Resident #7, Resident #9, Resident #10, Resident #12 and Resident #18 placed them in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator and Director of Nursing Services(DNS) were notified of the Immediate Jeopardy on 11/3/2022 at 1:45 PM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-656. The facility was cited at F-656 at a scope and severity of L. The Immediate Jeopardy was removed onsite and was effective from 8/23/2022 to 11/3/2022 at 11:00 PM. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/3/2022 at 11:00 PM. The corrective actions were validated onsite by the surveyors on 11/4/2022 at 1:15 AM. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Elopement, dated 4/2017, revealed, .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements .Newly admitted or readmitted residents are assessed for elopement risk .If an elopement risk is determined an individualized plan is established and intervention is initiated to mitigate that risk . Review of the facility's policy titled, Accidents and Supervision, dated 10/2022, revealed, .The resident environment will remain as free of accident hazards as is possible .Implementing interventions to reduce hazard(s) and risk(s) . Review of the facility's policy titled, Care Plans and Baseline Care Plans, revised 10/2022, revealed, .Care plans will be developed for all patients and residents based upon the RAI [Resident Assessment Instrument] manual and CMS [Center for Medicare and Medicaid Services] guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status . Review of the Quality Assurance and Performance Improvement (QAPI) Meeting minutes dated 8/23/2022, revealed, .Care plans reviewed to ensure elopement prevention/approaches are in place and UTD [up to date] .In compliance 8/23/2022 . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Dementia, Nicotine Dependence, and Other Symptoms and Signs involving Cognitive Functions and Awareness. Review of the undated Care Plan for Resident #5 revealed a focus for smoking, .At risk for smoking related injury . Interventions included, .Assist to and from Designated Smoking area .Assure smoking material is extinguished prior to patient leaving smoking area .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Place patient in position to assure visualization of ashtray . Review of the care plan detail for Resident #5 on 11/2/2022, revealed, .10/10/2022 .RESOLVED: At risk for elopement related to: Anger at placement in center . Review of the medical record for Resident #5 revealed there was no care plan focus for elopement after 10/10/2022, prior to surveyor request for documentation on 10/31/2022. Review of Resident #5's Elopement Risk Evaluation dated 8/23/2022 revealed question #7 answered as yes, the resident does wander aimlessly about the facility and/or exhibits night wandering. Continued review revealed resident was at risk for elopement. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction, Muscle Weakness, and Tobacco Use. Review of the undated Care Plan for Resident #9 revealed she had no focus for smoking. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Tobacco Use. Review of the undated Care Plan for Resident #10 revealed a focus for .[Named resident] is at risk for smoking related injury . Interventions included, .Assist resident to and from designated smoking area .Assure smoking material is extinguished prior to leaving smoking area .Provide resident a smoking apron while smoking .Resident not to have smoking materials on person .Storage of smoking materials per facility policy . Review of the medical record revealed Resident #12 (who resides on the Secured Unit) was admitted to the facility on [DATE] with diagnoses which included Nontraumatic Intracranial Hemorrhage, Cognitive Communication Deficit, and Tobacco Use. Review of the undated Care Plan revealed Resident #12 had a focus related to, .at risk for smoking related injury . Interventions included, .supervise resident while smoking and Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Patient not to have cigarettes or smoking material on person .Provide smoking apron while smoking . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Dependence on Oxygen, and Anxiety. Review of the undated Care Plan for Resident #18 revealed no focus for tobacco use. Observation and interview on 11/2/2022 at 12:10 PM, revealed Resident #9 and Resident #10 outside from the Sun Room, smoking with no supervision, no smoking aprons, or staff present on the patio. Continued observation of the patio revealed no smoking aprons available for residents as per individualized care plan. Observation on the Secured Unit on 11/2/2022 at 12:40 PM, revealed 9 residents sitting in the Secured Day Room area which opens to the outside patio. Continued observation revealed two residents (Resident #5 and Resident #12) outside smoking on the patio with Resident #12 sitting with her back to the glass panel which prevented visualization while she was smoking, and Resident #5 sitting at the patio table. Neither residents were wearing a smoking apron and no staff members were outside supervising the two residents as per individualized care plan. Observation and interview on 11/2/2022 at 2:52 PM revealed Resident #9 and Resident #10 outside smoking on the patio that exits from the Sun Room. Both residents were unsupervised and not wearing a smoking apron. Resident #9 had her cigarette pouch with the lighter in the side of the pouch. Resident #10 was sitting in his electric wheel chair and brought out his cigarette from his bag hanging on the side of the wheel chair and pulled out his lighter to light his cigarette and began smoking. Resident #9 and Resident #10 confirmed they are free to smoke at any time. Resident #18 was sitting outside and revealed he had a tobacco pouch in his mouth and showed the surveyor his tobacco can that was in his pocket. Resident #18 confirmed he keeps his tobacco in his pocket and doesn't leave it at the nurses station. Observation and interview on 11/2/2022 at 4:30 PM, revealed Resident #9 outside smoking. Resident #9 was asked if she ever wears a smoking apron and she stated, The aprons are just worn out and we don't have enough. Today when staff brought another resident out they pulled off the apron I had on and gave it to him. During an observation and interview on 11/3/2022 at 8:50 AM, LPN (Licensed Practical Nurse) #6 confirmed the Secured Unit has one smoking apron that has a tear in it. LPN #6 stated, We do the best we can. Observation and interview on 11/3/2022 at 8:57 AM, the Administrator stated, The smoking aprons should be hanging on the wall as you go out to the patio where residents smoke or in the cabinets in the Sun Room. Continued observation and interview in the Sun Room as you walk out to the patio, the Administrator confirmed no smoking aprons were hanging on the wall or in the cabinets. The Administrator stated, I ordered 6 yesterday. I promise the aprons are usually hanging here on the wall. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance, Other Symptoms and Signs involving Cognitive Functions and Awareness, and Disorientation. Review of the undated care plan history for Resident #6 revealed assessment/focus for short attention span evidenced by wandering in and out of activities initiated on 3/3/2022 and revised for elopement risk on 11/1/2022 after surveyor request for documentation on 10/31/2022. Review of Resident #6's Clinical Health Status Evaluation dated 10/7/2022 (readmitted ) revealed she was at risk for elopement. Continued review revealed question #5 related to history of elopement was answered yes, which prompted to implement care plan and care plan was not updated to reflect risk for elopement. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and Wandering. Review of the undated care plan history for Resident #7 revealed a focus for fall risk related to medication, impaired cognition and wanders initiated 9/28/2022. Continued review revealed a focus for risk of elopement related to wandering initiated 11/1/2022, after surveyor request for documentation on 10/31/2022. Review of Resident #7's Elopement Risk Evaluation dated 8/23/2022 revealed she was at risk for elopement. Continued review revealed question #5 related to history of elopement was answered yes, which prompted to implement care plan and care plan was not updated to reflect risk for elopement. Observation and interview on 11/1/2022 at 5:03 PM and 5:52 PM, revealed the DNS (Director of Nursing Services) confirmed the QAPI plan of action included review of the care plans for those at risk for elopement to ensure facility compliance. She confirmed any time there was a positive risk assessment she expected the care plan to be updated to reflect the outcome of the assessment. Observation and interview with the MDS (Minimum Data Set) Coordinators and the ADON (Assistant Director of Nursing) on 11/2/2022 at 4:55 PM, revealed MDS Coordinator #1 reviewed Resident #5's care plan and confirmed there was no care plan for elopement prior to 11/1/2022. She confirmed there had been a care plan for elopement due to anger at placement that had been resolved on 10/10/2022. MDS Coordinator #1 confirmed Resident #6 and Resident #7 did not have a care plan for elopement prior to 11/1/2022. During a telephone interview on 11/2/2022 at 9:16 AM, RN (Registered Nurse) #1 confirmed interventions for resident's at risk for elopement would be reflected in their care plan. During an interview on 11/2/2022 at 4:45 PM, the ADON confirmed she had changed Resident #5's care plan on 11/1/2022 from risk due to anger on placement to wandering because she did not display anger at placement anymore. She stated she did not know why the care plan indicated the change was a revision rather than initiation. She confirmed she had added elopement due to dementia to Resident #6 and Resident #7 because anyone on the Secured Unit should have a care plan for elopement. She stated the MDS Coordinator updated the care plans when a risk was identified. Review of the resident's care plans revealed they were not updated until the surveyor requested a copy of the care plan. The surveyors verified acceptable Immediate Action Removal Plan on 11/3/2022 at 11:15 PM by: 1. On 11/3/2022 the ADON and Director of Clinical Operations (DCO) reviewed the Care Plans for Residents #6, and #7 to assure accuracy. 2. On 11/3/2022 ADON and DCO reviewed all care plans to ensure all were updated and current for elopement risk and proper interventions were put into place. 3. All new admissions, readmissions and any resident who has had a change in condition will be audited to ensure the Interdisciplinary Team (IDT) or a member of the team reviews the elopement risk assessment for accuracy, care plan development if an elopement risk is identified and that proper interventions have been put in place for safety. During clinical start-up meeting, the IDT will review progress notes and clinical alerts to monitor for any condition changes that would require a new elopement risk assessment. The Administrator, Director of Clinical Operations, Regional [NAME] President or another member of the Support Center will review weekly to ensure compliance. 4. Any issues noted will be corrected immediately and reported to the Administrator and the QAPI committee. QAPI meetings will be held weekly and as needed until the jeopardy is cleared. 5. All smoking assessments were updated for all residents who smoke by DNS and ADON on 11/3/2022. Also care plans and Kardex were updated by the members of the nursing management team on 11/3/2022. 6. Monitoring: all new admit, readmits or change in status will have IDT review of their smoking risk assessment to determine accuracy, supervision status and additional safety intervention. A member from the IDT will confirm the care plan/Kardex/education for any tobacco users. 44724

This REQUIREMENT is not met as evidenced by: Based on medical record review and interview, the facility failed to notify the Physician when Resident #68 incurred substantial injury related to a fall, had a decline in status, and needed treatment alterations regarding a [MEDICATION NAME] Lumbar Spinal Orthopedic (TLSO) brace. Failure for the facility to notify the Physician on 11/1/17 resulted in Resident #68 developing an axillae pressure ulcer while experiencing pain from the TLSO brace (HARM). The findings included: Medical record review revealed Resident #68 sustained an initial fall on 8/6/17 at 11:01 AM which was unwitnessed with no injury reported and no interventions added to the Care Plan. Further review of the medical record revealed Resident #68 incurred a second fall on 10/31/17 at 2:50 PM which was unwitnessed with injury. Resident #68 was sent out to the Emergency Department and transferred to a Level II hospital equipped to care for such injury. Further review of the medical record revealed the Attending Physician was not notified of Resident #68's injury which was: multiple acute fractures of the T1, T2, T12, L1, and fractures of the right anterior fourth through the seventh ribs near the costochondral junction. Medical record review revealed Resident #68 incurred a substantial decline in physical and mental status as discussed during the Care Plan meeting on 11/13/17 with Resident's family present. Further review of the medical record revealed a timeframe of 14 days passing before Physician intervention when the TLSO was discontinued along with other additional orders. Interview with the Wound Care Nurse on 12/20/17 at 7:55 AM in the 200 Hall Nurses Station revealed .It was the brace that caused his wound, it was not properly fitting and rubbed him . Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .Resident #68 is scheduled to have weekly skin assessments . Further interview with LPN #3 confirmed the facility failed to follow the care plan to complete weekly skin assessments. A total of 26 skin assessments were missed during 11/1/17 through 11/14/17 when pressure ulcer under armpit was found. Interview with the Director of Nursing (DON) on 12/20/17 at 4:30 PM in her office confirmed, Resident #68 was sent to the hospital after the fall dated 10/31/17 and returned on 11/1/17 with a [DIAGNOSES REDACTED]. Resident #68 returned on 11/1/17 with a [MEDICATION NAME] Lumbar Spinal Brace in place. Interview with the DON on 12/20/17 at 4:30 PM revealed Resident #68 .came back with the brace on . Further interview confirmed .we were trying to get his orders clarified . When asked what is a reasonable time period to get Physicians orders clarified the DON responded, .as quick as possible . The DON confirmed the facility failed to adequately notify the Physician and obtain instructions for the [MEDICATION NAME] Lumbar Spinal Orthopedic brace and continued use of the brace which resulted in a pressure ulcer to Resident #68 (HARM).

Based on medical record review, observation, and interview, the facility failed to provide skin assessments for Resident (#68). Resulting in development of skin pressure ulceration to the right axilla and arm resulting in (HARM). Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/12/17, revealed the problem of .altered integument (skin) .fragile and poorly perfused skin . with approaches including .weekly skin assessment to be performed/documented by nursing . Further review of the Care Plan revealed Resident #68 was readmitted on [DATE] with intact, but fragile and poorly perfused skin. Medical record review revealed the last skin assessment documented was 9/27/17. Further review revealed 26 missed skin assessments between 11/1/17 through 11/14/17. Resident #68 observed lying in bed on 12/20/17 at 10:01AM in his room, with with a dressing intact to the right axilla area (armpit) and upper inner arm. Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .Resident #68 is scheduled to have weekly skin assessments . Further interview with LPN #3 confirmed the facility failed to follow the care plan to complete weekly skin assessments.

Based on medical record review, observation, and interview, the facility failed to provide timely treatment after a fall for 1 resident (#2), a fall resulting in [MEDICATION NAME] and Lumbar fractures for 1 resident (#68) and failed to utilize interventions to achieve maximum function of a [DIAGNOSES REDACTED] limb for 1 resident (#74) of 16 residents reviewed. The facility's failure to prevent falls resulted in HARM for Resident #2 and #68. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge with return anticipated Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had severe cognitive impairment with short term memory problems and required extensive assistance with bed mobility, transfers, Activities of Daily Living, eating, toileting and was always incontinent of bowel and bladder. Medical record review of a Facility Investigative report dated 8/30/17 for Resident #2 revealed .Resident leaning over in her chair and rolled out of chair into the floor, did not hit her head .Assisted resident out of the floor, vital signs obtained, total body assessment, doctor notified . Medical record review of General Notes dated 8/30/17 revealed .Resident sitting in day room this morning at 10:18 AM and was leaned over into her lap with her eyes closed. Nurse observed resident slide into the floor and not hit her head. Resident assessed and no injuries found. Denies pain . Medical record review of General Notes dated 8/31/17 revealed .Staff observed resident noted to have bruise on right hip, reddened area on right knee, and scratch to right upper thigh. Resident had a fall yesterday and did land on right side of her body when she fell . Staff reported that resident was grimacing holding her right hip and that when she transferred that she appeared to have more pain when using right leg. Nurse practitioner notified with no new orders received .Resident will continue to be monitored due to fall yesterday . Medical record review of General Notes dated 9/1/17 revealed .Signs of pain with transfers and bed mobility .Resident using wheelchair instead of walking since fall . Medical record review of General Notes dated 9/4/17 revealed .Resident with a new order .X-ray to right knee and right hip 2 views due to pain . Resident radiology report received showing results of fracture involving the right femoral neck with modest displacement .Nurse practitioner notified and ordered her to be sent out to emergency room for further evaluation . Medical record review of a Radiology Data entered on 9/5/17 revealed .Acute transcervical fracture through the right femoral neck with mild superior migration and varus deformity of the distal fracture fragment. No dislocation . Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/26/17 revealed no new intervention for the fall dated 8/6/17. Medical record review of a Facility Investigative Report dated 8/6/17 at 11:01 AM revealed, .resident stated he was trying to move from the bed to floor . Resident had a non-witnessed fall with complaint of hip pain. Further review of the Facility Investigative Report revealed the facility failed to complete a post fall investigation after the fall as evidenced by multiple sections left blank. Medical review of the MDS dated [DATE] revealed Resident #68 had a Brief Mental Interview for Status score of 0, indicating severe cognitive impairment. Medical record review of Facility Investigative Report dated 10/31/17 2:50 PM revealed .Resident observed lying on floor on his stomach in front of his bed. Resident stated he was trying to get in his bed and fell . Continued review revealed Resident #68 was sent to the Emergency Department and was diagnosed with [REDACTED].fractures of the T1, T2, T12, ([MEDICATION NAME] fractures of the mid spine, at levels 1, 2, and 12) and fracture at L1, (Lumbar [MEDICAL CONDITION] back) fractures of the right anterior fourth through the seventh ribs near the costochondral junction (near the sternum) .which correlating clinically for point tenderness . Interview with the DON (Director of Nursing) on 12/20/17 at 4:30PM in her office confirmed, Resident #68 was sent to the hospital after the fall dated 10/31/17 and returned on 11/1/17 with a [DIAGNOSES REDACTED]. Resident #68 returned on 11/1/17 with a [MEDICATION NAME] Lumbar Spinal Brace in place. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #74 was severely impaired cognitively. Continued review of the MDS revealed Resident #74 was dependent on 1 person for transfers and bathing; required extensive assistance of 1 person for dressing, grooming, and eating; had impairment of 1 upper extremity and both lower extremities for range of motion. Further review revealed Resident #74 was always incontinent of bowel and had an indwelling catheter. Medical record review of physician's orders [REDACTED].Put on left elbow splint and left hand splint at beginning of 7-3 (7 AM - 3 PM) shift. Take off left elbow splint and left hand splint at end of shift 7-3 (7 AM - 3 PM). Wear time no more than 8 hours . Observation on 12/18/17 at 9:15 AM revealed Resident #74 was lying in bed. Observation of the resident's left arm revealed no splint in place on the hand or elbow. Observation on 12/19/17 at 10:00 AM revealed Resident #74 lying in bed with no splint on the left hand or left elbow. Interview with Licensed Practical Nurse #2 on 12/19/17 at 10:07 AM at the 200 Hall Nurse's Station confirmed Resident #74 was ordered to have a left hand and elbow splint on during the 7:00 AM - 3:00 PM shift and the facility failed to apply the splint as ordered.

Based on facility policy review, medical record review, and interview, the facility failed to prevent a pressure ulcer for 1 resident (#68) of 7 residents reviewed. The facility's failure to prevent a pressure ulcer for Resident #68 resulted in HARM. The findings included: Review of facility policy, Skin Care Guideline, dated 6/2017 revealed .the plan of care will address problems, goals and interventions directed toward prevention of pressure ulcers in those at risk and for any skin integrity concerns identified . Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/12/17, revealed the problem of .altered integument (skin) .fragile and poorly perfused skin . with approaches including .weekly skin assessment to be performed/documented by nursing . Further review of the Care Plan revealed Resident #68 was readmitted on [DATE] with intact, but fragile and poorly perfused skin. Care Plan updated on 11/1/17 revealed .readmit 11/1/17 resident at risk for altered integument due to impaired mobility, altered judgment, altered perfusion, incontinence, as well as natural age-related physiological changes. This is evident by need for staff to provide peri-care/hygiene and extensive assist with bed mobility and transfers. Weekly skin assessment to be performed/documented by Nursing . Medical review of the Minimum (MDS) data set [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Observation of Resident #68 on 12/20/17 at 10:00AM in his room revealed the resident lying in bed with a dressing intact to the right axilla area (armpit) and upper inner arm. Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .Resident #68 is scheduled to have weekly skin assessments . Further interview with LPN #3 confirmed the facility failed to follow the care plan to complete weekly skin assessments. A total of 26 skin assessments were missed during 11/1/17 through 11/14/17 when pressure ulcer under armpit was found. Medical record review of a Facility Investigative Report dated 10/31/17 at 2:50 PM revealed .Resident observed lying on floor on his stomach in front of his bed. Resident stated he was trying to get in his bed and fell . Continued review revealed Resident #68 was sent to the Emergency Department and returned on 11/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident returned with a [MEDICATION NAME] Lumbar Spinal Orthopedic (TLSO) brace. Medical record review revealed Physicians Orders with no instructions for the TLSO brace. Continued review revealed .Occupational Evaluation and Plan of Treatment dated 11/3/17 [MEDICATION NAME] Lumbar Spinal brace . Medical record review revealed a Nursing Note dated 11/5/17 at 7:00 AM .[MEDICATION NAME] brace and right hand brace intact . Continued review revealed a Nurse's note dated 11/9/17 at 4:59 AM .No episodes of trying to .remove brace . Continued review revealed a Nurse's note dated 11/10/17 at 3:18 AM .no episodes of trying to crawl out of bed or attempts to remove brace . Further review of a Nurse's note dated 11/11/17 at 4:18 AM revealed .[MEDICATION NAME] brace and right hand (brace) removed reapplied . Further review revealed a Nursing Note dated 11/14/17 at 4:25 AM revealed .Resident heard calling for help at 11:45 PM. Resident has removed his [MEDICATION NAME] brace . Medical record review of the Dietary Note dated 11/14/17 at 11:32 AM revealed .follow up new wound areas per Wound Treatment Nurse . Medical record review of the Departmental Notes dated 11/14/17 at 2:52PM .Pressure Ulcer/Right Upper Quadrant .Therapist reported that patient had skin breakdown underneath brace. Up on assessment patient was noted to have 2 areas on right lateral chest wall under armpit. Smaller area measures 2.0 cm x 2.8 cm x 0.25cm. Noted to have bluish green drainage with foul odor noted. Center tissue with necrotic black tissue with whiteish gray slough at outer edges of wound . Medical record review of the Care Plan Conference Summary dated 11/15/17 revealed .Nursing spoke about the possibility of hospice from the last care plan. Nursing reports that Resident is declining. Nursing discussed the wounds from the brace (back brace) Resident is taking the brace off himself, son reports to take brace off Resident and leave him in bed . Interview with the Wound Care Nurse on 12/20/17 at 7:55 AM in the 200 Hall Nurses Station revealed .It was the brace that caused his wound, it was not properly fitting and rubbed him . Interview with Physical Therapy Assistant and Speech Language Pathologist (SLP) on 12/20/17 at 10:19 AM in the dining room revealed, .we were treating him after he returned from the Emergency Department and we were trying to get clarification about his brace SLP stated when she observed him it was usually early in the morning and she would get assistance from another staff member to positions him in the bed. Further interview revealed on 11/2/17, SLP observed Resident #68 wearing the brace while in bed. Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .He came back from the hospital with the brace on and on bed rest, he had a big decline after the last fall . Further interview revealed Resident #68 is scheduled to have weekly skin assessments. LPN #3 confirmed the last documented skin assessment was on 9/27/17. Interview with the Director of Nursing (DON) on 12/20/17 at 4:30 PM revealed Resident #68 .came back with the brace on . Further interview confirmed .we were trying to get his orders clarified . When asked what is a reasonable time period to get Physicians orders clarified the DON responded, .as quick as possible . The DON confirmed the facility failed to obtain clear orders with instructions for the [MEDICATION NAME] Lumbar Spinal Orthopedic brace and continued use of the brace resulted in pressure ulcer and HARM to Resident #68.

Based on medical record review, observation, and interview, the facility failed to update the Care Plan with interventions for Resident #68 after first fall on 8/6/17, which resulted in a second fall on 10/31/17 with multiple fractures. The failure to develop interventions to prevent falls for Resident #68 resulted in HARM from a fall. Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Minimum (MDS) data set [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Medical record review of a Facility Investigative Report dated 10/31/17 at 2:50 PM revealed .Resident observed lying on floor on his stomach in front of his bed. Resident stated he was trying to get in his bed and fell . Continued review revealed Resident #68 was sent to the Emergency Department and returned on 11/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident returned with a [MEDICATION NAME] Lumbar Spinal Orthopedic (TLSO) brace. Observation of Resident #68 on 12/20/17 at 10:00AM in his room revealed the resident lying in bed with a dressing intact to the right axilla area (armpit) and upper inner arm. Interview with the Director of Nursing (DON) on 12/20/17 at 4:30 PM confirmed Resident #68 fell on [DATE] and went to the hospital. This was the second documented fall for Resident #68. Failure of the facility to update the Care Plan with additional interventions after first fall on 8/6/17 resulted in HARM when Resident #68 fell again on 10/31/17.

Based on medical record review, observation, and interview, the facility failed to provide a safe transfer with a mechanical lift resulting in a fracture (Harm) for one resident (#1) and failed to provide a safe transfer in a sit to stand lift for one resident (#9) of four residents reviewed for accidents. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for daily decision making, required extensive assistance of two for bed mobility, and required total assistance of two for transfers. Medical record review of the Care Plan dated November 2013 revealed total mechanical lift to be used for all transfers and encourage resident to communicate presence of pain. Medical record review of the Certified Nurse Aid (CNA) Care Card no date revealed "...Mechanical lift with 2 assist...total x (times) 2 lift...turn and reposition every two hours with two assist..." Medical record review of a Nurse's Note dated January 27, 2014, at 3:45 p.m., revealed "...reported by the technician that resident had her knee bumped during transfer from her wheelchair to...bed using the total lift (January 26, 2014, at 1:30 p.m.)...examination right knee was swollen and painful to touch...reported to NP (Nurse Practitioner)...femur fracture..." Medical record review of a Radiology Report dated January 27, 2014, revealed " ...Conclusion: Acute spiral right knee fracture..." Medical record review of a NP Progress Note dated January 27, 2014, revealed "...being seen today per Nursing Request for Right Knee pain...being assisted back to bed yesterday (Sunday 1/26/14) in a lift and while moving in to bed Patient's right knee struck a support bar on the lift...complains to Provider today...right knee is painful...x-ray of right knee was ordered this AM immediately after evaluation by NP...Distal femur fracture...sent to ER (emergency department)...Impression: blunt force trauma to knee yesterday...NP notified of findings and incident this AM when arrived at facility..." Medical record review of an Incident Investigation dated January 27, 2014, at 12:44 p.m., revealed "...January 26, 2014, at 1:30 p.m., reported by the technician that resident had...knee bumped during transfer from...wheelchair to...bed using the total lift...Resident complained of pain and upon examination right knee was swollen and painful to touch...new orders received for an x-ray to...right knee...results showed right femur fracture...sent to Emergency Department for evaluation and treatment...upon further investigation the CNA (Certified Nurse Assistant) that had the resident...states the resident's right knee bumped the lift at that time the resident said...ouch...pushed on the right foot and leg to get leg around the lift this appeared to cause a twisting motion...finished up by laying the resident into bed...went to the charge nurse..." Medical record review of the resident's chart revealed no documentation of an assessment or of the accident with the mechanical lift. Medical record of a Consultation Report dated January 27, 2014, revealed "...Chief Complaint: Right femur fracture...apparently being moved in the Hoyer Lift yesterday when...foot or leg struck a solid object..." Review of a witness statement by CNA #4 dated January 27, 2014, revealed "...yesterday when I used the total lift...I was laying (resident)...back on the bed...leg hit the bar of the total and I tried to reposition leg in the right position...hollered in pain...then told the nurse...examined...leg ...I asked...if we should write an accident report...said no..." Review of a witness statement by Registered Nurse (RN) #1 dated January 27, 2014, revealed "...CNA notified me that...(resident)...had a bump on sit to stand lift to...right knee...no swelling bruise redness noted...did not say...having pain when I was in the room..." Review of a witness statement by CNA #5 dated January 27, 2014, revealed "...When I was giving...personal care...yelled the whole time...when I was finished told the nurse...knee was hurting...I never saw...go in the room..." Review of an Employee Issue dated January 27, 2014, at 3:26 p.m., revealed "...This morning a day shift CNA told the LPN (Licensed Practical Nurse) charge nurse that she accidentally hit one of the resident's legs with a lift yesterday...The CNA reportedly asked the RN (on duty at the time of the accident) if they should do an incident report. The RN told...there was no need to do an incident report because the resident was not hurting...(RN) failed to report this incident to anyone...nothing on the 24 hour report and did not report anything in the resident's chart..." Observation on March 12, 2014,at 9:30 a.m., revealed two staff members assisted the resident out of the bed with the total lift. Interview with RN #1 on March 12, 2014, at 4:15 p.m., by telephone, revealed the CNA reported the accident, the RN assessed the resident including Range of Motion with no acute findings, and had failed to document the accident or the assessment in the medical record. Continued interview revealed the RN failed to report the incident to the family, Physician, and/or the next shift. Interview with CNA #4 on March 13, 2014, at 9:06 a.m., by telephone, revealed the CNA reported the accident to the RN when the accident occurred. The RN went to the room and rubbed the resident's leg and gave the resident a pain pill. "I ask about filling out an incident report and the RN said no." Continued interview revealed the CNA had not reported the accident to the oncoming staff or documented the accident in the communication book. Further interview revealed the CNA worked the following day and reported the accident to the LPN on duty January 27, 2014. Interview with the NP on March 13, 2014, at 3:00 p.m., in the Conference Room, revealed "...on a Monday morning a CNA requested I examine a resident. The CNA explained the accident on January 26, 2014, (Sunday). I immediately examined the resident and found the right leg red swollen and hard to touch. When I touched the resident's leg the resident yelled with pain. In my opinion the RN could not have performed Range of Motion to the right leg. The resident would have complained of pain anytime the leg was moved." Interview with the Director of Nursing (DON) on March 13, 2014, at 3:40 p.m., in the Conference Room, confirmed the DON would expect the RN to document an assessment, complete an Incident Report, and notify the family and Physician. Continued interview revealed the resident had not received medical attention for the accident from January 26, 2014, at 1:30 p.m. until January 27, 2014, (over sixteen hours). Further interview confirmed the resident sustained [REDACTED]. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE], revealed the resident was cognitively intact, required extensive assistance of one for transfers. Medical record review of a Care Plan dated January 16, 2014, revealed assistance with transfers by sit to stand lift. Review of a facility investigation dated February 14, 2014, revealed resident #9 was being assisted from the commode to the chair by the sit to stand lift and the CNA had failed to properly attach the harness to the EZ stand. The resident fell striking the base of the lift. Medical record review of a NP Note dated February 21, 2014, revealed "...seen today per Nursing for pelvic pain and contusion to groin and buttocks...patient struck here in a fall that occurred one week ago...pain has gradually gotten worse...the ecchymotic (bruising) area has gradually spread from...vagina to buttocks...Pelvic x-ray ordered and obtained today is negative...contusion of perineum..." Interview with the DON on March 13, 2014, at 3:40 p.m., in the Conference Room confirmed the facility had failed to provide a safe transfer in the sit to stand lift for the resident. C/O #

Based on review of the Plan of Correction, observation, medical record review, review of the Lift Transfer Assessments, review of the Certified Nurse Aide Care Card, interview, and review of the facility fall report, the facility failed to implement the facility's plan of correction to prevent accidents by correctly assessing and identifying mechanical lift requirements for one resident (#7) of thirty-six residents assessed for use of lifts. The findings included: Review of the Plan of Correction with a completion date of June 2, 2014, revealed, "...The lift status of each resident was reassessed by the Restorative Nurse...facility staff..re-educated on how to interpret the sticker located on the resident's nameplate associated with the resident's lift status..." Observation on June 23, 2014, at 9:00 a.m., and interview with Licensed Practical Nurse (LPN) #1 confirmed the stickers on the residents' nameplates indicated the type of lift the resident required. Further interview revealed the "T" indicated a Total Lift was required and the "SS" indicated a Sit-To-Stand lift was required. Observation on June 23, 2014, at 9:21 a.m., with LPN #1 present, revealed the sticker on the nameplate of resident #7 revealed "SS" for Sit-To-Stand lift. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Lift Transfer assessment dated [DATE], revealed resident #7 required a Total Lift with assistance of two staff. Review of the CNA (Certified Nurse Aide) Care Card on the interior of resident #7's closet door revealed "SS with 1 assist" was required. Interview with LPN #2/Restorative Nurse on June 23, 2014, at 11:30 a.m., outside the room of resident #7, confirmed the sticker indicated a Sit-To-Stand lift. Further interview confirmed the Lift Transfer assessment dated [DATE], indicated a Total lift was required and the sticker was "wrong". Further interview revealed LPN #2 "...was responsible to do (lift) assessments at admission and any change identified by nursing and responsible to update the stickers..." Further interview revealed, "...staff probably used wrong lift for (resident #7)..." Interview with LPN #3 on June 23, 2014, at 11:42 a.m., outside the room of resident #7, revealed LPN #3 was responsible for the care of resident #7. Further interview revealed LPN #3 would use a Sit-To-Stand lift for resident #7 based on the sticker on the resident's nameplate. Interview with CNA #1 on June 23, 2014, at 11:44 a.m., outside the room of resident #7, revealed CNA #1 was responsible for the care of resident #7. Further interview revealed CNA #1 would use a Sit-To-Stand lift for resident #7 based on the sticker on the resident's nameplate. Review of the facility falls report, and interview with the Interim Director of Nursing, on June 23, 2014, at 1:25 p.m., confirmed resident #7 had not experienced a fall since the May 30, 2014, lift assessment. Telephone interview with CNA #2, on June 23, 2014, at 3:35 p.m., confirmed CNA #2 had been responsible for resident #7 on June 21 and 22, 2014, during the 11:00 p.m.-7:00 a.m. shift. Further interview confirmed CNA #2 had used the Sit-To-Stand lift to transfer the resident based on the sticker on the resident's nameplate.

Based on medical record review, review of the facility investigation and interview, the facility failed to use an appropriate lift during transfer resulting in a fall for one (#5) of eleven residents reviewed. The findings included: Resident #5 was admitted to the facility from the hospital on March 7, 2013, with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long-term memory problems with moderately impaired decision-making skills; was dependent on staff for all activities of daily living, rejected care; and had no falls. Medical record review of a physical therapy discharge summary dated December 30, 2013, revealed, "...Recommendations include remaining on total lift due to unsafe technique on sit to stand (lift)..." Medical record review of the care plan updated February 27, 2014, revealed, "...at risk for falls related to Dementia...Assist with transfers via TL (Total Lift)..." Medical record review of a nurse's note dated May 1, 2014, at 1:56 p.m., revealed, "...was getting up into...wheelchair with assist of one CNA (Certified Nursing Assistant) at 10:00 (a.m.) and sit to stand lift and lost...grip on stand and started lowering (self) to the floor. Four staff member lowered resident to the floor and used total lift to transfer resident back to bed. No injury noted..." Review of the facility's investigation by Licensed Practical Nurse (LPN) #1/Risk Manager dated May 1, 2014, revealed, "...Resident has a lift status of total lift...Nursing staff reeducated on lift policy and correct use of lift..." Interview with the Director of Nursing on May 19, 2014, at 2:25 p.m., in the training room revealed the CNA was non longer employed by the facility. Continued interview confirmed the resident required a total lift for transfer, and the CNA attempted to transfer the resident on May 1, 2014, with a sit-to-stand lift resulting in an assisted fall. Interview with LPN #1/Risk Manager on May 19, 2014, at 2:35 p.m., in the training room confirmed the CNA had knowledge the resident required a total lift for transfer and confirmed the CNA attempted to transfer the resident using a sit-to-stand lift.