Every finding on record at Southeast Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving misappropriation of resident property are reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures, for 1 of 4 residents (Resident #1) reviewed for misappropriation. The facility failed to ensure Resident #1's allegation of misappropriation related to missing money was reported to the SSA. This failure could lead to misappropriation or lack of oversight of residents. Findings included: Record review of Resident #1's admission Record, dated 7/31/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included legal blindness, as defined in USA. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Section B1000 of the MDS reflected Resident #1's vision was moderately impaired. Record review of the facility document titled Grievance/ Complaint Report, dated 7/10/2026, reflected the following documentation written by the LSW: Resident stated he had $450 from his [family member] selling his cart. He had nurse [sic] to count money on 7/9/26 which amounted to $180-182. He had this SW count money in wallet which was $240 ( (1) 100 (6) 20 (2) 10). Resident stated the only money spent was $10 for hangers. Resident stated he will check with dialysis today if money is there. In an observation and interview on 7/31/2026 at 11:26 AM, Resident #1 was observed attempting to count his money and to open a small lockbox in his bedside table. He said the facility had provided the lockbox after he reported that $200 cash had gone missing from his room. He said he had $400 in cash and discovered several days later that he only had $200 after he asked an unknown staff member at the facility to assist with counting the money because he was unable to see the numbers on the bills. He said the staff member counted $200, and he was unsure where the other $200 went. He said the money must have been taken by somebody because he had not spent it, but he was unsure if the money was taken at the facility or at the dialysis [artificial blood filtering] clinic he visits three times a week. He said he notified the staff at the dialysis clinic of the missing money, and he told the social worker at the facility that the money was missing, and she assisted him with obtaining the lockbox. He said he required physical assistance with managing his money because of his vision impairment, and the vision impairment was also the reason why he was unsure who took his money. In an interview with the LSW on 7/31/2026 at 1:19 PM, she said Resident #1 informed her that he thought someone had taken $200 from him, and she wrote the incident as a formal grievance, notified the ADM, and assisted Resident #1 with obtaining a lockbox to store his valuables in. She said she did not participate in the investigation of the missing money, and she was unsure if the incident had been reported to the SSA. In an interview with the ADM on 7/31/2026 at 1:58 PM, she said she performed an investigation of Resident #1's missing money after she was made aware of the incident and the grievance. She said she assisted Resident #1 with obtaining a lockbox for his valuables, and she instructed him not to count his money in front of facility staff because it could lead to theft. She said she didn't recall Resident #1 saying directly that he felt the money had been stolen, but she had new cameras installed at the facility as a result of the incident. She said the missing money was not reported to the SSA because it was unclear if someone had stolen the money or if it was misplaced. She said she was not told by the LSW that Resident #1 had alleged the money was stolen, and that knowledge may have influenced her decision to report the incident to the SSA. Record review of the facility policy titled Abuse, Neglect and Exploitation dated 10/24/2022 reflected the following: IV. Identification of Abuse, Neglect, and Exploitation . B. Possible indicators of abuse include, but are not limited to: . 4. Resident reports of theft of property, or missing property . A. The facility reports abuse and abuse allegations that include: 1.Reporting allegations involving . misappropriation of resident property .

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 14 residents (R #57) reviewed for accident hazards and supervision. The facility failed to monitor R #57 while he was on the secure unit patio. R #57 eloped from the facility between 6:45 p.m. to 7:10 p.m. on 3/29/26 and was found approximately ninety-six feet away from the facility near a busy two-lane road. This failure resulted in the identification of an IJ (Immediate Jeopardy) on 4/2/26 at 5:00 p.m. While the immediacy was removed on 4/3/26 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to install an extension of the patio fence, complete training of PRN staff, hire an activity assistant for the secure unit, and monitor the implementation and effectiveness of its Plan of Removal. This failure could lead to residents experiencing serious injury, serious harm, serious impairment to include death.Findings include: Record review of R #57's face sheet, dated 4/1/26, revealed the resident was admitted [DATE] and was a male; age [AGE]. The RP was listed as a family member. His diagnoses included: dementia (a decline in mental ability), wandering, alcohol abuse, heart failure, and history of falling. Record review of R #57's quarterly MDS dated [DATE], reflected the resident's BIMS score was 03, indicative of severe cognition. The resident was independent in ambulation. Record review of R #57's Elopement/Wandering Risk Assessment, dated 9/6/25, reflected a risk score of 5 meaning At risk for elopement or unsafe wandering. Record review of R #57's nursing notes from 10/12-15/25 revealed R #57 was exit seeking. Record review of R #57's Nurse Note dated 10/12/25 authored by LVN C reflected the resident was seeking in the facility and needed re-direction. Record review of R #57's Nurse Note dated 10/15/25 authored by LVN D reflected the RP was notified resident was exit seeking and needed a room change [placement in the secure unit]. Record review of R #57's physician's orders revealed order dated 10/20/25 for, Resident to be transferred into memory unit; DX: Unspecified Dementia. Record review of R#57's CP, dated 11/6/26, revealed that he was a risk for elopement.secondary to dementia. An intervention listed in the CP was more frequent rounding on resident. Record review of R #57's Fall Risk Score, dated 3/5/26, reflected a rating of zero indicative of no fall risk. Record review of the Facility's Provider Report dated 3/30/26 reflected the timeline was: on 3/29/26 between 6:45 p.m. and 7:10 p.m. [gap of 25 minutes], R #57 eloped by climbing over the secure unit's patio fence (6 feet high) and was discovered off the facility's grounds at 7:10 p.m. by LVN A. The report reflected the resident using a chair next to the fence to jump the fence and eloped. The report reflected that LVN B gave R #57 access at 6:45 p.m. to the patio and lost visible contact with the resident because she was distracted by R #42 at the nurse station. Record review of R #57's Nurse Note dated 3/29/26 at 7:30 p.m. authored by the DON revealed, Resident was found outside the facility walking on the sidewalk by outgoing nurse [LVN A] . Observation and interview on 4/1/2026 at 4:45 p.m., of the path R #57 took on 3/29/26 revealed: the nurse station was not in direct eye contact with the secure unit patio instead line of sight was through the window adjacent to the nurse station. The window shade was closed at the nurse station. Also, observation revealed a chair in the patio area. Entrance to the patio required entering a code in the keypad. The Regional Nurse stated the resident used a chair to lean against a 6-foot fence and climbed over. The Regional Nurse stated the keypad was triggered by LVN B. Observation with the DON revealed the resident crossed the facility's boundary of 50 feet and headed east for about another 96 feet outside the boundary of the facility with a busy two-lane road nearby. Further observation revealed the speed limit was 30 miles per hour, it was a business environment, and the temperature on 3/29/26 ranged from a low of 57 degrees Fahrenheit to a high of 84 degrees Fahrenheit. The DON stated the resident was heading back to the facility and found by LVN A. Observation and interview on 4/2/26 at 10:03 a.m., revealed R #57 was in bed, alert and oriented to self and place, with no skin tears, bruises or injuries present. The resident was ambulatory. The resident stated he did not remember eloping from the facility on 3/29/26. The resident nodded no to the question of any staff being present with him on the patio. During an observation and interview on 4/2/26 at 10:17 a.m., revealed R #42 was in his room, ambulatory, alert and oriented to self and place. The resident stated he was present with R #57 on the day of the elopement but did not remember any details involving the elopement. R #42 added that he did not remember interacting with LVN B. R #42 remembered leaving the patio. R #42 stated that there was no staff present with him or R #57 at the patio. During an interview on 4/2/26 at 10:37 AM, LVN A stated she left the facility around 6:55 p.m. and when she was driving away from the facility, she saw resident #57 outside of the facility near a shopping center. She approached the resident around 7:10 p.m. She was not aware the resident had eloped. The resident stated to her he left and wanted a Coke. LVN A stated the resident was escorted back to the facility. LVN A stated the harm the resident could have experienced included being hit by a car. LVN A stated a preventive measure for avoiding an elopement was to maintain visibility of residents and their whereabouts. During telephone interview on 4/2/26 at 11:09 a.m., LVN B stated that R #57's elopement could have occurred anytime between 6:40 PM and 7:10 PM. LVN B stated she was not aware of R #57 having a diagnosis of being a wanderer when she left him unattended in the secure unit enclosed patio. LVN B stated there was no requirement for staff to be physically present when a resident was on the secure unit patio except for line of sight. LVN B stated she became aware that the resident was missing when he was brought back to the secure unit by LVN A around 7:10 p.m. LVN B stated if R #57 had not been found the resident could have had an accident, a fall, been hit by a car, or missing in the community. During an interview on 4/2/26 at 11:33 a.m., the DON stated that a nurse working in the secure unit should know what resident a diagnosis had of being wanderer or exit seeking, which was found on the face sheet and CP. The DON stated LVN B lost line of sight of the resident on the patio because R #42 blocked her vision for about 10 minutes. The DON stated the main preventative measure to mitigate an elopement was knowing the whereabout of residents. The DON stated R #57 was located by chance by LVN A. The DON stated hypothetically if R #57 had not been located, he could have suffered a car accident, a fall, or been a missing person in the community. During an interview on 4/2/26 at 12:01 p.m., the Administrator stated the failure involving the elopement could have been the nurse [LVN B] being distracted by another resident [R #42] and losing sight of R #57. The Administrator stated that any resident was at risk for wandering in the secure unit. The Administrator stated that if the resident (R #57) was not found there could have been a negative outcome. The Administrator stated R #57 had a purpose in eloping because he wanted to get a Coke. During an interview on 4/2/26 at 2:30 PM, CNA E who was on duty on the day of the elopement incident stated she left duty around 6:06 PM and had contact with R #57 but was not present during the elopement. CNA E stated the resident had the daily habit of wandering throughout the secure unit and exit seeking. CNA E stated the staff had to monitor the residents' movements to ensure the residents did not elope from the unit. During a telephone interview on 4/2/26 at 2:45 p.m., the RP stated she was informed of the elopement on 3/29/26. The RP stated family visited the resident on 4/1/26 and the resident (R #57) could not remember he eloped from the facility or any details about the elopement. The RP added that back in October 2025 the family made a request to put the resident in the secure unit because the resident wandered and wanted to leave the facility before he was placed in the secure unit. During interview on 4/2/26 at 3:00 p.m., the NP stated that the Medical Director's office was notified of the elopement on 3/29/26. The NP stated the facility needed to follow its elopement protocol. The NP did not have any additional details involving the elopement to share with the surveyor. Record review of the facility's Missing Resident Policy, dated revised 8/15/23, read: .The facility will: ensure residents that exhibit wandering behavior/or are at risk for elopement received adequate supervision to prevent accidents. Record review of the facility's Abuse and Neglect policy, dated 3/13/25, revealed: .purpose to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation. Neglect was defined as : The failure to provide goods or services, including medical services, necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Administrator was notified of the Immediate Jeopardy (IJ) on 4/2/26 at 5:00 p.m. On 4/2/26 at 8:13 p.m., the facility provided a plan of removal, and it was accepted on 4/3/26 at 5:25 p.m. It was documented as follows: F-Tag 689 Accidents & Hazards4/2/26 at 5:10pm Immediate Jeopardy called[Facility]Medical Director [.] was notified of the IJ on 4/2/26 at 5:10pm1. Affected ResidentsResident #57 (elopement resident)Immediate action taken for the resident found to have been affected includes:On Sunday 3/29/26 at 7:10pm the resident was escorted back on the unit by the charge nurse that just clocked out from her shiftOn Sunday 3/29/26 at 7:20pm the Charge Nurse immediately completed a physical assessment - no injury foundOn Sunday 3/29/26 at 7:45pm the Charge Nurse Notification to medical provider and familyOn Sunday 3/29/26 at 7:30pm a Behavior and Monitoring log was initiated with q15 min checks for 24h then q30min checks for 3 days, as well as q shift documentation post event: all to be completed by the charge nurse. Increased supervision to be completed 4/2/26 at 7:30pmOn Sunday 3/29/26 the charge nurse checked all door/gate locking mechanisms and alarms were validated to be in working functioning order. Patio secured and restricted completed at 7:40pmOn 3/29/26 at 8:30pm the Plan of Care was reviewed and updated immediately by the DON. The DON also provided validation of all appropriate interventions updated as needed as well as Kardex [form used my nursing staff to determine the assistance a resident required for activities of daily living]On 3/29/26 at 8:35 the DON conducted an assessment for need for emotional support and found the resident was without need at this time. The Social Worker on 3/31/26 at 3:35pm completed a follow-up assessment on emotional need and residents [R #57] were assessed to be at baseline with no change.Psych Services was notified 3/29/26 at 9:00pm and informed the resident was stable without a noted change in condition and the NP on 4/2/26 at 9:18am completed a reassessment of the resident and medication management review.The Charge Nurse that left the resident unsupervised in on secure unit patio was given disciplinary action and one on one education, and was removed from the schedule at this time 3/29/26 at 9:11pmOn 3/29/26 7:45pm the NP was notified with no new orders. 3/31/26 the NP completed an evaluation of resident - labs and a UA was ordered pending results [lab results were negative]100% Elopement Risk Assessments were completed on all residents by the ADON and DON completed 3/31/26 Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring.A full investigation was conducted with a root cause analysisAs a result of the investigation and root cause analysis the assigned Nurse was terminated. The assigned nurse had multiple prior trainings and education received on requirements of direct supervision of residents residing on the secured unit and/or at risk for elopement. As a result of not following these requirements and failing to provide adequate supervision to maintain safety of residents, action was taken to remove and terminate.The DON provided education for all staff on the topic of elopement, identification of the signs, prevention of elopement, behavior resolution and redirection, Secure Unit/residents at risk for elopement supervision requirements (direct supervision), and Neglect: Started 3/29/26 at 9:20pm with 91% completion; all remaining 9% are PRN staff and are not currently scheduled. All PRN staff have been directed to be in-serviced and educated prior to working a shift.The DON conducted a Missing Resident Drill on 3/30/26 with completed QAPI tool. The missing resident who participated in drill was found within 4 mins and 43 sec. Staff met all procedure requirements and were deemed competent.Maintenance staff reassessed the patio of safety risks and all door mag lock systems for proper working function on 3/30/26 at 8:30am. Starting on 3/30/26 Maintenance will randomly check door functioning and locking audit 3 times daily x 3 days and then weekly thereafter.The Elopement Binder was reviewed based on findings of risk assessment as needed. The center's elopement risk binders were reviewed and validated to be current and maintained with no changes needed. Completed by DON and ADON on 3/31/26Life Safety conducted a survey/audit/test of doors, alarms and locking mechanisms on 3/31/26 during the annual survey all in proper working function, no safety or hazards identified.A motion sensor was installed on the locked unit patio and set to alarm if motion is detected on, over, under, crossing, and near fence and gate. The alarm speaker was installed inside of locked unit and can be heard from all points of location on the unit as well as all other units. In addition to the sensor alarm, secondary alarms have been installed on gates and when triggered the same speaker will alarm. Ordered 3/30/26 Delivered and Completed 4/2/26The rod iron fence and gate on the unit patio will be extended in height by 19 inches. Materials have been ordered 3/30/26 pending delivery and installed 4/3/26. Once delivered installation will be completed immediately and or the same day. Completion Date scheduled for 4/3/26Additional Action Taken for Prevention of ReoccurrenceAll current residents will have an elopement risk assessment completed quarterly, with changes as needed, readmission, and annually.All newly admitted residents will be assessed for elopement risk upon admission with a person-centered care [NAME] newly added position has been added for an activities assistant whom will primarily service the unit's needs for additional activities and add additional supervision to the unit daily.A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. [the Quality Assurance meeting was scheduled after the survey's exit] Verification of PORKey Observations: Observation on 4/3/26 at 12:51 p.m., revealed R #57 was present in the secure unit. Observation on 4/3/26 at 1:21 p.m. of the secured unit's patio area revealed entrance to the patio required triggering of the keypad door; the motion detector sounded; and two patio doors were secured by chains and locks. Observation on 4/3/27 at 1:30 p.m. of the facility's 7 locking system and 15-second egress doors revealed all functioned. Observation and review on 4/3/26 at 1:35 p.m. of the facility revealed an Elopement Binder at the front door, central nurse station and the secure unit. The binders contained face sheets of residents at risk for elopement. For the secure unit the binder contained 14 residents. Observation on 4/3/26 at 2:25 PM, revealed the patio area had a motion alarm that worked; alarm speaker was present; and a keypad to the patio door. Key Interviews:During an interview on 4/3/26 at 1:16 p.m., the DON stated she checked all locking mechanisms, and they were secured both in the facility and the secure unit. During an interview on 4/3/26 at 2:00 p.m., the Maintenance Assistant Supervisor stated he checked the door lock systems three times per day and documented on the door lock and functioning audit log. During an interview on 4/3/26 at 2:24 p.m., the Receptionist stated she was familiar with the Elopement Binder and if a resident tried to elope, she would notify nursing staff. During an interview on 4/3/26 at 2:39 PM, the Administrator stated the next QAPI meeting was scheduled for 4/7/26. During interviews on 4/3/26 from 3:15 p.m. to 3:40 p.m. of two shifts 1 (7:00 a.m.-7:00 p.m.) and shift 2 (7:00 p.m. to 7:00 a.m. and same shift on weekends) 9 staff for shift 1 (2 Rehab, 3 LVNs, 2 CNAs, 1 Receptionist and 1 SW) , 3 staff Shift 2 (7:00 p.m.-7:00 a.m.) (2 CNAs and 1 LVN) and 4 weekend staff (1 MA, 1 kitchen staff, and 2 LVNs) revealed return demonstration on the topics of elopement, identification of the signs of elopement, prevention of elopement, behavior resolution and redirection, and supervision to include line of sight for residents in the secure unit. The staff also revealed return demonstrations on ANE to include knowing the signs and symptoms and reporting any ANE to the Abuse Coordinator (the Administrator). Key Record Reviews:Record review of the facility's Behavior Monitoring log dated 3/29/26 reflected q shifts were done for residents at risk for elopement. Record review of R #57's psych services note dated 3/29/26 at 9:00 pm authored by the NPMH revealed a full evaluation and the resident had no new mental health concerns and the medication review resulted in no new orders. Record review of LVN B's employee file reflected a disciplinary notice and termination notice dated 3/29/26. Last day at work was 3/29/26. Record review of 79 elopement risk assessments of residents revealed they were completed on 3/31/26. Record review of the 5-day Provider Investigation Report reflected there was a positive elopement due to a nurse [LVN B] not supervising R #57 and lost line of sight. Record review of the facility's in-service sign-in sheets for a total staffing of 57 reflected 100 % completion with training started 3/29/26 at 9:30 p.m. and ended 3/31/26 at 8:00 p.m. Record review of the facility's sign in sheet for elopement drill reflected day and night shift completed on 3/30/26. Record review of the maintenance log started on 3/30/26 at 8:30 a.m. and continuing reflected checking of all alarm doors (egress) were functioning. Record review of the facility's sign in sheet for elopement drill reflected the day and night shift completed on 3/30/26. Record review of the maintenance log started on 3/30/26 at 8:30 am and continued reflected all alarm doors (egress) were checked and functioning. Record review of an invoice dated 3/30/26 reflected an order for a motion sensor alarm and higher fence extension. Record review of the facility's admission sheet from 3/31/26 to present (4/3/26) reflected only one new admission [R #87] dated 3/31/25 and an elopement assessment was completed with a score of zero for elopement. Record review of the HR posting, undated, for a new activity assistant for the secure unit reflected the posting was present. Record review of facility's Missing Resident Drill on 3/30/26 with completed QAPI tool. Record revealed the missing resident who participated in drill was found within 4 mins and 43 sec. Drill noted that Staff met all procedure requirements and were deemed competent. The Immediate Jeopardy was removed on 4/3/26 at 5:25 p.m. While the immediacy was removed on 4/3/26 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to install an extension of the patio fence, complete training of PRN staff, hire an activity assistant for the secure unit and monitor the implementation and effectiveness of its Plan of Removal.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff, and visitors for two resident halls (B Hall and E Hall) and the Dining Room, in that: 1. The biohazard storage room located on resident B Hall was unlocked, accessible by residents, staff, or visitors, and contained biohazard material.2. The housekeeping closet on resident E Hall was unlocked, accessible by residents, staff, or visitors, and contained potentially hazardous chemical cleaning materials.3. The maintenance closet on resident E Hall was not fitted with a door that locked, was accessible by residents, staff, or visitors, and contained a hammer, power tools, and insect spray.4. A dietary storage closet in the Dining Room was unlocked, accessible by residents, staff, or visitors, and contained approximately 25 individual cans of portable food warming mechanisms which were each labeled, harmful or fatal if swallowed.5. The activities closet on B Hall was unlocked, was accessible by residents, staff, or visitors, and contained paint, nail polish, and a hot glue gun. These deficient practices could result in residents living within, staff working within, and the public visiting within an environment that is not safe, clean, and/or comfortable and potentially coming into contact with harmful materials. The findings were: 1. Observation on 03/31/2026 at 10:42 a.m. revealed the biohazard storage room located on resident B Hall was unlocked, accessible by residents, staff, or visitors, and contained biohazard material. During an interview with LVN H on 03/31/2026 at 10:42 a.m., LVN H confirmed the biohazard storage room located on resident B Hall was unlocked, accessible by residents, staff, or visitors, and contained biohazard material. 2. Observation on 03/31/2026 at 11:02 a.m. revealed the housekeeping closet on resident E Hall was unlocked, accessible by residents, staff, or visitors, and contained potentially hazardous chemical cleaning materials. During an interview with the Head of Housekeeping and Laundry on 03/31/2026 at 11:02 a.m., the Head of Housekeeping and Laundry confirmed the housekeeping closet on resident E Hall was unlocked, accessible by residents, staff, or visitors, and contained potentially hazardous chemical cleaning materials. 3. Observation on 03/31/2026 at 11:10 a.m. revealed the maintenance closet on resident E Hall was not fitted with a door that locked, was accessible by residents, staff, or visitors, and contained a hammer, power tools, and insect spray. During an interview with Maintenance Assistant J on 03/31/2026 at 11:10 a.m., Maintenance Assistant J confirmed the maintenance closet on resident E Hall was not fitted with a door that locked, was accessible by residents, staff, or visitors, and contained a hammer, power tools, and insect spray. 4. Observation on 03/31/2026 at 12:35 p.m. revealed a dietary storage closet in the Dining Room was unlocked, accessible by residents, staff, or visitors, and contained approximately 25 individual cans of portable food warming mechanisms which were each labeled, harmful or fatal if swallowed. During an interview with the DON on 03/31/2026 at 12:35 p.m., the DON confirmed a dietary storage closet in the Dining Room was unlocked, accessible by residents, staff, or visitors, and contained approximately 25 individual cans of portable food warming mechanisms which were each labeled, harmful or fatal if swallowed. 5. Observation on 03/31/2026 at 12:48 p.m. revealed the activities closet on B Hall was unlocked, was accessible by residents, staff, or visitors, and contained paint, nail polish, and a hot glue gun. During an interview with the Activities Director on 03/31/2026 at 12:48 p.m., the Activities Director confirmed the activities closet on B Hall was unlocked, was accessible by residents, staff, or visitors, and contained paint, nail polish, and a hot glue gun. Record review of the facility policy, Homelike Environment, dated 04/24/2025, revealed, A homelike environment is essential for promoting the comfort, dignity and quality of life of residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. The trash can next to the hand-washing sink had a lid that was closed and was not operated via foot petal.2. Freezer #1 contained approximately 1/4 inch of ice at the bottom and on the sides, a section of the lower part of the freezer was loose and hanging approximately 1 inch from the freezer, and water was dripping from the top of the inside of the freezer onto the food items below.3. Freezer #1 contained frozen garlic bread. The garlic bread was stored in a plastic bag which was open and was in a cardboard box which was also open. The surveyor was able to reach in the box and bag without moving either and touch the exposed food item.4. Freezer #1 contained frozen meat patties. The meat patties were stored in a plastic bag which was open and in a cardboard box which was also open. The surveyor was able to reach in the box and bag without moving either and touch the exposed food item.5. A scoop was located in the plastic bin which also contained oatmeal.6. Refrigerator #1 contained milk and did not have a thermometer.7. Refrigerator #1 contained a tray with approximately eight individual cups of liquid and a ramekin of food which were unlabeled and undated.8. Refrigerator #2 contained corn bread which was unlabeled and undated.9. The table on which the drinks machine was placed was soiled.10. The floor and walls of the kitchen were soiled. These deficient practices could place residents who receive meals and or snacks from the kitchen in danger of foodborne illness. The findings were: 1. Observation on 03/31/2026 at 10:10 a.m. revealed the trash can next to the hand-washing sink had a lid that was closed and was not operated via foot petal. During an interview with [NAME] G on 03/31/2026 at 10:10 a.m., [NAME] G confirmed the trash can next to the hand-washing sink had a lid that was closed and was not operated via foot petal. Observation on 04/02/2026 at 11:20 a.m. revealed the trash can next to the hand-washing sink had a lid that was closed and was not operated via foot petal. During an interview with the Dietary Corporate Representative on 04/02/2026 at 11:20 a.m., the Dietary Corporate Representative confirmed the trash can next to the hand-washing sink had a lid that was closed and was not operated via foot petal. 2. Observation on 03/31/2026 at 10:10 a.m. revealed Freezer #1 contained approximately 1/4 inch of ice at the bottom and on the sides, a section of the lower part of the freezer was loose and hanging approximately 1 inch from the freezer, and water was dripping from the top of the inside of the freezer onto the food items below. During an interview with the Dietary Manager on 03/31/2026 at 10:10 a.m., the Dietary Manager confirmed Freezer #1 contained approximately 1/4 inch of ice at the bottom and on the sides, a section of the lower part of the freezer was loose and hanging approximately 1 inch from the freezer, and water was dripping from the top of the inside of the freezer onto the food items below. The Dietary Manager stated the facility had ordered a new freezer and stated that Freezer #1 was holding temperature appropriately. 3. Observation on 03/31/2026 at 10:10 a.m. revealed Freezer #1 contained frozen garlic bread. The garlic bread was stored in a plastic bag which was open and in a cardboard box which was also open. The surveyor was able to reach in the box and bag without moving either and touch the exposed food item. During an interview with the Dietary Manager on 03/31/2026 at 10:10 a.m., the Dietary Manager confirmed Freezer #1 contained Freezer #1 contained frozen garlic bread which was exposed to potential contamination. 4. Observation on 03/31/2026 at 10:10 a.m. revealed Freezer #1 contained frozen meat patties. The meat patties were stored in a plastic bag which was open and in a cardboard box which was also open. The surveyor was able to reach in the box and bag without moving either and touch the exposed food item. During an interview with the Dietary Manager on 03/31/2026 at 10:10 a.m., the Dietary Manager confirmed Freezer #1 contained Freezer #1 contained frozen meat patties which were exposed to potential contamination. 5. Observation on 03/31/2026 at 10:10 a.m. revealed a scoop was located in the plastic bin which also contained oatmeal. During an interview with the Dietary Manager on 03/31/2026 at 10:10 a.m., the Dietary Manager confirmed a scoop was located in the plastic bin which also contained oatmeal. 6. Observation on 04/02/2026 at 11:22 a.m. revealed Refrigerator #1 contained milk and did not have a thermometer. During an interview with the Dietary Corporate Representative on 04/02/2026 at 11:22 a.m., the Dietary Corporate Representative confirmed Refrigerator #1 contained milk and did not have a thermometer. Further observation on 04/02/2026 at 11:42 a.m. revealed a thermometer had been placed in Refrigerator #1 and the temperature was within acceptable range. 7. Observation on 04/02/2026 at 11:22 a.m. revealed Refrigerator #1 contained a tray with approximately eight individual cups of liquid and a ramekin of food which were unlabeled and undated. During an interview with the Dietary Corporate Representative on 04/02/2026 at 11:22 a.m., the Dietary Corporate Representative confirmed Refrigerator #1 contained a tray with approximately eight individual cups of liquid and a ramekin of food which were unlabeled and undated. 8. Observation on 04/02/2026 at 11:23 a.m. revealed Refrigerator #2 contained corn bread which was unlabeled and undated. During an interview with the Dietary Corporate Representative on 04/02/2026 at 11:23 a.m., the Dietary Corporate Representative confirmed Refrigerator #2 contained corn bread which was unlabeled and undated. 9. Observation on 04/02/2026 at 11:24 a.m. revealed the table on which the drinks machine was placed was soiled. During an interview with the Dietary Corporate Representative on 04/02/2026 at 11:24 a.m., the Dietary Corporate Representative confirmed the table on which the drinks machine was placed was soiled. 10. Observation on 04/02/2026 at 11:25 a.m. revealed the floor and walls of the kitchen were soiled. During an interview with the Dietary Corporate Representative on 04/02/2026 at 11:25 a.m., the Dietary Corporate Representative confirmed the floor and walls of the kitchen were soiled. During an interview with the Dietary Corporate Representative on 04/02/2026 at 12:27 p.m., the Dietary Corporate Representative stated the above noted deficiencies had been corrected. Record review of the facility policy, Food Safety and Sanitation Plan, revised 11/2017, revealed, It is the policy of this facility to follow an effective, practical food safety program that is [NAME] on preventing food safety hazards before they occur.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for residents, staff, and visitors for one resident halls (B Hall), in that: The resident shower room at the front of B Hall contained soiled towels in on the floor. This deficient practice could result in residents living within, staff working within, and the public visiting within an environment that is not safe, clean, and/or homelike. The findings were: Observation on 03/31/2026 at 10:57 a.m. revealed the resident shower room at the front of B Hall contained soiled towels in the floor. During an interview with Medication Aide I on 03/31/2026 at 10:57 a.m., Medication Aide I confirmed the resident shower room at the front of B Hall contained soiled towels in the floor. Record review of the facility policy, Homelike Environment, dated 04/24/2025, revealed, A homelike environment is essential for promoting the comfort, dignity and quality of life of residents.

Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 out of 8 rooms (room [ROOM NUMBER] and 108), reviewed for quality of life. Rooms 107 and room [ROOM NUMBER] had no toilet paper in the secure unit. This failure could affect residents that use the secure unit's commodes to suffer a decline in quality of life and experience a denial of respect and dignity.Findings were: Initial tour observation on 3/31/26 at 9:34 a.m., reflected there was no toilet paper in rooms 107 [R #17 resident in the room] and 108 [R# 57 and #64 resided in the room] in the secure unit. During an observation on 3/31/26 at 11:55 a.m. reflected the housekeeping staff placing toilet paper in residents' bathrooms in the secure unit. During an interview at 11:52 a.m., the Housekeeping Supervisor confirmed that rooms [ROOM NUMBERS] had no toilet paper. The Housekeeping Supervisor stated that all rooms in the secure unit (8 rooms with 14 residents) had no toilet paper, because it was a way of preventing residents from stuffing the toilets. The Housekeeping Supervisor stated the facility had removed toilet paper in the unit, date unknown, to prevent residents from stuffing the commode. The Housekeeping Supervisor stated the toilet paper was stored at the nurse station and residents needed to ask nursing staff for the toilet paper. When asked, if a resident was continent and ambulatory and needed to quickly go to the bathroom would there be enough time for the resident to get toilet paper, the Housekeeping Supervisor responded there would be a delay in getting the resident the toilet paper. The Housekeeping Supervisor stated the resident had a right to dignity. During an interview on 3/31/26 at 11:52 a.m., the Administrator stated toilet paper should be installed in rooms where residents were ambulatory and could use the toilet. The Administrator gave no explanation for toilet paper stored at the nurse station and not in resident bathrooms. Record review of the facility's Resident Rights policy reviewed 1/1/25 revealed: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for one of three residents (Resident #18) reviewed for privacy. The facility failed to ensure LVN F locked the computer, which exposed Resident #18's morning medication list after he walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings included: Record review of Resident #18's face sheet, dated 4/1/26, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #18 had diagnosis that included: Dementia (is a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), Osteoarthritis (is a chronic, degenerative joint disease that causes cartilage breakdown, leading to pain, stiffness, and reduced mobility), and Mononeuropathy (is damage to a single peripheral nerve. It can cause symptoms like pain, numbness and muscle weakness). Record review of Resident #18's Quarterly MDS assessment, dated 3/13/26, reflected a BIMS score of 4, which suggested severe cognitive impairment. Observation on 4/1/26 at 9:08 am revealed a locked medication cart with a computer, unattended in the Fiesta hallway, exposing Resident #18's morning medication list. On 4/1/26 at 9:10 AM, LVN F explained that the medication aide had called in sick, so he was expected to pass his own medications. He prepared and administered medications for Resident #18, and he walked away for about five minutes to assist another Resident. As a result, he did not minimize the screen, leaving Resident #18's HIPAA information exposed. LVN F verbalized he should have minimized the computer screen when he stepped away from the medication cart. Interview on 4/2/26 at 9:21 AM, the DON stated she was not aware Resident #18's records were left open and unattended. The DON mentioned it was her expectation for the facility nursing staff to uphold HIPAA regulations and lock computer screens when they were away from them. The DON emphasized that all staff members were responsible for ensuring the protection of residents' information. The DON stated leaving residents' charts open and unattended could lead to unauthorized access. The DON also stated her ADON's would be responsible for overseeing compliance with this task, and she would monitor it by conducting random computer screen checks. Record review of the facility policy titled Residents' Rights, dated 2/20/2021, revealed: Privacy and confidentiality, the resident has the right to personal privacy and confidentiality of his or her personal and medical records.

Based on observation, interview and record review the facility failed to ensure that residents received proper treatment and care to maintain good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 of 2 Residents (Resident #1) whose records were reviewed for foot care. The facility failed to ensure they referred Resident #1 for podiatry care. Resident #1's toenails were long and her right great toenail had discoloration. This deficient practice could affect any resident and contribute to a decline in the resident's health status. The findings were:Review of Resident #1's face sheet, dated 1/6/26, revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Hypertensive Heart Disease (a number of complications of high blood pressure that affect the heart.) and Enterocolitis (inflammation of both the small intestine and the colon) due to Clostridium Difficile (bacterium that can cause severe intestinal infections, particularly after antibiotic use.) Review of Resident #1's admission MDS assessment, dated 10/10/25, revealed her BIMS score was 15 out of 15 reflective of no cognitive impairment, she required substantial to maximum assistance with ADL's while in bed and was dependent for toileting. Review of Resident #1's Care Plan, revised 12/24/25, revealed Resident has a diagnosis of diabetes and is at risk for unstable blood sugars andabnormal lab results. The goal was Resident will have a reduced risk for complications related to diabetes through the next review date. Goals included Weekly skin checks to monitor skin for redness, circulatory problems, infection, and breakdown. Notify physician of any new skin conditions. Refer to podiatrist to treat as needed. Review of Resident #1's consolidated physician orders for January 2026 revealed an order dated 12/25/25, May be seen for evaluation and treatment of mycotic nail care and development. Review of skin noted dated 1/6/26 at 09:44 read: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device.Foot evaluation completed. Further review revealed there was no documentation related to Resident #1's toenails. Observation and interview on 1/6/26 at 12:36 PM with Resident #1 revealed she was lying in bed. Resident #1 engaged in conversation easily. Further observation revealed Resident #1's nails were long. Resident #1 stated they were like claws. She stated her toenails were also long and needed to get cut. Interview on 1/7/25 at 5:06 PM with LVN B revealed Resident #1 was not Diabetic and the CNAs could provide nail care on shower days including foot care. Upon reviewing Resident #1's EHR, he clarified that Resident #1 had Diabetes Type 2 (happens when the body cannot use insulin correctly and sugar builds up in the blood.) and was receiving insulin at 6AM every day. He stated nursing staff should provide nail care. He stated he rounded on Resident #1 twice on this date, 1/6/26, and did not notice if she had long fingernails and stated Resident #1 did not say anything to him. Observation and interview on 1/6/26 at 5:20 PM with Resident #1 and LVN B revealed Resident #1 was lying in bed. Upon assessment, LVN B stated Resident #1's toenails were long, needed to get cut, and he identified her right great toenail had discoloration and if it was fungus., the podiatrist would have to assess her. LVN B stated they would have to refer the resident for podiatry care. Interview on 1/7/25 at 11:10 AM with the DON revealed Resident #1 would refuse care or would state she asked for specific type of care and she had not. She stated nursing staff should document in a progress note if Resident #1 refused care and what type of care she refused. The DON stated Resident #1's foot assessment would be captured on the weekly skin assessment. She stated there was not any documentation on the skin assessment dated , 1/6/26, that reflected Resident #1's toenails were long and needed cutting including whether there was any discoloration to the right great toenail. The DON stated nursing staff should refer the Resident #1 to podiatry as needed and to her knowledge had not been referred to podiatry care until, yesterday 1/6/26, after LVN B reported the results of Resident #1's foot assessment, condition of her toenails. The DON stated it was especially important to capture long toenails right away because Resident #1 was Diabetic. If she sustained a skin tear it would take longer to heal and she could get an infection which would create additional health problems. The DON stated Resident #1's health condition was very compromised due to her comorbidities. Review of facility policy, Special Needs, revised 2/1/25, read in relevant part To address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with the professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the residents goals and preferences. This policy pertains to the following needs: podiatry.Policy Explanation and Compliance Guidelines:2. The facility will utilize a systematic approach for the management of the needs of special needs, including efforts to identify risks; stabilize, reduce, or remove underlying risks factors monitor the impact of the interventions, and modify the interventions as appropriate. 4. The facility will communicate relevant information with outside providers to ensure safe, continuous care of the resident.6. A person-centered care plan will be developed, based on specific risk factors identified in assessments and physician orders, and in accordance with the resident's goals and preferences.7. Medical conditions will be monitored and managed to prevent complications. a. The attending physician will assume responsibility for the overall care and treatment of the resident's medical conditions.b. RNs and LPNs will participate in the management of medical conditions by following physician orders, assessments of residents, and reporting changes in condition to the resident's physicians. 8. Policies and procedures related to special need will reflect current professional standards of practice.

Based on interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 1 Resident (Resident #1) whose records were reviewed for dignity and respect. The facility failed to return Resident #1's identification card, social security card and debit card upon request. This deficient practice could contribute to residents believing staff do not care about their wishes. The findings were:Review of Resident #1's face sheet, dated 1/6/26, revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Major Depressive Disorder (Clinical depression causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) and Hemiplegia (paralysis) unspecified affecting left non-dominant side. Review of Resident #1's admission MDS assessment, dated 10/10/25, revealed her BIMS score was 15 out of 15 reflective of no cognitive impairment, she required substantial to maximum assistance with ADL's while in bed and was dependent for toileting. Review of Resident #1's Care Plan, revised 1/5/26, revealed she had impaired cognition and was at risk of further decline in cognition and functional abilities related to mild cognitive impairment. The goal was Resident would have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained by the next review date. Observation and interview on 1/6/26 at 12:36 PM with Resident #1 revealed she was lying in bed. Resident #1 engaged in conversation easily. She stated upon admission she gave her identification and social security card to one of the staff at the front office. She stated the staff also had her bank card and asked for it last week but staff had not returned the items. Resident #1 stated staff told her they would get it to her but had not returned with her items. Resident #1 stated she had her belongings in storage and had to make a payment. Interview on 1/6/26 at 4:26 PM with the BOM revealed she had worked at the facility for almost 2 years. The BOM stated she had Resident #1's debit card. She stated upon admission staff locked Resident #1's debit card in the medication cart and then Resident #1 agreed to have it locked in the safe. The BOM stated Resident #1 requested her debit card last week; maybe Wednesday and she had not taken it to the resident because she had been busy with the end of the month tasks. The BOM commented she was concerned that something would happen to it; someone would take it or it would get lost. She stated Resident #1 had not asked for her debit card again. The BOM stated they could provide Resident #1 a locked box for her room to safe keep her important belongings but had not discussed it or offered Resident #1 that option. The BOM stated she did not know what expenses or reason Resident #1 would need her debit card but not providing it might cause the resident anxiety. She stated Resident #1 could also become distressed about not having it available to take care of financial obligations. The BOM stated she did not have Resident #1's ID or SS card. Interview on 1/7/26 at 4:15 PM with the ADON revealed she had Resident #1's keys and her wallet with her ID, SS and VA card. She stated she locked up the items in one of the filing cabinets in her office and thought other staff new she had Resident #1's items. She stated she had not thought about them until the BOM was talking about it. The ADON stated she should have asked Resident #1 what she wanted to do with the items. She stated she understood Resident #1 had the right to ask and get her personal items upon request. The ADON stated she understood Resident #1 was probably feeling stressed and anxious about not having her belongings. Interview on 1/7/26 at 3PM with the DON revealed she learned Resident #1 asked staff for her debit card, ID and SS card. She stated staff should have provided Resident #1 with her personal items upon request and not a week later. The DON stated Resident #1 was probably feeling anxious and like staff was not listening to her. The DON stated withholding her personal items was a violation of the resident's rights. Review of a facility policy, Resident Rights, revised 1/1/25, read in relevant part, Policy: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility. a. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights.

Based on observation, interview and record review the facility failed to provide therapeutic diets prescribed by the attending physician to 1 of 5 Residents (Resident #2) whose records were reviewed for therapeutic menus. Dietary staff failed to serve Resident #2 a renal diet according prescribed by her primary care physician. This deficient practice could result in a decline in the resident's health status. The findings were: Review of Resident #2's quarterly MDS assessment, dated 12/26/26, revealed she was admitted to the facility on [DATE] with diagnosis including Diabetes (refers to a group of diseases that affect how the body uses blood sugar (glucose). Further review revealed Resident #2's BIMS score was 13 of 15 reflective she had minimal cognitive impairment. Review of Resident #2's Care Plan revised on 4/1/25 read Nutritional Status: Resident is on a CCHO Renal diet, Regular texture, THIN LIQUIDSconsistency. One of the goals was to Provide, serve diet as ordered. Monitor intake and record q meal. Review of Resident #2's physician orders for January 2026 revealed an order dated 12/31/25 CCHO (Consistent Carbohydrate, High-Outcome diet or Controlled Carbohydrate diet) Renal Diet Regular texture, thin liquids. Review of Resident #2's CCHO-Renal menu for Tuesday Lunch 1/6/26 read Baked Chicken Breast - 3 ounces, Chicken Gravy, 2 ounces, Orange twist, 1 each. Buttered chopped spinach, 4 ounces, rice, 3 ounces, buttered dinner roll - 1 each, sugar cookies 1 individual, beverage of choice 8 ounces, hot coffee or hot tea 6 ounces.Review of the monthly calendar, week at a glance revealed the lunch menu for Tuesday, 1/6/26 included fried chicken, spinach, mashed potatoes, sugar cookies and buttered dinner roll. Observation on 1/6/25 at 12:07 PM of the written menu posted outside the dining room read: Lunch: fried chicken, spinach, mashed potatoes, sugar cookies and buttered dinner roll. Observation and interview on 1/6/26 at 12:10 PM with Resident #2 revealed she was served baked chicken, mashed potatoes, egg noodles, sugar cookie and buttered dinner roll. Further observation revealed Resident #2 had eaten about 50 % of her meal including the mashed potatoes and noodles. Resident #2 stated she was a Diabetic and understood she should limit her carbohydrate intake because it could make her sugars go up. She stated she was often served items that were not on the menu or that she should not have but she was hungry. She stated she had complained about it before, but it did not help. Interview on 1/7/26 at 3PM with the DON revealed Resident #2 was on a CCHO diet per physician orders and should not have received mashed potatoes for lunch on 1/6/26. She stated the therapeutic diet helped to regulate her carbohydrate intake and regulate her sugars. Too much sugar intake could cause a hyperglycemic (high sugar) episode and result in health complications. Interview on 1/7/26 at 5:13 PM with the DM revealed the lunch meal for 1/6/26 on the calendar a week at a glance included fried chicken, spinach, mashed potatoes, sugar cookies and a buttered dinner roll. She stated Resident #2 was on a CCHO diet prescribed by her physician and should have received rice instead of mashed potatoes. She stated the menu did not call for egg noodles either. She stated she talked to the [NAME] who stated he substituted the egg noodles for the rice which was ok but Resident #2 should not have received the mashed potatoes. The DM stated the [NAME] should have followed the menu and should have discussed any substitutions with her and added them to the substitution log for the Dietician's review. The DM stated Resident #2 was prescribed a therapeutic diet to control her sugar intake in order to regulate her sugars better. Otherwise, it could cause her sugar levels to go up and create health problems for Resident #2. Review of a facility policy Diets, Nutrition and Hydration revised on 7/2022 read in relevant part: Fundamental Information: The facility will provide each resident with three meals daily and a nourishing snack at bedtime. Each meal will be provided according to physician orders, Facility Diet Manual, and menu spread sheet. Review of a policy, Menu Changes and Substitutions, dated 10/2010 read in relevant part: Any variations from the planned menu will be properly documented by the DSM and reviewed and signed by the Dietician. Menu changes and substitutions, when necessary, will be made with foods of equivalent nutritive value.

Based on observation, interview and record review the facility failed to follow the menu for 1 of 2 days of observation (1/6/26) for the lunch meal service. Dietary Staff failed to follow the lunch menu on 1/6/26 which included fried chicken, spinach, mashed potatoes, sugar cookies and buttered dinner roll. This deficient practice could contribute to resident dissatisfaction. The findings were: Review of the monthly calendar, week at a glance revealed the lunch menu for Tuesday, 1/6/26 included fried chicken, spinach, mashed potatoes, sugar cookies, buttered dinner roll. Observation on 1/6/25 at 12:07 PM of the written menu posted outside the dining room read: Lunch: fried chicken, spinach, mashed potatoes, sugar cookies and buttered dinner roll. Observation on 1/6/26 at 12:10 PM revealed some residents were served gravy with their mashed potatoes, some were served egg noodles, but not all. Further observation revealed and interviews with Resident #2 and Resident #3 revealed Resident #3was served gravy with the mashed potatoes and Resident #2 was not served gravy. Resident #2 was also served egg noodles with her meal. Interview with Resident #2 and #3 revealed they did not always get all items as reflected on the menu. They stated they had complained about not always get all items as reflected on the menu because they did not like when this happened, but it did not help. They stated they continued to receive items per the menu, and they accepted that they could not do anything about it. Interview on 1/7/26 at 5:13 PM with the DM revealed the lunch meal for 1/6/26 on the calendar a week at a glance included fried chicken, spinach, mashed potatoes, sugar cookies and a buttered dinner roll. She stated gravy was not part of the menu but per residents request the [NAME] added gravy to the mashed potatoes. She stated the menu did not call for egg noodles either. She stated the [NAME] should have followed the menu and for any substitutions he should have discussed it with her and added them to the substitution log for the Dietician's review. The DM stated the residents had a right to know in advance what they were receiving so they could choose an alternative if they did not like what was being served. She stated some residents would get upset if they were not served what the menu called for because they were either looking forward to it or they would have wanted to consider their options. Review of a policy, Menu Changes and Substitutions, dated 10/2010 read in relevant part: Any variations from the planned menu will be properly documented by the DSM and reviewed and signed by the Dietician. Menu changes and substitutions, when necessary, will be made with foods of equivalent nutritive value.

Based on observation, interview and record review the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 1 Resident (Resident #1) reviewed for grievances. LVN B failed to follow the grievance process when Resident #1 reported a concern against staff. This deficient practice could result in the resident's concerns not being resolved and to the continuation of poor resident care. The findings were: Review of Resident #1's face sheet, dated 1/6/26, revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Major Depressive Disorder (Clinical depression causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) and Hemiplegia (paralysis) unspecified affecting left non-dominant side. Review of Resident #1's admission MDS assessment, dated 10/10/25, revealed her BIMS score was 15 out of 15 reflective of no cognitive impairment, she required substantial to maximum assistance with ADL's while in bed and was dependent for toileting. Review of Resident #1's Care Plan, revised 1/5/26, revealed she was incontinent of bowel and bladder, required frequent checks for wetness and soiling and was hemiplegia and required extensive assistance with toileting. Observation and interview on 1/6/26 at 12:36 PM revealed Resident #1 was lying in bed. She engaged in conversation easily and talked non-stop. Resident #1 stated she had diarrhea for 1-week. She stated she would have to bang on the wall to get staff to help her, it would take staff hours to come to her room. Resident #1 stated sometimes the call light was not within reach. She stated she was paralyzed on her left side and could not grab the call light with left hand when staff placed it on her left side. Resident #1 stated there was a male and a female CNA who were verbally aggressive and one time they woke her up at 3:00 AM and insisted on showering her. She stated the staff manhandled her during the shower. Resident #1 stated she preferred bed baths and preferred to use a bed pan when toileting. Resident #1 stated the female CNA would talk to her in a loud tone, would talk down to her and give her a hard time. Resident #1 stated the female CNA wanted her to use the brief, but she did not want to because she did not like to feel dirty. Resident #1 stated she had expressed her concerns to different nursing staff. Interview on 1/6/26 at 3:12 PM with CNA A revealed she had worked at the facility for almost 1 year. She stated she was familiar with Resident #1 and would work with her. CNA A stated Resident #1 told her a few weeks ago that some staff were rough and would give her a hard time about putting her on the bed pan or about giving her a bed bath instead of a shower. CNA A stated Resident #1 would get confused with the shifts staff worked so it was difficult to determine who Resident #1 was talking about. Resident #1 was not able to provide staff names. CNA A stated she reported Resident #1's concerns to one of the charge nurses but could not remember the nurse's name. Observation and interview on 1/6/25 at 5:20 PM with Resident #1 and LVN B revealed Resident #1 was lying in bed. Resident #1 re-iterated verbatim what she reported to Surveyor during her individual interview on this same date, 1/6/26 at 12:36 PM. She reported the same concerns to LVN B. Interview on 1/6/25 at 5:46 PM with LVN B revealed he identified Resident #1's concerns regarding a black CNA talking loudly and giving Resident #1 a hard time about putting her on the bedpan, not wanting to give her bed baths and staff taking a long time to help her when she asked for help. LVN B stated Resident #1 also mentioned staff manhandling her during a shower. LVN B stated he did not remember Resident #1 saying anything about an African American male CNA. LVN B stated he would report Resident #1's concerns to the DON. He stated he was required to write a progress note related to Resident #1's concerns. He would follow up with anything else the DON instructed him to do. Interview on 1/7/25 at 2:45 PM with the ADM revealed she was the grievance officer but department heads would get involved when addressing resident concerns. She stated she would ensure the grievance was addressed and a resolution was reached. She stated she would then talk to the resident or resident representative about the outcome. The ADM stated she did not know anything about Resident #1 concerns regarding customer service. Interview on 1/7/26 at 2:54 PM with LVN B revealed he told the ADON/DON yesterday about Resident #1's concerns after meeting with Resident #1 and after talking with the Surveyor. LVN B stated the DON and ADON stated they were already looking into it. LVN B stated he did not enter a progress note which he should have done and did not complete a grievance about Resident #1's concerns. He stated he worked for the facility on a PRN basis and was new to long-term care. He stated he should have asked about the grievance process and wrote up Resident #1's concerns at the time she reported them to him. He stated writing a grievance would ensure staff followed up with Resident #1's concerns. LVN B stated if he did not follow protocol then there was a possibility the resident would continue to have the same experiences and it could affect the resident negatively believing no one cared about her. Interview on 1/7/26 at 3PM with the DON revealed she met with Resident #1 yesterday evening and followed up with Resident #1's concern. The DON stated the only thing Resident #1 mentioned was that a black CNA would talk loudly to her during the evening shift. She stated LVN B talked with her about his conversation with Resident #1 but she again Resident #1 only told her about the one CNA and that was what she followed up on. The DON stated LVN B was a new nurse to long term care and was not sure if he was familiar with the grievance process. She stated she probably should have instructed him to complete a grievance form including all of Resident #1's concerns she reported directly to him. The DON stated LVN B should at a minimum entered a progress note. She stated upon reviewing Resident #1 progress notes, she did not see an entry by LVN B regarding his conversation with Resident #1 on 1/6/26. Review of facility policy, Grievance Policy, revised 8/1/25, read in relevant part: Residents have the right to file a grievance without the fear of reprisal. The designated grievance officer is the Administrator. Fundamental Information: Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection for residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. 1. The facility failed to store plastic bowls to allow for air-drying in the dish room. 2. The facility failed to use the correct log to record the dish machine wash cycle temperatures and chlorine sanitizer concentrations, resulting in no record of chlorine sanitizer concentrations recorded. 3. The facility failed to properly store an opened package of cream cheese and pre-packaged hard-boiled eggs in the reach-in cooler. 4. The facility failed to discard hard-boiled eggs past their use-by date. 5. The facility failed to ensure the tabletop can opener blade and base were free of grime and debris. 6. The facility failed to ensure an opened bag of powdered sugar was properly sealed in the dry storage room. 7. The facility failed to remove a dented #10 can of beans from the rack of canned goods in the dry storage room. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 02/09/2025 at 10:28 AM revealed a plastic three with nine overturned plastic bowls on the clean side of the dish machine. There was not an air-drying net separating the bowls from the tray to allow for air circulation. During an interview on 02/09/2025 at 10:230 AM, the DM stated the wet, plastic bowls should not have been placed face-down on a wet tray without an air-drying net separating the bowls from the tray to prevent the potential accumulation of bacteria which could lead to food borne illness. Staff working in the dish room were trained on how to store clean but damp dishware. They were trained upon hire and periodically throughout there year. The facility had an adequate supply of air-drying nets. 2. Observation of the dish machine in the dish room revealed it utilized a chemical sanitizer (chlorine) used in a sanitizing solution for ware washing. Record review on 02/09/2025 at 10:31 AM of the Dishmachine Temperature Log for the dates 02/03/2025 - 02/09/2025 provided by the facility revealed it stated, High-Temperature Dishmachine Temperature Log and had the following columns: Day (three spaces per day), Time, Date, Final Rinse (Thermolabel or Thermometer Temperature Reading), Wash Water Temperature, Initials and Corrective Action. There was no column to record the concentration of the chemical sanitizer and none were recorded for any day. During an interview on 02/09/2025 at 10:33 AM, the DM stated he understood the facility was using the incorrect temperature log for the type of machine in the dish room, there was no record any measurements of chemical sanitizer concentration recorded, and this failure could result in inadequate or no sanitizing of dishes and flatware, potentially causing foodborne illness. The DM further stated he had been in the position approximately one month and was in the process of resolving issues in the kitchen. Further observation at 10:35 AM revealed the concentration of the chlorine sanitizer in the machine was 50 ppm, which was within the acceptable range. 3. Observation on 02/09/2025 at 10:38 AM in the reach-in cooler revealed an opened container of cream cheese stored in a plastic bag that was not sealed. There were also two separate packages of commercially procured hard boiled eggs in packages that were opened and stored in clear plastic bags that were not sealed. 4. Observation on 02/09/2025 at 10:38 AM in the reach-in cooler revealed he date on one package containing three hard boiled eggs was 01/30. During an interview on 02/09/2025 at 10:40 AM, the DM stated the packages of cream cheese and hard-boiled eggs should have been sealed, and the eggs dated 01/30 should have been discarded. Ensuring opened foods returned to the cooler for storage were properly labeled, dated and sealed was critical to prevent spoilage and potential foodborne illness. All employees storing food in the coolers were responsible for labeling and dating. 5. Observation on 02/09/2025 at 10:41 AM in the kitchen revealed the tabletop can opener was covered with sticky grime that was black and brown in color. The grime covered the blade portion of the can opener, the adjustable bar, and also surrounded the base that was affixed to the table with screws. During an interview on 02/09/2025 at 10:42 AM, the DM stated that the can opener blade, bar and base were covered in sticky grime and should not have been. The DM stated the cooks were responsible for ensuring the can opener and area surrounding the base remained clean and free of debris, and that failing to do so could result in contamination of food from bacteria lingering on the blade and potential foodborne illness. 6. Observation on 02/09/2025 at 10:44 AM in the dry storage room revealed an opened 2 lb. bag of powdered sugar on a shelf. The bag was approximately 3/4 full, had been opened, and placed inside a bag with a zip lock that was not sealed. During an interview 02/09/2025 at 10:44 AM, the DM stated the bag of powdered sugar was not sealed, and the bag should have been stored either in a larger bag with a zip lock or a sealed container. All kitchen staff stored food in the dry storage room, and failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests. 7. Observation on 02/09/2025 at 10:45 AM in the dry storage room revealed a #10 can (6 lbs.) of pinto beans with a large dent in the bottom third of the can in close proximity to the seal. The can was stored on the same rack with the other cans of various foods. During an interview 02/09/2025 at 10:44 AM, the DM stated the dented can should have been removed from the rack of canned goods and stored separately for return to the facility's food supplier, as dented cans could potentially harbor harmful bacteria that could lead to serious foodborne illness. He did not know why the dented can was in the dry storage room, as all dietary employees were trained to remove them upon identification. Record review of facility policy, Ware Washing dated October 2019 revealed, Action Steps: 3. The Dining Services Director is responsible for insuring appropriate completion of temperature and/ or sanitizer concentration logs as appropriate. 4. The Dining Services Director ensures that all dishware is air dried and properly stored. Record review of the Job Description, Job Title: Director of Food and Nutrition Services, undated, revealed, Essential Duties and Responsibilities: Unit Supervision. Ensures equipment and work areas are clean, safe and orderly; and strict adherence to procedures regarding cleaners or hazardous materials or objects; ensure standard precautions and infection control, isolation, fire, safety and sanitation practices and procedures are followed; and promptly address any hazardous conditions and equipment. Record review of facility policy, Frozen and Refrigerated Storage revised 12/05/2017 revealed, Policy: PHF/TCS (Potentially hazardous/Time temperature control for safety) foods will be properly refrigerated or frozen to reduce the potential for food borne illness and maintain product integrity. 7. Proper labeling of cooked foods includes the date placed in the refrigerator, and an expiration or 'use by' date. Refrigerated products that are opened must be labeled with an 'opened on' date. The 'use by' date is 7 days from when the product was opened, unless there is a manufacturer's use by, expiration or sell by date. 13. On a daily basis the Cooks will: b. Check labeling and dating, use any items that are close to their use by date and discard any items that are past their use by date. Record review of facility policy, Dry Food Supplies Storage revised 11/15/2017 revealed, 9. All opened products must be resealed effectively and properly labeled, dated and rotated for use. This may require storage in an approved NSF container or food grade storage bag. 11. Canned goods that have a compromised seal will be removed from service and stored in a separate area, until they are picked up by the distributor of discarded. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-205.15 Package Integrity. Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants such as Clostridium botulinum may find their way into the food. In anaerobic conditions (lack of oxygen), botulism toxin may be formed. Packaging defects may not be readily apparent. This is particularly the case with low acid canned foods. Close inspection of cans for imperfections or damage may reveal punctures or seam defects .Suspect cans must be returned and not offered for sale.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: During an interview on 02/09/2025 at 10:50 AM, the DM stated he was not a certified dietary manager or certified food service manager, he did not have an associate's or higher degree in food service management or in hospitality, and he had not been a dietary manager in a long-term care facility for over two years. This was his first position as the DM in a nursing facility and his hire date was 01/02/2025. He was enrolled in a certified dietary manager program but had not completed any classes at that time. During an interview on 02/11/2025 at 3:30 PM, the consultant RD stated she did not work at the facility full time. She provided approximately 12 - 16 hours of consultative hours to the facility per month. During an interview on 02/12/2025 at 9:40 AM, the administrator stated he was not aware the DM was not a CDM and was also not aware the requirement had changed requiring the individual in the position to have this certification upon hire. The facility contracted with a foodservice company, and all the dietary staff, including the DM, were employed by the contractor. He understood it was critical the DM be proficient in food sanitation, safety, and how to meet the individual dietary needs of the residents. Record review of the Job Description for Job Title: Director of Food and Nutrition Services provided by the facility, undated, revealed: Qualifications: Must be a Registered Dietitian or CDM or other per Federal and State Regulation. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 6 resident hallways (Hallway A and Hallway F) reviewed for environmental concerns. 1. The facility failed to ensure resident rooms #104 and #107, located on hallway A, had back lids covers for the toilet bowl and room [ROOM NUMBER], also located on hallway A, did not have a 2 foot strip of floor baseboard molding attached to the wall. 2. The facility failed to ensure the bottom half of the bathroom door in room [ROOM NUMBER], on hallway F, was repaired and did not have numerous horizontal linear scrapes and a jagged opening near the door hinge where the outer cover of the door was partially missing, and failed to ensure the wall opposite the toilet inside the bathroom did not have numerous scrapes and small holes in the wall. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: 1. During an observation on 02/10/25 from 11:00 a.m. to 11:05 a.m. with LVN A revealed the following: a. In room [ROOM NUMBER] on Hallway A the bathroom toilet had no back lid cover for the toilet bowl. b. In room [ROOM NUMBER] on Hallway A there was a 2-foot strip of floor baseboard molding in the bathroom that was not attached to the side of the wall. c. In room [ROOM NUMBER] on Hallway A the bathroom toilet had no back lid cover for the toilet bowl. During an interview with LVN A on 02/10/25 at 11:10 a.m. revealed that repairs were needed in room #'s 104, 106, and 107 for a more pleasant environment for the residents. During an observation with the Maintenance Director on 02/10/25 from 11:10 a.m., to 11:15 revealed the following: a. In room [ROOM NUMBER] on Hallway A the bathroom toilet had no back lid cover for the toilet bowl. b. In room [ROOM NUMBER] on Hallway A there was a 2 foot strip of floor baseboard molding in the bathroom that was not attached to the side of the wall, c. In room [ROOM NUMBER] on Hallway A the bathroom toilet had no back lid cover for the toilet bowl. During an interview with the Maintenance Director on 02/10/25 at 11:20 a.m., he stated the process of being alerted to a problem that needed repair required a staff member to tell him about it or to write it down in the Maintenance Book kept at the Nurses station; the Maintenance Director stated he had not been made aware of the problems on the secure unit and would address the repairs immediately. 2. Observation on Hallway F on 02/09/2025 at 12:32 p.m., revealed in room [ROOM NUMBER], the bottom part of the bathroom door had numerous horizontal linear scrapes and a jagged opening near the door hinge where the outer cover of the door was missing which revealed the hollow inside of the door; and numerous scrapes and small holes in the wall opposite the toilet. Interview on 02/10/2025 at 12:32 p.m. with the Maintenance Director revealed that he was made aware the day before (02/09/2025) of the condition of the bathroom door and wall in room [ROOM NUMBER] after the State Surveyor had been observed looking at it and had replaced the door with another door that he had available and patched the wall. The Maintenance Director stated the resident in room [ROOM NUMBER] uses a wheelchair and had impaired vision and would frequently run into the door and wall with his wheelchair causing damage to the door and wall, and frequent repair was needed. He stated he was in the process of updating and making repairs to the entire facility, noting that it was an old building, and he had just not gotten to room [ROOM NUMBER] yet for needed repairs. Record review of the facility maintenance request log did not reveal any requests logged for repair of the door and wall in room [ROOM NUMBER]. Record review of the facility's policy on Maintenance Inspection dated 1/2/25 stated the Director of Maintenance Services will perform routine inspections of the physical plant and opportunities will be corrected as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure the residents had a right to a safe, clean, comfortable, and homelike environment for 2 of 24 residents (Residents #10 and #14 ) reviewed for a safe, clean, comfortable, and homelike environment, in that: 1. The bed-side dresser of Resident #10 was broken with drawers that would not stay closed. 2. Resident #14's bathroom did not have any toilet paper, and her waste basket was filled with used paper towels that she stated she had been using because she had no toilet paper. This failure could result in psychosocial harm due to diminished quality of life. The findings included: 1. Record review of Resident #10's face sheet, dated 2/12/25, revealed the [AGE] year female resident was originally admitted to the facility on [DATE] with diagnoses including: Parkinson's disease ( a disorder of the central nervous system that affects movements), type 2 diabetes mellitus ( a condition in which the body has trouble controlling blood sugar), and major depressive disorder (a mental health condition with persistent depressed mood). Record review of Resident #10's Quarterly MDS, dated [DATE], revealed a BIMS score of 12 which indicated mild cognitive impairment. Record review of Resident #10's care plan, initiated 02/1/2024, revealed resident had impaired visual function and was at risk for falls. Observation on 2/10/25 at 11:45 a.m., revealed that a 3 drawer bed-side dresser for Resident #10 had a hand towel placed between the first and second drawer and a hand towel placed between the second and third drawers. During an interview on 2/10/25 at 11:4.5 a.m., with Resident #10 she stated that the hand towels were placed in her bed-side dresser drawers to keep the drawers from opening on their own. Resident #10 stated that she wanted the drawers fixed and was afraid her belongings would fall out. Resident #10 stated she believed that maintenance was made aware of the broken bed-side dresser. Record review of the Resident Council Meeting notes dated 12/13/24 revealed an entry stating that the bedside dresser for Resident #10 needed balancing. Record review of the Maintenance Log noted an entry for 2/4/25 that the bed-side dresser for Resident #10 was unsteady. During an interview on 2/10/25 at 12:00 noon LVN-B stated she was not aware the bed-side dresser drawers for Resident #10 were broken and would notify maintenance in the work order request log. During an interview on 2/10/25 at 12:10 p.m., the Maintenance Director stated that he was aware of the problem with the bed-side dresser for Resident #10 for about a week and would immediately address the problem. During an interview on 2/11/25 at 12:50 p.m., with the Administrator he stated that he had not reviewed the resident council minute notes dated 12/13/24 which indicated a problem with the bed-side dresser for Resident #10. The Administrator stated that if he had reviewed these notes in December 2024, he would have directed the bed-side dresser for Resident #10 to be fixed at that time. Record review of the facility policy named Maintenance Inspections dated 1/2/25 revealed the Maintenance Director would perform routine inspections and correct all opportunities as soon as possible. 2. Record review of Resident #14's face sheet dated 02/09/2025 revealed she was a [AGE] year old woman originally admitted to the facility on [DATE] with re-admit on 08/24/2020 and with diagnoses which included: Conversion Disorder with Seizures (a psychiatric condition where psychological stressors manifest as physical symptoms that can't be explained medically); Dementia (general term for impairment of brain function such as memory, thinking and ability to perform daily activities); Generalized Anxiety Disorder (Severe, ongoing anxiety that interferes with daily activities). Record review of Resident #14's Significant Change MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognition and was assessed as needing supervision or touching assistance for toileting hygiene. Record review of Resident #14's Care Plan initiated 11/29/2019 revealed resident had visual impairment, risk for falls, fragile skin and may require assistance with her activities of daily living. Observation on 02/09/2025 at 10:20 a.m., in room [ROOM NUMBER] revealed the toilet paper holder was empty, the trash can was overflowing with used brown paper towels, and the floor had 4 used paper towels on the floor. During an interview on 02/09/25 at 10:23 a.m., with Resident #14 in room [ROOM NUMBER], she stated she had been without toilet paper for about 4 days and had to use the brown paper towels to wipe herself which she did not like, they felt rough. Resident #14 stated she had asked the Nurse for more toilet paper, but no one has come to bring her more. During an interview on 02/09/2025 at 10:30 a.m. with CNA C, and after observation of the bathroom in room [ROOM NUMBER], CNA C stated that she had not been aware of the condition of the bathroom and found it to be unacceptable. She stated Resident #14 should have been provided with toilet paper, and they were just lucky she had put the used paper towels in the trash can and not try to flush them down the commode as it would cause a clog. CNA C stated that it was housekeeping's responsibility to restock toilet paper in the restrooms and clean the bathrooms. Interview on 02/09/2025 at 10:35 a.m. with Housekeeper D revealed that he stated that the resident has had diarrhea and goes through a lot of toilet paper, but stated it was not acceptable that she had to use paper towels instead because she did not have any toilet paper. He stated that he cleans all the restrooms on the halls he was assigned starting in the morning, and then returns as needed after he has cleaned all the restrooms and rooms. He stated the last time he cleaned and stocked the bathroom in room [ROOM NUMBER] was the prior morning, but he could not remember if he left an extra roll out for the resident. He stated that working today, were 2 full-time housekeepers and 1 just working half-day and one in the laundry. During an interview with the EVS Manager on 02/12/2025 at 11:25a.m., the EVS Manager stated that the housekeepers clean and re-stock the bathrooms with toilet paper as they go room to room down the hallway cleaning. She stated that if the housekeepers are aware the resident has diarrhea, they are to make more frequent rounds to see if they need to be re-stocked and have bathroom cleaned. She stated extra toilet paper rolls are stocked on the housekeepers' carts and in the laundry area, and Nurse's and CNA's could ask the housekeepers for some toilet paper off their housekeeping cart if a resident was requesting additional toilet paper. The EVS Manager stated that the resident should not have been without toilet paper and that by not providing her with toilet paper, it increased the risk that she could clog the toilet which could affect everyone as the system was all connected. Record review of the facility policy titled Resident Rights dated 02/23/2026 revealed The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. 33866

Based on observation, interviews and record review, the facility failed to provide pharmaceutical eservices (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication rooms reviewed for pharmacy services. Inspection on 02/11/2025 of the facility medication storage room revealed two expired vials Lorazepam 2mg/ml for Resident #50. This failure could place resident at risk of residents not receiving appropriate therapeutic effects from their medications. The findings include: Record review of Resident #50's admission record dated 01/12/2025 revealed he was a [AGE] year-old man initially admitted on [DATE] with re-admit on 09/12/2024 and with diagnoses which included: Dementia (a condition that causes memory loss and other cognitive decline); Epilepsy (seizure disorder); and Anxiety Disorder (mental health disorder characterized by feelings of worry anxiety, or fear strong enough to interfere with daily activities). Record review of Resident #50's quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 2, indicating severe cognitive impairment. Record review of Resident #50's Order Summary dated 02/12//2025 revealed an order for LORazepam Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth two times a day related to DEMENTIA IN OTHER DISEASES CLASSIFED ELSEWHERE, SEVERE, WITH ANXIETY. Observation with the DON on 02/11/2025 at 3:19 p.m. of the facility's medication storage room revealed inside the locked compartment inside the refrigerator was a sealed bag containing 5 vials of Lorazepam 2mg/ml for Resident #50. Further inspection revealed 2 of the 5 vials of Lorazepam were expired, with expiration dates of 11/2024 on their labels. During an interview with the DON on 02/11/2025 at 3:38 p.m., the DON confirmed the 2 vials of Lorazepam were expired, and she stated that the Pharmacist Consultant had just audited the medication room last Friday and did not find any expired medications. The DON stated that expired medications may not be as effective if administered or could even cause an adverse effect. Record review of the facility policy titled Medication Storage dated 01/20/2021 revealed: -It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. -During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart; and - .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with facility policy.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #42) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #42's oxygen tubing and nasal cannula were stored properly and that the humidifier bottle or tubing were dated on 02/09/2025 and 02/11/2025 This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and infection. Findings included: Record review of Resident #42's admission record dated 02/09/2025 revealed he was a [AGE] year-old man initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included: malignant neoplasm of colon (colon cancer); and dementia (a general term to describe loss of memory, thinking, language and ability to perform daily activities). Record review of Resident #42's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 indicating moderate cognitive impairment. Record review of Resident #42's Order Summary Report dated 02/11/2025 revealed an order for May use supplemental oxygen 2-4L NC for SOB dated 01/30/2025. Observation on 02/09/2025 at 2:14 p.m. in Resident #42's room revealed an oxygen concentrator not currently in use next to his bed, with no date on the humidifier bottle but the oxygen tubing was dated 2/4/2025. The oxygen tubing and connected nasal cannula were hanging loosely over the humidifier bottle, not in a bag. Observation on 02/11/2025 at 11:05 a.m. in Resident #42's room revealed his oxygen concentrator was next to his bed, the oxygen tubing and nasal cannula were hanging loosely over the concentrator and extending down behind the concentrator almost touching the floor. The oxygen tubing was not dated, and the humidifier bottle was dated 02/01/2025. Observation and interview with the DON on 02/11/2025 at 11:10 a.m. in Resident #42's room revealed she confirmed the oxygen tubing and nasal cannula were hung loosely over the concentrator and she stated they should have been stored in a bag off the floor, and the oxygen tubing should be dated. The DON stated the tubing should be dated because it needs to be changed out once a week, and if not dated cannot tell when it was last changed. She further stated that if the tubing was not stored in a bag it could lead to cross contamination and if the tubing was not changed weekly, it could lead to the tubing becoming a breeding ground for infection. Record review of the facility policy titled Oxygen Administration reviewed 1/5/2020 revealed the following: - Use pre-filled humidifier bottle. Label bottle with date. Change bottle when empty. - When oxygen not in use, store oxygen tubing and nasal cannula or mask in small plastic bag. - Change disposable parts once a week and label with date (tubing, plastic bag, mask or cannula)

33866 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #42) of 8 residents reviewed for care plans. The facility failed to include oxygen treatment in Resident #42's comprehensive care plan initiated 02/10/2022. This deficient practice could affect residents who received oxygen and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings Included: Record review of Resident #42's admission record dated 02/09/2025 revealed he was a [AGE] year-old man initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included: malignant neoplasm of colon (colon cancer); and dementia (a general term to describe loss of memory, thinking, language and ability to perform daily activities). Record review of Resident #42's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 indicating moderate cognitive impairment. Record review of Resident #42's Order Summary Report dated 02/11/2025 revealed an order for May use supplemental oxygen 2-4L NC for SOB dated 01/30/2025. Record review of Resident #42's Care Plan initiated 02/10/2022 revealed there was no focus area for oxygen therapy. Observation on 02/09/2025 at 2:14 p.m. in Resident #42's room revealed an oxygen concentrator not currently in use next to his bed, with no date on the humidifier bottle but the oxygen tubing was dated 2/4/2025. The oxygen tubing and connected nasal cannula were hanging loosely over the humidifier bottle, not in a bag. Observation on 02/11/2025 at 11:05 a.m. in Resident #42's room revealed his oxygen concentrator was next to his bed, the oxygen tubing and nasal cannula were hanging loosely over the concentrator and extending down behind the concentrator almost touching the floor. The oxygen tubing was not dated, and the humidifier bottle was dated 02/01/2025. During an interview with the DON on 02/11/2025 at 11:10a.m., the DON confirmed Resident #42's use of oxygen and stated she would address the problems noted with the oxygen tubing storage and dating. Interview on 02/11/2025 at 01:04 p.m. with LVN E revealed she was one of 2 MDS Nurse's at the facility. LVN E stated that she was not aware that Resident #42 had been ordered PRN oxygen, and that if he was using oxygen, it should be included in his Care Plan, so that all the staff had the information on the need for and care of his oxygen. She stated she would look into and add it to his Care Plan. Record review of the facility policy titled Comprehensive Care Plans dated 02/10/2021 revealed The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 22 residents (Resident #175) reviewed for advanced directives, in that: The facility failed to ensure Resident #175's signature on his Out-of-Hospital Do Not Resuscitate (OOH DNR) was properly witnessed as Resident #175's signature was dated [DATE], and the two witness's signatures were dated [DATE]. This failure could place residents at risk of having their end of life wishes dishonored, and of having Cardiopulmonary resuscitation (CPR) performed against their wishes. The findings included: Record review of Resident #175's admission record, dated [DATE] revealed he was a [AGE] year-old man who had an initial admitted d of [DATE] with re-admission on [DATE], with diagnoses which included: Chronic Kidney Disease, Stage 5 (the most advanced stage of chronic kidney disease and indicates the kidneys are no longer able to perform their essential function), Hemiplegia and Hemiparesis following cerebral infarction affecting right non-dominant side (Partial paralysis or weakness on one side of body: and chronic ischemic heart disease (heard damage caused by poor blood flow to heart. Further review of Resident #175's admission record revealed the resident was identified as DNR status. Record review of Resident #175's discharge MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating intact cognition. Record review of Resident #175's care plan initiated [DATE], revealed the resident had a focus area for: Resident has physician's orders that include an order for DNR. Date initiated: [DATE]. Record review of Resident #175's Order Summary Report, dated [DATE], revealed an Order for DNR with start date of [DATE]. Record review of Resident #175's OOH DNR revealed that Resident #175's signature was dated [DATE], and the two witness's signatures were dated [DATE]. Further review of the witness section of the document revealed a statement listed above the witness signatures that read: We have witnessed the above-noted competent adult person or authorized declarant making his/her signature above and if applicable, the above-noted adult person making an OOH-DNR by nonwritten communication to the attending physician. During an interview with the SW on [DATE] at 12:52 p.m., the SW stated the signature dates of the witnesses on Resident #175's OOH-DNR was not the same date as the Resident's signature, and she noted that the OOH-DNR for Resident #175 was completed and provided to the facility by his Hospice provider. Further interview revealed that even though it was completed by the Hospice Provider it was still the facility's responsibility to ensure there was a valid OOH-DNR for Resident #175, and that having the witness signatures on a different date than the Resident's signature on the DNR could indicate that they did not actually witness the Resident's signature, making it invalid. During an interview with the DON on [DATE] at 3:55p.m., the DON stated she had been made aware of the concerns with Resident #175's DNR, and she had corrected his DNR by re-verifying with the resident his wish for DNR status, asked him to re-sign the DNR with a Notary witness and have his physician sign. The DON provided a copy of the new DNR dated [DATE], but also stated that prior to [DATE], Resident #175 did not have a valid OOH-DNR. Record review of the Texas Department of State Health Services Document titled Honoring an Out-of-Hospital DNR Order A guide for Health Care Professionals, two witnesses or a notary public must sign that they have witnessed the patient's signature or the signature of a person(s) acting on the patient's behalf in sections A-E. Further review revealed Incomplete or incorrect forms: Medical professionals can refuse to honor a OOH-DNR if it is: -Not signed properly by all required parties. - Filled out incorrectly. -Suspected to be fraudulent (e.g., unnatural circumstances surrounding death).

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for quality of care in that: The facility failed to assess and treat resident #1's left foot great toe when the resident developed a wound to his LLE from [DATE] until [DATE] which resulted in a decline in health, a worsening of the wound including the toe turning black, infection, necrosis, gangrene, sepsis, hospitalization , and amputation. The facility also failed to identify and treat a wound to Resident #1's sacrum. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on [DATE] at 11:54 a.m., the facility remained out of compliance at a scope of pattern and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice placed residents at risk of unidentified and untreated wounds, infection, a decline in health, amputation, and death. The findings included: Record review of a facility self-report dated [DATE] the facility reported Resident #1 wound care orders placed in chart on [DATE] were not followed up. Resident #1 became septic and resulted in amputation of big toe. The facility listed RN D and LVN B as the alleged perpetrators. Record review of Form 3613-A dated [DATE] and signed by the facility Administrator on [DATE] revealed an allegation of abuse and neglect was made by family of abuse and neglect on an unknown date and time regarding Resident #1. The report stated Resident #1 required total assistance with care and was not interviewable was transferred to a local hospital for a worsening wound on [DATE] with the Wound Care Nurse listed as the perpetrator. The report stated that the Wound Care Nurse was not providing wound care and was not being supervised by the DON. Lack of services, training and supervision led to worsening of the wound. In a verbal conversation with the hospital, the left foot was amputated. The investigative findings were confirmed Record review of Resident #1 face sheet dated [DATE] revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a potential for the development of a pressure ulcer with no evidence of an actual pressure ulcer or wound. The care plan did not address any actual wounds for Resident #1. Record review of a Doctor's Progress Note dated [DATE] revealed: Left foot with arterial wound to great toe, 2nd toe, 3rd toe. Clean left foot arterial wound to great toe, 2nd toe, 3rd toe, apply betadine daily. Wound Consult [illegible word], signed by the NP. Record review of a physician order dated [DATE] for wound care revealed LVN B put orders into the computer on [DATE] at 8:18 p.m. which were signed by the MD on [DATE]. The orders did not have a schedule for administration attached and indicated the orders were for the TX (wound) Nurse as non-medication orders. The orders were: wound care orders for atrial (sic) [arterial] wounds to the left foot, clean with normal saline, pat dry and apply betadine daily until wound consult to follow. Record Review of Resident #1's [DATE] TAR revealed no orders for wound care to the left great toe or left foot. The physician orders for treatment of the wounds to the left foot had not carried over to the TAR and there was no indication wound care was performed. Record review of the facility wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's [DATE] TAR revealed orders for weekly skin assessments scheduled for Fridays with staff initials to indicate the assessment was completed. Friday [DATE] was not marked as completed. The skin assessments for [DATE], [DATE], and [DATE], were initialed completed by LVN B. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facility wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's [DATE] TAR revealed an order for weekly skin assessments scheduled for Fridays with staff initials to indicate the assessment was completed. Friday [DATE] and Friday [DATE].2023 were not marked as completed. Friday [DATE], had an x marked through the assessment date. The skin assessments were completed 2 out of 5 opportunities. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facilities wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIM's score of 8 which indicated a moderate cognitive impairment. The assessment was coded for no ulcers, wounds, or skin problems. Record review of Resident #1's July TAR revealed orders for weekly skin assessments scheduled for Mondays with staff initials to indicate the assessment was completed. Monday [DATE], and Monday [DATE]th, 2023, were not marked as completed. This indicated skin assessments were completed 1 out of 3 opportunities for [DATE]. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed until [DATE]. Record review of the facilities wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's shower sheet dated [DATE] revealed a shower was not given for refusal of care written on the form. No skin issues were documented. The nurse signature was not legible. A second shower sheet dated [DATE] was documented that a shower was given, and no new skin issues were assessed by the nurse. The nurse signature was not legible. No other shower sheets could be located for Resident #1. Record review of Resident #1's progress notes revealed no documentation of skin assessment or wound assessments from [DATE]-current in the medical record. Record review of Resident #1's weekly skin integrity review dated [DATE] and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins. Record review of Resident #1's weekly skin integrity review dated [DATE] and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins and the buttocks. There was no other skin assessment prior to [DATE] or after [DATE] in the notebook. Record review of the 24-Hour Report Sheet (nurse to nurse communication between shifts) for Resident #1 revealed: [DATE]: Left toe dressing done [DATE]: big left toe needs wound nurse orders [DATE]: get treatment (nurse) to do wound care to left big toe [DATE]: get treatment (nurse) to do wound care to left big toe [DATE]: get treatment (nurse) to do wound car to left big toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe .hospice now, hospice will be in to write orders on Monday [DATE]: dressing to big left toe .hospice not, hospice to write orders Monday [DATE]: new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders, culture collected/pending . [DATE]: hospice orders pending, new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders . Record review of Resident #1's progress notes dates [DATE] revealed MD notified of condition of wound to LLE great toe. New orders received to get wound culture, CBC, renal panel, x-ray to LLE great toe to rule to osteomyelitis (infection of the bone), initial dose of Augmentin 500 mg (antibiotic) and Cipro 500 mg given and is to be continued for the next 10 days. Also received wound treatment orders . Record review of Resident #1's progress notes dated [DATE] documented by LVN B revealed: results in from x-ray of left toes .osteomyelitis not excluded .results faxed to MD, new orders pending. Record review of Resident #1's x-ray dated [DATE] of the left toe revealed minimal patchy osteolytic lesion involving first-proximal phalanx (great toe) ; mild diaphysis: osteomyelitis not excluded. Record review of Resident #1's physician order summary for [DATE] revealed an order for admit to hospice services with a start date of [DATE]. Record review of Resident #1's progress notes dated [DATE] documented by the ADON revealed: Resident sent out to [a local hospital] for worsening wound issues .that the family is concerned about. Per the family's request after a care plan meeting was completed, facility initiated a call for EMS to com(e) and transfer resident to the hospital. Notified MD of the hospital transfer . Record review of Resident #1's Care Plan Conference notes dated [DATE] and signed by the former DON on [DATE] revealed the form was blank and no information had been entered. Record review of Resident #1's hospital admission record dated [DATE] revealed the resident presented to the ER by EMS for necrotic toe present for over 1 week and a sore on the sacrum that is healing. Necrotic toe on the left gangrene (tissue death) , x-rays of extremity foot reveal osteomyelitis with gangrene and necrosis (infection of the bone with tissue death) .concerned about osteomyelitis with severe soft tissue infection. Patient does require admission. Impression: sepsis, toe necrosis, soft tissue infection, elevated lactic acid (indicated infection and is clinically significant as it shows correlation with sepsis and can indicate likelihood of critical illness), osteomyelitis of toe (infection that is in the bone), tachycardia (elevated heart rate which can indicate sepsis) . Record review of Resident #1's hospital record of x-ray to foot dated [DATE] revealed .soft tissue swelling is noted about the great toe with osseous erosive change involving the proximal phalanx (toe) .concerning for osteomyelitis with possible superimposed fracture (fracture can occur from severe osteomyelitis which weakens the bone). Record review of Resident #1's hospital record of physician assessment dated [DATE] revealed: Musculoskeletal/Skin: .left great toe notes severely necrotic changes to the soft tissue consistent with a mix of dry and wet gangrene, putrid odor coming from the foot. There is a palpable DP (dorsal pedal-pulse on the top of the foot indicating there is blood flow to the foot) pulse. There is surrounding erythema (redness) and purulent drainage (pus). Patient has a sacral decubitus (bed sore) ulcer with granulation tissue overlying it with no evidence of infection. Orthopedic consulted .Patient will need admission for further management and IV antibiotics and possible surgical intervention for his gangrenous infection of the left great toe. Record review of Resident #1's hospital record of wound culture to left great toe revealed the toe was infected with a moderate growth of proteus mirabilis (bacteria), very light growth of klebsiella pneumoniae a multi-drug resistant organism (bacteria that is resistant to many antibiotics), moderate growth of staphylococcus (bacteria). Record review of a hospital record for Resident #1 dated [DATE] revealed: Assessment/Plan: severe sepsis with shock initially requiring low dose of vasopressor (medication used to raise blood pressure in ICU setting which a sign of shock), WBC trending up (indicated infection), remains afebrile (without fever). Left first toe gangrene (tissue death with osteomyelitis (infection of the bone): continue vancomycin, cefepime, Flagyl (antibiotics), per ortho needs amputation. Record review of an undated photo of Resident #1's left foot revealed the left great toe from top of the foot view was dark black in color from the tip of the toe to the first joint with the appearance of a missing toenail. The area below the first joint was red and purple in color. There was a partially removed gauze from the toe revealed heavily soiled gauze with discharge that was beige, yellow, brown, pink, and red in color. There was a large amount of swelling to the right side of the great left toe starting at the tip of the toe, with the largest amount of swelling near the first joint that was discolored black, grey, brown, yellow, and pink and extending to the base of the first toe. The skin was peeling off the first toe. There was a large amount of drainage and moisture on the toe, and gauze. The other toes were obscured from view by the gauze. During an interview on [DATE] at 12:01 p.m. the Hospice Admission Nurse stated she admitted Resident #1 to hospice on [DATE]. She stated at the time of admission Resident #1 had a wound that was gooey, purulent with foul odor that smelt gangrenous and was poorly bandaged. She stated Resident 1 was very weak and had slow slurred speech that could not be understood. The Hospice Admission Nurse stated she asked the facility if Resident #1 was on antibiotics and they confirmed that he was on Augmentin, Cipro (antibiotics) and Dakin's (wound cleaner). She stated that she only admitted Resident #1 to hospice services and had no other interaction prior to his discharge. During an interview on [DATE] at 1:22 p.m., Resident #1's RP stated she had noticed the wrap to the resident's toe had not been changed (date unknown). She stated she got hospice involved (unknown date) because she did not feel like Resident #1 was getting the attention, he needed from the facility staff. She stated she had a meeting with the facility (names of staff unknown) on ,d+[DATE]. She stated they told her she could not put him in the hospital even though he was declining, but she did it anyway on the same date. She stated she did not want her family member to die. She stated she only got hospice because they told her he would get extra help. The RP stated Resident #1 was now going to have to have an amputation. The RP stated Resident #1 had dementia and was not interviewable. During an interview on [DATE] at 1:49 p.m. CNA E stated she was assigned to provide showers. She stated she had not given Resident #1 a shower because she thought he was on hospice and hospice usually provided showers. She stated she had a paper that told her which residents were on hospice but was unable to produce the paper. She stated she did not see any wounds to Resident #1 because she did not give him a shower. She stated she was trained to document open wounds on a shower sheet and verbally tell the nurse. During an interview on [DATE] at 1:55 p.m., CNA EE stated she never gave Resident #1 a shower because she was told (unknown person) he was on hospice and hospice was showering him. She stated she did not know of any wounds. She stated she reviewed a list of residents on hospice provided by former ADON DD. During an interview on [DATE] at 2:05 p.m. CNA FF stated she was assigned to Resident #1's hallway. She stated she did not remember ever filling out a shower sheet for Resident #1. She stated she thought he was hospice. She stated sometimes she would get him in the shower, but he did not like to take a shower and he would say stuff and yell. She stated she was mostly providing Resident #1 with bed baths. She stated she could not remember any wounds on his sacrum or wounds on his feet and did not remember if she saw any dressings. CNA FF stated Resident #1 had declined but she did not know why he left the facility. CNA FF stated she was trained to notify the nurse and wound care of any skin issues or wounds. She stated she was trained to fill out a shower sheet for showers and bed baths and document any wounds, redness, or anything unfamiliar or new. She stated she was trained to turn the shower sheet into the nurse and also tell the nurse verbally. During an interview on [DATE] at 2:17 p.m., the Wound Care Nurse stated she worked a M-F schedule. She stated on [DATE] and [DATE] she documented on a weekly skin assessment sheet that she kept in a binder in her office and was not part of the medical record that Resident #1 had redness to the left foot great toe. She stated on [DATE] Resident #1 also had redness to his bottom (sacrum) that was blanchable. The Wound Care Nurse stated she did not notify the physician about the redness to the bottom (sacrum) because she had zinc oxide as standing orders to take care of it. She stated she did not notify the physician about the redness to Resident #1's left great toe because it was positional. She stated she knew it was positional redness because the resident was bedbound and refuses. She stated in her nursing judgement there was no concern to notify. The Wound Care Nurse stated weekly head to toe skin assessments were documented in PCC (electronic medical chart) as a check on the resident TAR to show completion. She stated she did not document the results of the skin assessments in the resident medical record. She stated she kept the results on a paper document in a binder which she kept in her office. The Wound Care Nurse stated she only had weekly skin assessments documented for [DATE]. She stated she did not have any other documentation for July other than [DATE] and [DATE]. She stated she did not do weekly skin assessments last week ([DATE]-[DATE]) because she was out. She stated she did not know if weekly skin assessments had been completed in her absence and did not know if the nurses had access to the binder in her office. She stated the nurses or the ADON would have to do wound care in her absence. She stated she was told to keep the weekly skin assessment in a binder in her office. She stated she asked (unknown person) why she was not documenting in the medical record and was told by someone she could not remember to just keep them the skin assessments in her office. When asked how continuity of care was provided, where other nurses, physicians, etc. could review the skin assessments for residents if she was keeping skin assessments in a binder in her office, the Wound Care Nurse stated if there was an issue there would be an order for wound care that would pop up (in the computer). She stated she is notified of resident wounds by the charge nurses or when she completes the head-to-toe skin assessments. She stated the facility had house orders (standing orders/wound protocol) for wound care for wound care orders that she used on new wounds. The Wound Care Nurse stated the facility used to have a WC NP (Wound Care Nurse Practitioner) until two weeks ago. She stated the facility no longer had one as she was not meeting the Corporation's needs. The Wound Care Nurse stated the WC NP would see all residents with wounds except for patients on hospice and those with certain types of insurance. She stated she did not know what types of insurance were excluded. The Wound Care Nurse stated the facility did not have process to document condition of the wound because the WC NP documents it. When asked about the process for residents in which the WC NP did not see or in absence of a WC NP, the Wound Care Nurse stated the facility had not had any hospice residents with wounds and she hoped to have a new WC NP soon. The Wound Care Nurse stated she had received no training when she took the position as Wound Care Nurse, she stated the facility supplier of wound care supplies, and the physician were available to her for questions or concerns. She stated the wound care supplier was also a LVN that would come and train her when she requested. During an interview on [DATE] at 6:30 p.m., the Wound Care Nurse denied knowledge that Resident #1 had a wound to his left foot great toe. The Wound Care Nurse stated on [DATE] Resident #1 had redness to his sacrum and she applied zinc oxide per standing orders. She stated the next day he was okay and had so more redness. She stated she did not write the zinc oxide as an order in PCC. She stated she thought there was already an order for it in PCC. She stated the redness never progressed to anything beyond redness. The Wound Care Nurse stated sometime last week (date unknown) she heard that LVN notified the MD and got an x-ray and lab for Resident #1. She stated she also heard that Resident #1 was supposed to be seen by the NP for his toe. The Wound Care Nurse stated she provided wound care and assessed Resident 1's toe but did not document that assessment, only the treatment. She stated she did not know what the toe or wound looked like. She stated she was trained in nursing school to document assessments but had not been trained by the wound care supplier. She stated the wound care supplier gave her the run down on wound care and was supposed to return this week to give her further detail. The Wound Care Nurse stated she was notified by LVN B that Resident #1's toe was an open wound, but she could not remember the date. She stated it was sometime last week. The Wound Care Nurse stated she could not recall if Resident #1's toe or wound was discussed or if it was brought up during morning meetings. The Wound Care Nurse stated she was not in for parts of last week or she came in late, so she was not aware. Record review of the Wound Care Nurses Timecard for [DATE] revealed: Monday, [DATE]-clocked in for 5.25 hours from 8:54 a.m.-2:51 p.m. Tuesday, [DATE]-clocked in for 9.75 hours from 8:18 a.m.-6:30 p.m. Wednesday, [DATE]-clocked in for 3 hours from 4:05 p.m.-6:59 p.m. Thursday, [DATE]-clocked in for 5.75 hours from 6:49 am-8:34 am and 12:32 p.m.-4:56 p.m. Friday, [DATE]-clocked in for 7.75 hours from 8:44 a.m.-5:02 p.m. Monday, [DATE]-clocked in for 8.0 hours from 9:00 a.m.-5:25 p.m. Tuesday, [DATE]-clocked in for 9.0 hours from 9:00 a.m.-6:34 p.m. Wednesday, [DATE]-clocked in for 9.0 hours from 7:25 a.m.-5:07 p.m. Thursday, [DATE]-clocked in for 10.25 hours from 7:39 a.m.-6:28 p.m. Friday, [DATE]-clocked in for 4 hours from 2:25 p.m.-6:34 p.m. Monday, [DATE]- did not clock in or out, no hours reported Tuesday, [DATE]-clocked in for 6.0 hours from 1:10 p.m.-7:47 p.m. Wednesday, [DATE]-clocked in for 12 hours from 9:21 a.m.-9:49 p.m. Thursday, [DATE]- clocked in for 11.25 hours from 8:44 a.m.-8:29 p.m. Friday, [DATE]-clocked in for 8.25 hours from 10:58 a.m.-7:43 p.m. During an interview on [DATE] at 9:59 a.m., CNA A stated she used to be the shower aide on Resident #1's hallway approximately 1 month ago. She stated there was a lot of staff inconsistency because it was a heavy workload hall, and nobody wanted to work it. CNA A stated she had not provided Resident 1 showers in the last month. She stated previously he had a wound on his bottom (unknown date) She stated she notified the nurse. She stated she did not remember who the nurse was at the time. She stated she was trained that anytime she saw something new she would go immediately to the nurse. CNA A stated when she saw the wound on Resident #1's bottom it was an open wound without skin on top, about the size of a dime. She stated she thinks it might have been LVN B that she notified but could not be certain. She stated later she saw white medicine on Resident #1's bottom. CNA A stated her responsibility was to report and it was the nurse's responsibility to take the next steps. She stated her communicated with the nurses verbally. CNA A stated she saw Resident #1 with a bandage on his foot, and she smelled something rotten. She stated she started looking in Resident #1's room for the location of the smell and finally realized it was coming from his foot. CNA A stated it was the same day Resident #1 got the x-ray of his foot. She stated after assisting with the x-ray she told the nurse that his foot smelled really bad, and the toe was brown. She stated the following day when she came in the bandage had been changed and the smell was better. CNA A stated when she first noticed the wound on Resident #1's bottom, he already had a bandage on his foot. She stated the whole foot was bandaged (unsure if it was right or left foot) and there was blood on the bandage ear his big toe. She stated she never saw the wound and even during rounds when coming on shift it was never reported that Resident #1 had a wound during rounds. During an interview on [DATE] at 11:01 a.m., LVN B stated she was assigned as the nurse to Resident #1's hallway and worked 6 a.m. to 6 p.m. LVN B stated Resident #1 had an old atrial [arterial] wound to his left foot since [DATE]. LVN B stated in [DATE], CNA A came to her and told her about a wound to Resident 1's foot. She stated she called the MD and received wound care orders in [DATE] and the receptionist at the MD's office told her to inform the in house Wound Care Nurse. LVN B stated she notified the Wound Care Nurse via text. She stated she had since deleted the text. She stated there were orders to treat the wound that she put in PCC. LVN B stated she did not provide wound care to the wound because the facility had a Wound Care Nurse to provide treatments. LVN B stated she did not know what happened to the order for wound care in [DATE]. She stated she got the orders the very first time she saw it but may have passed the orders on to the next shift to complete. She stated she could not remember. She stated she did not know the outcome of the wound because she left the charge nurse position to do facility staffing, although she came back to the charge nurse position in [DATE]. LVN B stated she looked at the wound on the weekends and it looked good. LVN B stated resident #1 was a diabetic and was not moving around and he could no longer sit himself up in bed. She stated he had become bedbound. LVN B stated the resident was not eating and the facility had recommended hospice. LVN B stated the family initially refused hospice. LVN B stated, in [DATE], a family member and herself saw blood on the floor, a few specks. LVN B stated she discovered the blood was coming from Resident #1's toe, but nothing big. LVN B stated she first noticed the wound on his foot approximately [DATE] and that was the last time she assessed it. LVN B stated Resident #1 was put on hospice care ([DATE]) right before he went to the hospital ([DATE]). She stated the (left foot great) toe looked discolored, but not necrotic. She said the toe was purplish kind of like a bruise and had the same opening on it from April. LVN B stated it looked the same. LVN B stated the ADON went to see the wound. LVN B stated she was not aware of a wound to Resident #1's bottom (sacrum). She stated she also completed a skin assessment but did not document the findings. LVN B stated she only documents negative findings in progress notes and does not document otherwise. LVN B stated Resident #1's wound was documented in the 24-hour notes (not part of medical record). LVN B stated she did not document because a family member was in the room and the facility had a WC NP who would do wound care rounds. She stated she addressed the wounds with the WC NP. LVN B stated in [DATE] Resident #1 declined. She stated Resident #1's family member said he looked sick, and he was not eating. LVN B stated Resident #1 looked kind of grayish, like he was going to pass on. She stated that was expected. LVN B stated Resident #1 did not go to the hospital because of his wound, he went because the family requested. She stated the family kept telling EMS that Resident #1 was not on hospice and that they facility do not care about him. During an interview on [DATE] at 11:19 a.m., CNA C stated when he provided care to Resident #1 (unknown date), he had noticed scratches to his arms which had resolved and a wound to the left foot ankle area (unknown time frame). CNA C stated he never saw a wound on Resident #1's bottom (sacrum). CNA C stated he had an uncle that was similar to Resident #1, so he did not look at Resident #'1 feet because it grossed him out. CNA C stated he knew Resident #1 had a wound big toe, although he was not sure which foot. CNA C stated he first noticed the wound when he removed a blanket from Resident #1 and his toe stuck to the sheet, pulling off a piece of skin when he removed the sheet. He stated this might have occurred during the first week of [DATE], but he was not certain. CNA C stated Resident #1's toenail was intact but some of the skin was missing near the side of the nail approximately 1 cm long. He stated there was [NAME] but no blood. He described the [NAME] as what a wound looks like when a scab is removed. CNA C stated there was no redness or swelling. He stated he notified RN D, who stated she would look at it. He stated RN D never mentioned it again and his assignment changed during the shift, so he did not see what happened. During an interview on [DATE] at 12:19 p.m., the ADON stated the facility did not have a DON. He stated the other ADON, (ADON DD) died suddenly a few days ago. The ADON stated he was new the facility as ADON as of [DATE]. The ADON stated confirmation that Resident #1 had a wound to wound to toe (left great toe) in which LVN B put created an order for wound care on [DATE] but did not activate the order and it did not populate to the MAR (TAR) as an order. The ADON stated a CNA pointed out to LVN B that the wound had not been changed and LVN B let the Wound Care Nurse know. The ADON stated the CNA saw the wound had not been changed a told the Wound Care Nurse know and she changed the wound right then. The ADON stated the wound was not changed from then (date unknown) until he saw the wound on [DATE]. The ADON stated he went to look at the wound when the RP demanded the facility address some issues in which the RP thought the dressing looked old. The ADON stated the dressing was a kerlix gauze that was stretched out and discolored with red, black and yellow drainage. He stated the dressing was not dated and it did look old. The ADON stated the wound had an odor that smelled rancid, like a rotting smell. He stated once he removed the old dressing the odor hit him in the face. He described the smell as overwhelming. The ADON stated when he removed the dressing multiple layers of skin were also removed with the dressing. He stated there was yellow, green and necrotic tissue that was moist, black and liquidly. The ADON stated the entire toenail from the base forward came off with the dressing. He stated the area under the nail was completely black. After looking at a photo of the toe, the ADON stated the toe was worse than the picture. He stated in the picture parts of the wound looked dry, but when he saw it was completely moist. The ADON stated there bubbles of stuff resembling pus coming out of the toe when he tried to clean the wound. He described the pus as yellow/black in color with a mixture of greyish brown. He stated no one had told him of the condition of the wound before he saw it. He stated it was very alarming to him. The ADON stated he was not even aware there was a [TRUNCATED]

Based on interview and record review the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 1 of 8 residents (Resident #1) and for 4 of 6 licensed staff (Wound Care Nurse, RN D, LVN B and LVN II) reviewed for competent staff, in that: 1. The facility failed to ensure the Wound Care Nurse had completed training for a license violation and remediation and failed to ensure she was competent to perform skin assessments, wound assessments, obtain and implement physician orders and document her finding in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. 2. The facility failed to ensue RN D had the competencies to identify a resident change of condition, obtain and implement physician orders for wound care, assess wounds and document her findings in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. 3. The facility failed to ensure LVN B had the competencies and training to assess and identify wounds, obtain, and implement wound care orders and document her findings in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. 4. The facility failed to ensure LVN II had the competencies and training to assess and identify wounds, obtain, and implement wound care orders and document her findings in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. An IJ was identified on 8/18/2023. The IJ template was provided to the facility on [DATE] at 11:15 a.m. While the IJ was removed on 8/19/2023 at 6:46 p.m., the facility remained out of compliance at a scope of pattern and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. These failures could place residents at risk for not receiving nursing services by adequately trained and licensed nurses and could result in untreated wounds, a decline in health, infection, amputation and/or death. The findings included: 1. Record review of a facility self-report dated 8/2/2023 the facility reported Resident #1 wound care orders placed in chart on 4/27/2023 were not followed up. Resident #1 became septic and resulted in amputation of big toe. The facility listed RN D and LVN B as the alleged perpetrators. Record review of Form 3613-A dated 8/02/2023 and signed by the facility Administrator on 8/4/2023 revealed an allegation of abuse and neglect was made by family of abuse and neglect on an unknown date and time regarding Resident #1. The report stated Resident #1 required total assistance with care and was not interviewable was transferred to a local hospital for a worsening wound on 7/21/2023 with the Wound Care Nurse listed as the perpetrator. The report stated that the Wound Care Nurse was not providing wound care and was not being supervised by the DON. Lack of services, training and supervision led to worsening of the wound. In a verbal conversation with the hospital, the left foot was amputated. The investigative findings were confirmed. Record review of Resident #1 face sheet dated 7/25/23 revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's Care Plan dated 9/21/2022 revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record review of Resident #1's Care Plan dated 7/20/2023 revealed the resident had a potential for the development of a pressure ulcer with interventions to included administer analgesics as needed for discomfort or pain, reposition frequently and check frequently for wetness or soiling. The care plan did not address an actual pressure ulcer or wound for Resident #1 Record review of a Doctor's Progress Note dated 4/27/2023 revealed: Left foot with arterial wound to great toe, 2nd toe, 3rd toe. Clean left foot arterial wound to great toe, 2nd toe, 3rd toe, apply betadine daily. Wound Consult [illegible word], signed by the NP. Record review of a physician order dated 4/27/2023 for wound care revealed LVN B put orders into the computer on 4/27/2023 at 8:18 p.m. which were signed by the MD on 4/30/2023. The orders did not have a schedule for administration attached and indicated the orders were for the TX (wound) Nurse as non-medication orders. The orders were: wound care orders for atrial (sic) [arterial] wounds to the left foot, clean with normal saline, pat dry and apply betadine daily until wound consult to follow. Record Review of Resident #1's April 2023 TAR revealed no orders for wound care to the left great toe or left foot. The physician orders for treatment of the wounds to the left foot had not carried over to the TAR and there was no indication wound care was performed. Record review of the facility wound log for April 2023 revealed Resident #1 was not listed on the log. Record review of Resident #1's May 2023 TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facility wound log for May 2023 revealed Resident #1 was not listed on the log. Record review of Resident #1's June 2023 TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facilities wound log for June 2023 revealed Resident #1 was not listed on the log. Record review of Resident #1's July 2023 TAR revealed no orders for wound care and there was no indication wound care was performed until July 18, 2023. The TAR revealed on July 18, 2023 the left great toe was treated with 1/2 strength Dakin's external solution 0.25% and covered with a non-adherent dressing. Record review of the facilities wound log for July 2023 revealed Resident #1 was not listed on the log. Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIM's score of 8 which indicated a moderate cognitive impairment. The assessment was coded for no ulcers, wounds, or skin problems. Record review of Resident #1's weekly skin integrity review dated 7/02/2023 and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins. There were no other skin assessments prior to 7/02/2023. Record review of Resident #1's weekly skin integrity review dated 7/10/2023 and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins and the buttocks. There was no other skin assessment after 7/10/2023 in the notebook. Record review of the 24-Hour Report Sheet (nurse to nurse communication between shifts) for Resident #1 revealed the following entries between July 1- July 19th, 2023. There were no signatures or indication of who wrote the entries: 7/01/2023: Left toe dressing done 7/02/2023: big left toe needs wound nurse orders 7/03/2023: get treatment (nurse) to do wound care to left big toe 7/05/2023: get treatment (nurse) to do wound care to left big toe 7/06/2023: get treatment (nurse) to do wound car to left big toe 7/11/2023: dressing to big left toe 7/12/2023: dressing to big left toe 7/13/2023: dressing to big left toe 7/14/2023: dressing to big left toe 7/15/2023: dressing to big left toe 7/16/2023: dressing to big left toe .hospice now, hospice will be in to write orders on Monday 7/17/2023: dressing to big left toe .hospice not, hospice to write orders Monday 7/18/2023: new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders, culture collected/pending . 7/19/2023: hospice orders pending, new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders . Record review of Resident #1's progress notes dates 7/18/2023 revealed MD notified of condition of wound to LLE great toe. New orders received to get wound culture, CBC, renal panel, x-ray to LLE great toe to rule to osteomyelitis (infection of the bone), initial dose of Augmentin 500 mg (antibiotic) and Cipro 500 mg given and is to be continued for the next 10 days. Also received wound treatment orders . Record review of Resident #1's progress notes dated 7/18/2023 documented by LVN B revealed: results in from x-ray of left toes .osteomyelitis not excluded .results faxed to MD, new orders pending. Record review of Resident #1's x-ray dated 7/18/2023 of the left toe revealed minimal patchy osteolytic lesion involving first-proximal phalanx (great toe) ; mild diaphysis: osteomyelitis not excluded. Record review of Resident #1's physician order summary for July 2023 revealed an order for admit to hospice services with a start date of 7/19/2023. Record review of Resident #1's progress notes dated 7/21/2023 documented by the ADON revealed: Resident sent out to [a local hospital] for worsening wound issues .that the family is concerned about. Per the family's request after a care plan meeting was completed, facility initiated a call for EMS to com(e) and transfer resident to the hospital. Notified MD of the hospital transfer . Record review of Resident #1's Care Plan Conference notes dated 7/21/2023 and signed by the former DON on 7/21/2023 revealed the form was blank and no information had been entered. Record review of Resident #1's hospital admission record dated 7/21/2023 revealed the resident, presented to the ER by EMS for necrotic toe present for over 1 week and a sore on the sacrum that is healing. Necrotic toe on the left gangrene (tissue death) , x-rays of extremity foot reveal osteomyelitis with gangrene and necrosis (infection of the bone with tissue death) .concerned about osteomyelitis with severe soft tissue infection. Patient does require admission. Impression: sepsis, toe necrosis, soft tissue infection, elevated lactic acid (indicated infection and is clinically significant as it shows correlation with sepsis and can indicate likelihood of critical illness), osteomyelitis of toe (infection that is in the bone), tachycardia (elevated heart rate which can indicate sepsis) . Record review of Resident #1's hospital record of x-ray to foot dated 7/21/2023 revealed, .soft tissue swelling is noted about the great toe with osseous erosive change involving the proximal phalanx (toe) .concerning for osteomyelitis with possible superimposed fracture (fracture can occur from severe osteomyelitis which weakens the bone). Record review of Resident #1's hospital record of physician assessment dated [DATE] revealed: Musculoskeletal/Skin: .left great toe notes severely necrotic changes to the soft tissue consistent with a mix of dry and wet gangrene, putrid odor coming from the foot. There is a palpable DP (dorsal pedal-pulse on the top of the foot indicating there is blood flow to the foot) pulse. There is surrounding erythema (redness) and purulent drainage (pus). Patient has a sacral decubitus (bed sore) ulcer with granulation tissue overlying it with no evidence of infection. Orthopedic consulted .Patient will need admission for further management and IV antibiotics and possible surgical intervention for his gangrenous infection of the left great toe. Record review of a hospital record for Resident #1 dated 7/22/2023 revealed: Assessment/Plan: severe sepsis with shock initially requiring low dose of vasopressor (medication used to raise blood pressure in ICU setting which a sign of shock), WBC trending up (indicated infection), remains afebrile (without fever). Left first toe gangrene (tissue death with osteomyelitis (infection of the bone): continue vancomycin, cefepime, Flagyl (antibiotics), per ortho needs amputation. Record review of an undated photo of Resident #1's left foot revealed the left great toe from top of the foot view was dark black in color from the tip of the toe to the first joint with the appearance of a missing toenail. The area below the first joint was red and purple in color. There was a partially removed gauze from the toe revealed heavily soiled gauze with discharge that was beige, yellow, brown, pink, and red in color. There was a large amount of swelling to the right side of the great left toe starting at the tip of the toe, with the largest amount of swelling near the first joint that was discolored black, grey, brown, yellow, and pink and extending to the base of the first toe. The skin was peeling off the first toe. There was a large amount of drainage and moisture on the toe, and gauze. The other toes were obscured from view by the gauze. During an interview on 7/25/2023 at 12:01 p.m. the Hospice Admission Nurse stated she admitted Resident #1 to hospice on 7/19/2023. She stated at the time of admission Resident #1 had a wound that was gooey, purulent with foul odor that smelt gangrenous and was poorly bandaged. She stated Resident 1 was very weak and had slow slurred speech that could not be understood. The Hospice Admission Nurse stated she asked the facility if Resident #1 was on antibiotics and they confirmed that he was on Augmentin, Cipro (antibiotics) and Dakin's (wound cleaner). She stated that she only admitted Resident #1 to hospice services and had no other interaction prior to his discharge. During an interview on 7/25/2023 at 1:22 p.m., Resident #1's RP stated she had noticed the wrap to the resident's toe had not been changed (date unknown). She stated she got hospice involved (unknown date) because she did not feel like Resident #1 was getting the attention, he needed from the facility staff. She stated she had a meeting with the facility (names of staff unknown) on 721/2023. She stated they told her she could not put him in the hospital even though he was declining, but she did it anyway on the same date. She stated she did not want her family member to die. She stated she only got hospice because they told her he would get extra help. The RP stated Resident #1 was now going to have to have an amputation. The RP stated Resident #1 had dementia and was not interviewable. During an interview on 7/25/2023 at 2:17 p.m., the Wound Care Nurse stated she worked a M-F schedule. She stated on 7/03/2023 and 7/10/2023 she documented on a weekly skin assessment sheet that she kept in a binder in her office and was not part of the medical record that Resident #1 had redness to the left foot great toe. She stated on 7/10/2023 Resident #1 also had redness to his bottom (sacrum) that was blanchable. The Wound Care Nurse stated she did not notify the physician about the redness to the bottom (sacrum) because she had zinc oxide as standing orders to take care of it. She stated she did not notify the physician about the redness to Resident #1's left great toe because it was positional. She stated she knew it was positional redness because the resident was bedbound and refuses to be turned and positioned. She stated in her nursing judgement there was no concern to notify. The Wound Care Nurse stated she only had weekly skin assessments documented for July 2023. The Wound Care Nurse stated she worked a M-F schedule but was out last week (7/17/21-7/21/23) so no skin assessments were completed, and she did not know if the charge nurse did assessments. She stated she did not know if the nurses had access to the skin assessment binder because she kept it in her office. The Wound Care Nurse stated when she was not in the facility the nurses or the ADON wound have to provide wound care. She stated either the ADON or DON would have to inform the nurses she was not at work. The Wound Care Nurse stated she had been in the wound care position officially in June 2023 although she had been in the position and performing wound care before that time (dates unknown). She stated she is notified of resident wounds by the charge nurses or when she completes the head-to-toe skin assessments. She stated the facility had house orders (standing orders/wound protocol) for wound care for wound care orders that she used on new wounds. The Wound Care Nurse stated the facility used to have a WC NP (Wound Care Nurse Practitioner) until two weeks ago. She stated the facility no longer had one as she was not meeting the Corporation's needs. The Wound Care Nurse stated the WC NP would see all residents with wounds except for patients on hospice and those with certain types of insurance. She stated she did not know what types of insurance were excluded. The Wound Care Nurse stated weekly head to toe skin assessments were documented in PCC (electronic medical chart) as a check on the resident TAR to show completion. She stated she did not document the results of the skin assessments in the resident medical record. She stated she kept the results on a paper document in a binder which she kept in her office. The Wound Care Nurse stated she was told to document in the binder. She stated she asked why she was documenting in a binder, and they told her to just keep it in the binder. She stated she does not remember who told her. The Wound care nurse stated she only keeps the current ones in the binder, and she only had July 2023. When asked how continuity of care where other nurses, physicians, etc. could review the skin assessments a was provided for residents if she was keeping skin assessments in a binder in her office, the Wound Care Nurse stated if there was an issue there would be an order for wound care that would pop up (in the computer). The Wound Care Nurse stated the facility did not have a process to document redness on the skin assessment other than just redness. When asked if she assessed if redness was blanchable and how she documented, she stated redness was not anything that was severe. She stated if a wound was not blanchable she wound notify the physician because it indicated poor circulation. She stated it was a nursing judgment. She stated redness was usually located on the bum or as dryness to the legs and was nothing to notify the physician about. She stated she had standing orders for zinc oxide to take care of it. The Wound Care Nurse stated the facility relied on wound measurement and wound description documentation as documented by the WC NP who came to the facility 1 time a week. She stated if without a WC NP she wound document on the skin assessment or progress note if there was a concern, but she did not have to do measurements because the WC NP was already doing them, and she was never told to document it. The Wound Care Nurse stated the facility did not have process to document condition of the wound because the WC NP documents it. When asked about the process for residents in which the WC NP did not see or in absence of a WC NP, the Wound Care Nurse stated the facility had not had any hospice residents with wounds and she hoped to have a new WC NP soon. The Wound Care Nurse stated she had received no training when she took the position as Wound Care Nurse, she stated the facility supplier of wound care supplies, and the physician were available to her for questions or concerns. She stated the wound care supplier was also a LVN that would come and train her when she requested. During an interview on 7/25/2023 at 6:30 p.m., the Wound Care Nurse denied knowledge that Resident #1 had a wound to his left foot great toe. The Wound Care Nurse stated on 7/10/2023 Resident #1 had redness to his sacrum and she applied zinc oxide per standing orders. She stated the next day he was okay and had so more redness. She stated she did not write the zinc oxide as an order in PCC. The Wound Care Nurse stated she thought there was already an order for it in PCC. She stated the redness never progressed to anything beyond redness. The Wound Care Nurse stated sometime last week (date unknown) she heard that LVN B notified the MD and got an x-ray and lab for Resident #1. She stated she also heard that Resident #1 was supposed to be seen by the NP for his toe. The Wound Care Nurse stated she provided wound care and assessed Resident #1's toe but did not document that assessment, only the treatment (after intervention by LVN B). The Wound Care Nurse stated she did not know what the toe or wound looked like. She stated she was trained in nursing school to document assessments but had not been trained by the wound care supplier. She stated the wound care supplier gave her the run down on wound care and was supposed to return this week to give her further detail. The Wound Care Nurse stated she was notified by LVN B that Resident #1's toe was an open wound, but she could not remember the date. She stated it was sometime last week. The Wound Care Nurse stated she could not recall if Resident #1's toe or wound was discussed or if it was brought up during morning meetings. The Wound Care Nurse stated she was not in for parts of last week or she came in late, so she was not aware. Record review of the Wound Care Nurses Timecard for July 2023 revealed: Monday, 7/03/2023-clocked in for 5.25 hours from 8:54 a.m.-2:51 p.m. Tuesday, 7/04/2023-clocked in for 9.75 hours from 8:18 a.m.-6:30 p.m. Wednesday, 7/05/2023-clocked in for 3 hours from 4:05 p.m.-6:59 p.m. Thursday, 7/06/2023-clocked in for 5.75 hours from 6:49 am-8:34 am and 12:32 p.m.-4:56 p.m. Friday, 7/07/2023-clocked in for 7.75 hours from 8:44 a.m.-5:02 p.m. Monday, 7/10/2023-clocked in for 8.0 hours from 9:00 a.m.-5:25 p.m. Tuesday, 7/11/2023-clocked in for 9.0 hours from 9:00 a.m.-6:34 p.m. Wednesday, 7/12/2023-clocked in for 9.0 hours from 7:25 a.m.-5:07 p.m. Thursday, 7/13/2023-clocked in for 10.25 hours from 7:39 a.m.-6:28 p.m. Friday, 7/14/2023-clocked in for 4 hours from 2:25 p.m.-6:34 p.m. Monday, 7/17/2023- did not clock in or out, no hours reported Tuesday, 7/18/2023-clocked in for 6.0 hours from 1:10 p.m.-7:47 p.m. Wednesday, 7/19/2023-clocked in for 12 hours from 9:21 a.m.-9:49 p.m. Thursday, 7/20/2023- clocked in for 11.25 hours from 8:44 a.m.-8:29 p.m. Friday, 7/21/2023-clocked in for 8.25 hours from 10:58 a.m.-7:43 p.m. During an interview on 7/26/2023 at 9:59 a.m., CNA A stated she used to be the shower aide on Resident #1's hallway approximately 1 month ago. She stated there was a lot of staff inconsistency because it was a heavy workload hall, and nobody wanted to work it. CNA A stated she had not provided Resident 1 showers in the last month. She stated previously he had a wound on his bottom (unknown date) She stated she notified the nurse. She stated she did not remember who the nurse was at the time. She stated she was trained that anytime she saw something new she would go immediately to the nurse. CNA A stated when she saw the wound on Resident #1's bottom it was an open wound without skin on top, about the size of a dime. She stated she thinks it might have been LVN B that she notified but could not be certain. She stated later she saw white medicine on Resident #1's bottom. CNA A stated her responsibility was to report and it was the nurse's responsibility to take the next steps. She stated her communicated with the nurses verbally. CNA A stated she saw Resident #1 with a bandage on his foot, and she smelled something rotten. She stated she started looking in Resident #1's room for the location of the smell and finally realized it was coming from his foot. CNA A stated it was the same day Resident #1 got the x-ray of his foot. She stated after assisting with the x-ray she told the nurse that his foot smelled really bad, and the toe was brown. She stated the following day when she came in the bandage had been changed and the smell was better. CNA A stated when she first noticed the wound on Resident #1's bottom, he already had a bandage on his foot. She stated the whole foot was bandaged (unsure if it was right or left foot) and there was blood on the bandage near his big toe. She stated she never saw the wound and even during rounds when coming on shift it was never reported that Resident #1 had a wound during rounds. During an interview on 7/27/2023 at 1:25 p.m., the Administrator stated the WC NP was let go on 7/21/2023 after giving her a 30-day notice on 6/21/2023. The Administrator stated the wound care product supplier was not providing wound care, only education. During an interview on 7/27/2923 at 1:36 p.m., an LVN from the wound care product supplier stated her company provided part B wound care products. She stated they also assisted with in-service training, skin sweeps and staff training. The LVN stated she was training the Wound Care Nurse and started approximately 1 week ago with desk training. She stated they did not go in depth during the training, and she was supposed to come back. During an interview on 7/27/2023 at 1:52 p.m., the Regional Compliance RN stated she spoke with the former DON about getting more education for the Wound Care Nurse. She stated they scheduled the training, but the Wound Care Nurse did not come in and another time it did not happen (dates unknown). She stated she had provided the educational opportunities, but they had not yet happened. The Regional Compliance RN stated the Wound Care Nurse needed additional training because she was asking questions about treatment. She stated she told the former DON she needed to help the Wound Care Nurse out and support her to be successful. The Regional Compliance RN stated she had been in the building on and off but not every week. She stated she had no set schedule. The Regional Compliance RN stated she spoke with the former DON about getting more education for the Wound Care Nurse. She stated they scheduled the training, but the Wound Care Nurse did not come in and another time it did not happened (dates unknown). She stated she had provided the educational opportunities, but they had not yet happened. The Regional Compliance RN stated the Wound Care Nurse needed additional training because she was asking questions about treatment. She stated she told the former DON she needed to help the Wound Care Nurse out and support her to be successful. The Regional Compliance RN stated she had not recently seen the Wound Care Nurses work. She stated she was with her in the past (dates unknown). She stated the Wound Care Nurse was nervous, but she could not say she did a bad job. She stated the Wound Care Nurse had started as an intern and stepped up to the role and offered to help the facility out and the former DON and former Administrator put her in the job permanently. The Regional Compliance RN stated she did not have any input on that decision. She stated the Wound Care Nurse should do measurements, know drainage, condition wound bed, condition of the surrounding tissues, but as a LVN she could not stage a wound. She stated they had asked the Wound Care Nurse to describe the wounds and then the RN/NP wound then determine etiology and staging. She stated the Wound Care RN was to document the wound description in the wound care product supplier website and as a wound note in PCC. The Regional Compliance RN stated the Wound Care RN should be assessing wounds and documenting at least weekly. She stated the former DON was responsible for oversight of wound care and resident care and systems. The Regional Compliance RN stated the DON may delegate but she had overall responsibility to effectively manage it. During an interview on 7/27/2023 at 2:11 p.m. the WC NP (Wound Care Nurse Practitioner) stated she no worked at the facility as of July 17, 2023. She stated while she was working for the facility the staff would notify her of new wound. She stated she saw all new wounds and all new admits checking their skin. The WC NP stated there were some hospice residents she did not see unless hospice requested it. She stated there was just a few incidents of residents she did not see. She stated Resident #1 discharged from the facility on 7/21/2023. She stated she last saw Resident #1 on 4/10/2023 due to a right traumatic amputation (other foot, not current foot involved). She stated she never saw Resident #1 after that date and was never called again to consult on him and never heard his name again. The WC NP stated she did have concerns about the Wound Care Nurse not changing bandages (unknown residents) but not related to Resident #1. She stated on 7/17/2023 she rounded with the ADON because the Wound Care Nurse was not at the facility. She stated during round there were some patients with the same bandages from 7/12/2023 and the ADON saw it too. She stated she put a list together and gave it to the ADON via email and discussed it with the former DON. She stated she did not have access to the resident names at the time of interview. The WC NP stated she discussed concerns with the former DON of numerous occasions including not having supplies ordered and staff putting on wrong bandages. She stated it was important for the residents to receive the correct bandages. The WC NP stated she was having issues with the supply person. She stated without the proper supplies the wounds were not getting proper treatment. The WC NP stated she was relieved when her contract with the facility ended. She stated she felt like the Wound Care Nurse did not feel like putting in an effort. She stated the nurses were complaining that the Wound Care Nurse was asking them to do wound care when she had been at the facility all day. During an interview on 7/27/2023 at 2:32 p.m., the ADON stated confirmation that he had received complaints about the Wound Care Nurse. He stated she had written new dates on old dressings with sharpy. He stated he told the former Administrator who referred him to the former DON. The ADON stated he told the former DON who stated she would handle it and address it. The ADON stated the DON had told him that they (clinical management team) were all equals, so he did not have authority to correct the Wound Care Nurse. He stated the DON told him he was not allowed to counsel the Wound Care Nurse on wound care. She said she would do it herself. The ADON stated he thought Resident #1's wounds and wound care got missed due to lack of professionalism from the Wound Care Nurse and the DON. He stated no corrective action was ever taken by the DON. He stated he communicated with the former Administrator and former DON depending on the issue they always get notified either by text or in-person. He stated he was not given the authority to monitor staff. He stated the staff would have to tell him when they would go on break, when they clocked in and out, but nothing related to resident care. The ADON stated as an ADON in other facilities he had previously worked at he would do audits. He stated when he started at this facility, he was told he could not do that by the Wound Care Nurse and the former DON backed her up. The ADON stated the DON asked him not to document in PCC and document on paper. He stated he did what she asked him to do and gave her the document like she requested. He stated he did not know what happened to the note. The ADON stated he was familiar with the wound care policy. He stated it was available on the shared drive to all staff including the DON. The ADON stated to protect residents from harm he had to take charge, just like he did when he found out about Resident #1's toe wound. He stated when he found out (7/17/2023) he did not delegate he notified the MD, got antibiotics orders, labs and x-rays ordered. The ADON stated yes, this was neglect. He stated he did not consider it abuse because the actions were not intentional. He stated the lack of wound care to Resident #1 had some factors of abuse but was not done out of spite, therefore he considered it more neglect [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #1) reviewed for neglect, in that: The facility failed to develop and implement systems to properly treat Resident #1's arterial wound to his left foot great toe from [DATE] until [DATE] which resulted in hospitalization , sepsis, gangrene, necrosis and amputation. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on [DATE] at 11:54 a.m., the facility remained out of compliance at a scope of pattern and severity of harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice placed residents at risk of psychosocial harm, infection, a decline in health, amputation and death. The findings were: Record review of a facility self-report dated [DATE] revealed the facility reported Resident #1 wound care orders placed in chart on [DATE] were not followed up. Resident #1 became septic and resulted in amputation of big toe. The facility listed RN D and LVN B as the alleged perpetrators. Record review of Form 3613-A dated [DATE] and signed by the facility Administrator on [DATE] revealed an allegation of abuse and neglect was made by family of abuse and neglect on an unknown date and time regarding Resident #1. The report stated Resident #1 required total assistance with care and was not interviewable was transferred to a local hospital for a worsening wound on [DATE] with the Wound Care Nurse listed as the perpetrator. The report stated that the Wound Care Nurse was not providing wound care and was not being supervised by the DON. Lack of services, training and supervision led to worsening of the wound. In a verbal conversation with the hospital, the left foot was amputated. The investigative findings were confirmed Record review of Resident #1 face sheet dated [DATE] revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIMS's score of 8 which indicated a moderate cognitive impairment. The assessment was coded for no ulcers, wounds, or skin problems. Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a potential for the development of a pressure ulcer with no evidence of an actual pressure ulcer or wound. The care plan did not address any actual wounds for Resident #1. Record review of a Doctor's Progress Note dated [DATE] revealed: Left foot with arterial wound to great toe, 2nd toe, 3rd toe. Clean left foot arterial wound to great toe, 2nd toe, 3rd toe, apply betadine daily. Wound Consult [illegible word], signed by the NP. Record review of a physician order dated [DATE] for wound care revealed LVN B put orders into the computer on [DATE] at 8:18 p.m. which were signed by the MD on [DATE]. The orders did not have a schedule for administration attached and indicated the orders were for the TX (wound) Nurse as non-medication orders. The orders were: wound care orders for atrial (sic) [arterial] wounds to the left foot, clean with normal saline, pat dry and apply betadine daily until wound consult to follow. Record Review of Resident #1's [DATE] TAR revealed no orders for wound care to the left great toe or left foot. The physician orders for treatment of the wounds to the left foot had not carried over to the TAR and there was no indication wound care was performed. Record review of the facility's wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's [DATE] TAR revealed orders for weekly skin assessments scheduled for Fridays with staff initials to indicate the assessment was completed. Friday [DATE] was not marked as completed. The skin assessments for [DATE], [DATE], and [DATE], were initialed completed by LVN B. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facility wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's [DATE] TAR revealed an order for weekly skin assessments scheduled for Fridays with staff initials to indicate the assessment was completed. Friday [DATE] and Friday [DATE].2023 were not marked as completed. Friday [DATE], had an x marked through the assessment date. The skin assessments were completed 2 out of 5 opportunities. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facilities wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's July TAR revealed orders for weekly skin assessments scheduled for Mondays with staff initials to indicate the assessment was completed. Monday [DATE], and Monday [DATE]th, 2023, were not marked as completed. This indicated skin assessments were completed 1 out of 3 opportunities for [DATE]. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed until [DATE]. Record review of the facilities wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's shower sheet dated [DATE] revealed a shower was not given for refusal of care written on the form. No skin issues were documented. The nurse signature was not legible. A second shower sheet dated [DATE] was documented that a shower was given, and no new skin issues were assessed by the nurse. The nurse signature was not legible. No other shower sheets could be located for Resident #1. Record review of Resident #1's progress notes revealed no documentation of skin or wound assessments from [DATE] to date of investigation ([DATE]) in the medical record. Record review of Resident #1's weekly skin integrity review dated [DATE] and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins. Record review of Resident #1's weekly skin integrity review dated [DATE] and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins and the buttocks. There was no other skin assessments for Resident #1 prior to [DATE] or after [DATE] in the notebook. Record review of the 24-Hour Report Sheet (nurse to nurse communication between shifts) for Resident #1 revealed the following entries which were note signed or initialed by staff: [DATE]: Left toe dressing done [DATE]: big left toe needs wound nurse orders [DATE]: get treatment (nurse) to do wound care to left big toe [DATE]: get treatment (nurse) to do wound care to left big toe [DATE]: get treatment (nurse) to do wound car to left big toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe .hospice now, hospice will be in to write orders on Monday [DATE]: dressing to big left toe .hospice not, hospice to write orders Monday [DATE]: new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders, culture collected/pending . [DATE]: hospice orders pending, new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders . Record review of Resident #1's progress notes dates [DATE] revealed MD notified of condition of wound to LLE great toe. New orders received to get wound culture, CBC, renal panel, x-ray to LLE great toe to rule to osteomyelitis (infection of the bone), initial dose of Augmentin 500 mg (antibiotic) and Cipro 500 mg given and is to be continued for the next 10 days. Also received wound treatment orders . Record review of Resident #1's progress notes dated [DATE] documented by LVN B revealed: results in from x-ray of left toes .osteomyelitis not excluded .results faxed to MD, new orders pending. Record review of Resident #1's x-ray dated [DATE] of the left toe revealed minimal patchy osteolytic lesion involving first-proximal phalanx (great toe) ; mild diaphysis: osteomyelitis not excluded. (infection of the bone) Record review of Resident #1's physician order summary for [DATE] revealed an order for admit to hospice services with a start date of [DATE]. Record review of Resident #1's progress notes dated [DATE] documented by the ADON revealed: Resident sent out to [a local hospital] for worsening wound issues .that the family is concerned about. Per the family's request after a care plan meeting was completed, facility initiated a call for EMS to com(e) and transfer resident to the hospital. Notified MD of the hospital transfer . Record review of Resident #1's Care Plan Conference notes dated [DATE] and signed by the former DON on [DATE] revealed the form was blank and no information had been entered. Record review of Resident #1's hospital admission record dated [DATE] revealed the resident presented to the ER by EMS for necrotic toe present for over 1 week and a sore on the sacrum that was healing. Necrotic toe on the left gangrene (tissue death), x-rays of extremity foot reveal osteomyelitis with gangrene and necrosis (infection of the bone with tissue death) .concerned about osteomyelitis with severe soft tissue infection. Patient does require admission. Impression: sepsis, toe necrosis, soft tissue infection, elevated lactic acid (indicated infection and is clinically significant as it shows correlation with sepsis and can indicate likelihood of critical illness), osteomyelitis of toe (infection that is in the bone), tachycardia (elevated heart rate which can indicate sepsis). Record review of Resident #1's hospital record of x-ray to foot dated [DATE] revealed .soft tissue swelling is noted about the great toe with osseous erosive change (changes in the bone) involving the proximal phalanx (toe) .concerning for osteomyelitis with possible superimposed fracture (fracture can occur from severe osteomyelitis which weakens the bone). Record review of Resident #1's hospital record of physician assessment dated [DATE] revealed: Musculoskeletal/Skin: .left great toe notes severely necrotic changes to the soft tissue consistent with a mix of dry and wet gangrene, putrid odor coming from the foot. There is a palpable DP (dorsal pedal-pulse on the top of the foot indicating there is blood flow to the foot) pulse. There is surrounding erythema (redness) and purulent drainage (pus). Patient has a sacral decubitus (bed sore) ulcer with granulation tissue overlying it with no evidence of infection. Orthopedic consulted .Patient will need admission for further management and IV antibiotics and possible surgical intervention for his gangrenous infection of the left great toe. Record review of a hospital record for Resident #1 dated [DATE] revealed: Assessment/Plan: severe sepsis with shock initially requiring low dose of vasopressor (medication used to raise blood pressure in ICU setting which a sign of shock), WBC trending up (indicated infection), remains afebrile (without fever). Left first toe gangrene (tissue death with osteomyelitis (infection of the bone): continue vancomycin, cefepime, Flagyl (antibiotics), per ortho needs amputation. Record review of an undated photo of Resident #1's left foot revealed the left great toe from top of the foot view was dark black in color from the tip of the toe to the first joint with the appearance of a missing toenail. The area below the first joint was red and purple in color. There was a partially removed gauze from the toe revealed heavily soiled gauze with discharge that was beige, yellow, brown, pink, and red in color. There was a large amount of swelling to the right side of the great left toe starting at the tip of the toe, with the largest amount of swelling near the first joint that was discolored black, grey, brown, yellow, and pink and extending to the base of the first toe. The skin was peeling off the first toe. There was a large amount of drainage and moisture on the toe, and gauze. The other toes were obscured from view by the gauze. During an interview on [DATE] at 12:01 p.m. the Hospice Admission Nurse stated she admitted Resident #1 to hospice on [DATE]. She stated at the time of admission Resident #1 had a wound that was gooey, purulent with foul odor that smelt gangrenous and was poorly bandaged. She stated Resident 1 was very weak and had slow slurred speech that could not be understood. The Hospice Admission Nurse stated she asked the facility if Resident #1 was on antibiotics and they confirmed that he was on Augmentin, Cipro (antibiotics) and Dakin's (wound cleaner). She stated that she only admitted Resident #1 to hospice services and had no other interaction prior to his discharge. During an interview on [DATE] at 1:22 p.m., Resident #1's RP stated she had noticed the wrap to the resident's toe had not been changed (date unknown). She stated she got hospice involved (unknown date) because she did not feel like Resident #1 was getting the attention, he needed from the facility staff. She stated she had a meeting with the facility (names of staff unknown) on ,d+[DATE]. She stated they told her she could not put him in the hospital even though he was declining, but she did it anyway on the same date. She stated she did not want her family member to die. She stated she only got hospice because they told her he would get extra help. The RP stated Resident #1 was now going to have to have an amputation. The RP stated Resident #1 had dementia and was not interviewable. During an interview on [DATE] at 2:17 p.m., the Wound Care Nurse stated she had been in the wound care position officially in [DATE] although she had been in the position and performing wound care before that time (dates unknown). She stated she was notified of resident wounds by the charge nurses or when she completes the head-to-toe skin assessments. She stated the facility had house orders (standing orders/wound protocol) for wound care for wound care orders that she used on new wounds. The Wound Care Nurse stated the facility used to have a WC NP (Wound Care Nurse Practitioner) until two weeks ago. She stated the facility no longer had one as she was not meeting the Corporation's needs. The Wound Care Nurse stated the WC NP would see all residents with wounds except for patients on hospice and those with certain types of insurance. She stated she did not know what types of insurance were excluded. The Wound Care Nurse stated weekly head to toe skin assessments were documented in PCC (electronic medical chart) as a check on the resident TAR to show completion. She stated she did not document the results of the skin assessments in the resident medical record. She stated she kept the results on a paper document in a binder which she kept in her office. The Wound Care Nurse stated she was told to document in the binder. She stated she asked why she was documenting in a binder, and they told her to just keep it in the binder. She stated she does not remember who told her. The Wound care nurse stated she only keeps the current ones in the binder, and she only had [DATE]. When asked how continuity of care was provided where other nurses, physicians, etc. could review the skin assessments a was provided for residents if she was keeping skin assessments in a binder in her office, the Wound Care Nurse stated if there was an issue there would be an order for wound care that would pop up (in the computer). The Wound Care Nurse stated she worked a M-F schedule but was out last week ([DATE]-[DATE]) so no skin assessments were completed, and she did not know if the charge nurse did assessments. She stated she did not know if the nurses had access to the skin assessment binder because she kept it in her office. The Wound Care Nurse stated when she was not in the facility the nurses or the ADON would have to provide wound care. She stated either the ADON or DON would have to inform the nurses she was not at work. The Wound Care Nurse stated the facility did not have a process to document redness on the skin assessment other than just redness. When asked if she assessed if redness was blanchable and how she documented, she stated redness was not anything that was severe. She stated if a wound was not blanchable she would notify the physician because it indicated poor circulation. She stated it was a nursing judgment. She stated redness was usually located on the bum or as dryness to the legs and was nothing to notify the physician about. She stated she had standing orders for zinc oxide to take care of it. The Wound Care Nurse stated the facility relied on wound measurement and wound description documentation as documented by the WC NP who came to the facility 1 time a week. She stated without a WC NP she would document on the skin assessment or progress note if there was a concern, but she did not have to do measurements because the WC NP was already doing them, and she was never told to document it. The Wound Care Nurse stated the facility did not have process to document condition of the wound because the WC NP documents it. When asked about the process for residents in which the WC NP did not see or in absence of a WC NP, the Wound Care Nurse stated the facility had not had any hospice residents with wounds and she hoped to have a new WC NP soon. The Wound Care Nurse stated she received no training when she took the position as Wound Care Nurse. She stated the facilities supplier of wound care supplies, and the physician were available to her for questions or concerns. She stated the wound care supplier was also a LVN that would come and train her when she requested. During an interview on [DATE] at 6:30 p.m., the Wound Care Nurse stated on [DATE] Resident #1 had redness to his sacrum and she applied zinc oxide per standing orders. She stated the next day he was okay and had no more redness. She stated she did not write the zinc oxide as an order in PCC. She stated she thought there was already an order for it in PCC. The Wound Care Nurse denied knowledge that Resident #1 had a wound to his left foot great toe. She stated the redness never progressed to anything beyond redness. The Wound Care Nurse stated sometime last week (date unknown) she heard that LVN B notified the MD and got an x-ray and lab for Resident #1. She stated she also heard that Resident #1 was supposed to be seen by the NP for his toe. The Wound Care Nurse stated she provided wound care and assessed Resident 1's toe but did not document that assessment, only the treatment. She stated she did not know what the toe or wound looked like. She stated she was trained in nursing school to document assessments but had not been trained by the wound care supplier. She stated the wound care supplier gave her the run down on wound care and was supposed to return this week to give her further detail. The Wound Care Nurse stated she was notified by LVN B that Resident #1's toe was an open wound, but she could not remember the date. She stated it was sometime last week. The Wound Care Nurse stated she could not recall if Resident #1's toe or wound was discussed or if it was brought up during morning meetings. The Wound Care Nurse stated she was not in for parts of last week or she came in late, so she was not aware. Record review of the Wound Care Nurses Timecard for [DATE] revealed: Monday, [DATE]-clocked in for 5.25 hours from 8:54 a.m.-2:51 p.m. Tuesday, [DATE]-clocked in for 9.75 hours from 8:18 a.m.-6:30 p.m. Wednesday, [DATE]-clocked in for 3 hours from 4:05 p.m.-6:59 p.m. Thursday, [DATE]-clocked in for 5.75 hours from 6:49 am-8:34 am and 12:32 p.m.-4:56 p.m. Friday, [DATE]-clocked in for 7.75 hours from 8:44 a.m.-5:02 p.m. Monday, [DATE]-clocked in for 8.0 hours from 9:00 a.m.-5:25 p.m. Tuesday, [DATE]-clocked in for 9.0 hours from 9:00 a.m.-6:34 p.m. Wednesday, [DATE]-clocked in for 9.0 hours from 7:25 a.m.-5:07 p.m. Thursday, [DATE]-clocked in for 10.25 hours from 7:39 a.m.-6:28 p.m. Friday, [DATE]-clocked in for 4 hours from 2:25 p.m.-6:34 p.m. Monday, [DATE]- did not clock in or out, no hours reported Tuesday, [DATE]-clocked in for 6.0 hours from 1:10 p.m.-7:47 p.m. Wednesday, [DATE]-clocked in for 12 hours from 9:21 a.m.-9:49 p.m. Thursday, [DATE]- clocked in for 11.25 hours from 8:44 a.m.-8:29 p.m. Friday, [DATE]-clocked in for 8.25 hours from 10:58 a.m.-7:43 p.m. During an interview on [DATE] at 9:59 a.m., CNA A stated she used to be the shower aide on Resident #1's hallway approximately 1 month ago. She stated there was a lot of staff inconsistency because it was a heavy workload hall, and nobody wanted to work it. CNA A stated she had not provided Resident 1 showers in the last month. She stated previously he had a wound on his bottom (unknown date) She stated she notified the nurse. She stated she did not remember who the nurse was at the time. She stated she was trained that anytime she saw something new she would go immediately to the nurse. CNA A stated when she saw the wound on Resident #1's bottom it was an open wound without skin on top, about the size of a dime. She stated she thought it might have been LVN B that she notified but could not be certain. She stated later she saw white medicine on Resident #1's bottom. CNA A stated her responsibility was to report and it was the nurse's responsibility to take the next steps. She stated her communicated with the nurses verbally. CNA A stated she saw Resident #1 with a bandage on his foot, and she smelled something rotten. She stated she started looking in Resident #1's room for the location of the smell and finally realized it was coming from his foot. CNA A stated it was the same day Resident #1 got the x-ray of his foot. She stated after assisting with the x-ray she told the nurse that his foot smelled really bad, and the toe was brown. She stated the following day when she came in the bandage had been changed and the smell was better. CNA A stated when she first noticed the wound on Resident #1's bottom, he already had a bandage on his foot. She stated the whole foot was bandaged (unsure if it was right or left foot) and there was blood on the bandage near his big toe. She stated she never saw the wound and even during rounds when coming on shift it was never reported that Resident #1 had a wound during rounds. During an interview on [DATE] at 11:01 a.m., LVN B stated she was assigned as the nurse to Resident #1's hallway and worked 6 a.m. to 6 p.m. LVN B stated Resident #1 had an old atrial [arterial] wound to his left foot since [DATE]. LVN B stated in [DATE], CNA A came to her and told her about a wound to Resident 1's foot. She stated she called the MD and received wound care orders in [DATE] and the receptionist at the MD's office told her to inform the in house Wound Care Nurse. LVN B stated she notified the Wound Care Nurse via text. She stated she had since deleted the text. She stated there were orders to treat the wound that she put in PCC. LVN B stated she did not provide wound care to the wound because the facility had a Wound Care Nurse to provide treatments. LVN B stated she did not know what happened to the order for wound care in [DATE]. She stated she got the orders the very first time she saw it but may have passed the orders on to the next shift to complete. She stated she could not remember. She stated she did not know the outcome of the wound because she left the charge nurse position to do facility staffing, although she came back to the charge nurse position in [DATE]. LVN B stated she looked at the wound on the weekends and it looked good. LVN B stated Resident #1 was a diabetic and was not moving around and he could no longer sit himself up in bed. She stated he had become bedbound. LVN B stated the resident was not eating and the facility had recommended hospice. LVN B stated the family initially refused hospice. LVN B stated, in [DATE], a family member and herself saw blood on the floor, a few specks. LVN B stated she discovered the blood was coming from Resident #1's toe, but nothing big. LVN B stated she first noticed the wound on his foot approximately [DATE] and that was the last time she assessed it. LVN B stated Resident #1 was put on hospice care ([DATE]) right before he went to the hospital ([DATE]). She stated the (left foot great) toe looked discolored, but not necrotic. She said the toe was purplish kind of like a bruise and had the same opening on it from April. LVN B stated it looked the same. LVN B stated the ADON went to see the wound. LVN B stated she was not aware of a wound to Resident #1's bottom (sacrum). She stated she also completed a skin assessment but did not document the findings. LVN B stated she only documents negative findings in progress notes and does not document otherwise. LVN B stated Resident #1's wound was documented in the 24-hour notes (not part of medical record). LVN B stated she did not document because a family member was in the room and the facility had a WC NP who would do wound care rounds. She stated she addressed the wounds with the WC NP. LVN B stated in [DATE] Resident #1 declined. She stated Resident #1's family member said he looked sick, and he was not eating. LVN B stated Resident #1 looked kind of grayish, like he was going to pass on. She stated that was expected. LVN B stated Resident #1 did not go to the hospital because of his wound, he went because the family requested. She stated the family kept telling EMS that Resident #1 was not on hospice and that the facility did not care about him. During an interview on [DATE] at 11:19 a.m., CNA C stated when he provided care to Resident #1 (unknown date), he had noticed scratches to his arms which had resolved and a wound to the left foot ankle area (unknown time frame). CNA C stated he never saw a wound on Resident #1's bottom (sacrum). CNA C stated he had an uncle that was similar to Resident #1, so he did not look at Resident #'1 feet because it grossed him out. CNA C stated he knew Resident #1 had a wound to his big toe, although he was not sure which foot. CNA C stated he first noticed the wound when he removed a blanket from Resident #1 and his toe stuck to the sheet, pulling off a piece of skin when he removed the sheet. He stated this might have occurred during the first week of [DATE], but he was not certain. CNA C stated Resident #1's toenail was intact but some of the skin was missing near the side of the nail approximately 1 cm long. He stated there was [NAME] but no blood. He described the [NAME] as what a wound looks like when a scab is removed. CNA C stated there was no redness or swelling. He stated he notified RN D, who stated she would look at it, he said RN D never mentioned it again and his assignment changed during the shift, so he did not see what happened. During an interview on [DATE] at 12:19 p.m., the ADON stated the facility did not have a DON. He stated the other ADON, (ADON DD) died suddenly a few days ago. The ADON stated he was new the facility as ADON as of [DATE]. The ADON stated the facility did not have an internal process to assess wounds and track wounds. He stated the WC NP did their own assessment and submitted a weekly wound report for the wounds the NP treated. The ADON stated confirmation that Resident #1 had a wound to the toe (left great toe) in which LVN B put created an order for wound care on [DATE] but did not activate the order and it did not populate to the MAR (TAR) as an order. The ADON stated a CNA pointed out to LVN B that the wound had not been changed and LVN B let the Wound Care Nurse know. The ADON stated the CNA saw the wound had not been changed a told the Wound Care Nurse know and she changed the wound (dressing) right then. The ADON stated the wound was not changed from then (date unknown) until he saw the wound on [DATE]. The ADON stated he went to look at the wound when the RP demanded the facility address some issues in which the RP thought the dressing looked old. The ADON stated the dressing was a kerlix gauze that was stretched out and discolored with red, black, and yellow drainage. He stated the dressing was not dated and it did look old. The ADON stated the wound had an odor that smelled rancid, like a rotting smell. He stated once he removed the old dressing the odor hit him in the face. He described the smell as overwhelming. The ADON stated when he removed the dressing multiple layers of skin were also removed with the dressing. He stated there was yellow, green, and necrotic tissue that was moist, black and liquidly. The ADON stated the entire toenail from the base forward came off with the dressing. He stated the area under the nail was completely black. After looking at a photo of the toe, the ADON stated the toe was worse than the picture. He stated in the picture parts of the wound looked dry, but when he saw it was completely moist. The ADON stated there were bubbles of stuff resembling pus coming out of the toe when he tried to clean the wound. He described the pus as yellow/black in color with a mixture of greyish brown. He stated no one had told him of the condition of the wound before he saw it. He stated it was very alarming to him. The ADON stated he was not even aware there was a wound at all. He stated no one had notated the wound. He stated the Wound Care Nurse was responsible for weekly skin assessments. The ADON stated if the Wound Care Nurse was not at the facility or unable to complete a wound or skin assessment, she was supposed to personally notify a floor nurse to do it or should catch up on the day she returned. The ADON stated he had not seen her books until after this occurred. He stated after reviewing the Wound Care Nurses documentation he does not believe skin assessments were being doing consistently. He stated he did not even know about the Wound Care Nurses skin assessment book until this situation occurred. He stated there were shower sheets the CNAs were supposed to document wound issues. The ADON stated once a week the WC NP completed weekly rounds and submitted a weekly wound report that they used to track wound progress. The ADON stated he noticed the skin assessments were not catching all wounds. He stated he told the DON and the WC NP told the DON. He stated the DON, and the Wound Care Nurse blamed the WC NP which ended the WC NP contract. The ADON stated the WC NP contract was severed last Thursday ([DATE]). The ADON stated he his job duties did not include monitoring of medical records or audits. He stated the former ADON (ADON DD) was responsible for ensuring completion of orders. The ADON stated his expectations of the CNA staff were for them to immediately notify a charge nurse or the Wound Care Nurse and escalate up to ADON if needed. He stated he al [TRUNCATED]

Based on interview and record review, the facility failed to immediately inform the resident's primary care provider when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 7 residents (Resident #1) reviewed for notification of changes in that: The facility failed to notify the wound care physician and primary care provider (physician) when Resident #1's left foot great toe had a worsening of the wound and turned black. An IJ was identified on 08/18/2023 at 11:15 a.m. after review of the evidence. The IJ template was provided to the facility on [DATE] at 11:15 a.m. While the IJ was removed on 8/19/2023 at 6:46 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice could place residents at risk of not having their primary care provider informed when there is a change in condition resulting in a delay in medical intervention and decline in health. The findings included: Record review of Resident #1 face sheet dated 7/25/23 revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's Care Plan dated 9/21/2022 revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record review of Resident #1's Care Plan dated 7/20/2023 revealed the resident had a potential for the development of a pressure ulcer with no evidence of an actual pressure ulcer or wound. The care plan did not address any actual wounds for Resident #1. Record review of the 24-Hour Report Sheet (nurse to nurse communication between shifts) for Resident #1 revealed: 7/01/2023: Left toe dressing done 7/02/2023: big left toe needs wound nurse orders 7/03/2023: get treatment (nurse) to do wound care to left big toe 7/05/2023: get treatment (nurse) to do wound care to left big toe 7/06/2023: get treatment (nurse) to do wound car to left big toe 7/11/2023: dressing to big left toe 7/12/2023: dressing to big left toe 7/13/2023: dressing to big left toe 7/14/2023: dressing to big left toe 7/15/2023: dressing to big left toe 7/16/2023: dressing to big left toe .hospice now, hospice will be in to write orders on Monday 7/17/2023: dressing to big left toe .hospice not, hospice to write orders Monday 7/18/2023: new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders, culture collected/pending . 7/19/2023: hospice orders pending, new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders . Record review of Resident #1's physician order summary for July 2023 revealed an order for admit to hospice services with a start date of 7/19/2023 (after the change of condition occurred). Record review of Resident 1's progress notes revealed no documentation of the wound/wounds to the residents left foot great toe prior to 7/17/2023. Record review of Resident #1's assessments in the medical record revealed no documentation of the results of a wound or skin assessment. During an interview on 7/25/2023 at 2:17 p.m., the Wound Care Nurse stated she worked a M-F schedule. She stated on 7/03/2023 and 7/10/2023 she documented on a weekly skin assessment sheet that she kept in a binder in her office and was not part of the medical record that Resident #1 had redness to the left foot great toe. She stated on 7/10/2023 Resident #1 also had redness to his bottom (sacrum) that was blanchable. The Wound Care Nurse stated she did not notify the physician about the redness to the bottom (sacrum) because she had zinc oxide as standing orders to take care of it. She stated she did not notify the physician about the redness to Resident #1's left great toe because it was positional. She stated she knew it was positional redness because the resident was bedbound and refuses. She stated in her nursing judgement there was no concern to notify. During an interview on 7/29/2023 at 6:51 p.m. RN D stated she found a wound on Resident #1's left big toe after he was on morphine with hospice (7/19/2023). When asked why it was documented on the 24-hour notes at the beginning of July 2023, RN D stated she went into Resident #1's room one night during night shift, lifted the sheet up and saw that half of his big toe was black. She stated it looked like it was also going to the next toe. She stated she gave Resident #1 a [wound] treatment and wrote it on the 24-hour note to let the Wound Nurse know it needed treatment. RN D stated she put something on it and wrapped it. She stated the facility does not have standing orders for wound care. She stated she did not notify the physician because she thought Resident #1 was on hospice, she stated he needed to be. When asked if she notified a hospice nurse, she stated she could not remember. She stated she knows she should have notified the physician but when a resident was on hospice, they just notify hospice. RN D stated Resident #1 had diarrhea, he did not want to eat, he was on comfort care, and he was on his way to heaven. She stated the reason she documented on the 24-hour notes was because that was what the nurses read. After reviewing the 24-hour notes from July 2023, RN D stated confirmation that the notes were from her. She stated she regretted not notifying someone. During an interview on 8/02/2023 at 12:09 p.m., the ADON stated nurses should notify the physician, family, ADON/DON of any resident change of condition. The ADON stated notification of the physician was important because it was the only way a change of condition could be addressed. He stated some changes of conditions were emergencies and required collaboration with the physician to ensure patient care was done. The ADON stated night shift nurses should follow the same procedures. The ADON stated it was important to notify the physician when a toe turns black because the toe is debilitated, and the condition is eminent. During an interview on 8/03/2023 at 1:34 p.m., Resident's #1's physician/Medical director (MD) stated he first became aware of a wound in mid-July. He stated within a day or so of getting initial orders (7/17/2023) the events unfolded. The MD stated at that time he was told there was a wound with drainage, he stated staff did not give a description of necrosis or ischemic findings (diminished blood supply), just drainage. The MD stated he would have wanted to have been notified immediately of any color changes to a toe. He stated that would be the standard of care. During an interview on 8/03/2023 at 2:49 p.m., the RN Nurse Educator stated the medical doctor/physician should be notified first for a resident change of condition. She stated it was important to notify the physician because even a minor change of condition for foretell a more serious complication. Record review of a facility policy, titled Notification of Changes last revised on 1/10/2020 revealed: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately .consult with the resident's physician .: 3. A significant change I the physical, mental or psychosocial status of the resident. The Administrator was notified of an IJ on 8/18/2023 at 11:15 a.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 8/19/2023 at 6:35 p.m. and included the following: The facility's Plan of Removal was accepted on 8/19/2023 at 6:36 p.m. and included: 1. Immediate Action Taken B. On 7/28/2023 and on 7/30/2023 RN D received education from Regional Nurse consultant of Skin management policy regarding . physician notification . C. On 7/28/2023 and on 7/30/2023 LVN B received education from Regional Nurse consultant on Skin management policy regarding . physician notification . D. On 7/28/2023 and on 7/30/2023 LVN II received education from Regional Nurse consultant on Skin management policy regarding . physician notification . 2. Identification of Residents Affected or Likely to be Affected: A. On 7/27/2023 the DON/Designees completed 100% skin audit throughout the facility and identified other residents with new pressure ulcers. This was completed at 5:30 pm on 7/27/2023. No other resident has been affected by this since 7/27/2023. B. On 7/27/2023 an audit was completed by DON/Designee to validate residents with no pressure ulcers receive a weekly skin assessment by Charge nurse and initialed completion on the skin observation worksheet. This was completed at 8:00 pm on 7/27/2023 and no other resident has been affected by this since 7/27/2023. 3.Actions to Prevent Occurrence/Recurrence: A. On 7/27/2023 the DON/Designee began education with all licensed nurses on Skin Management policy which details . physician notification . This was completed at 6:00 pm on 7/27/2023 and no licensed nurse was allowed to work until they completed this education. C. On 7/27/2023 the DON/Designee began education with licensed nurses and nurse assistants on completion of skin observation worksheets at time of shower/bath to document any identified skin issues and allow charge nurse to complete an assessment and notify the DON/Designee on any identified issue. This was completed at 6:00 pm on 7/27/2023 and no licensed nurse or nurse assistant was allowed to work until they had completed this education. D. On 7/27/2023 the DON/Designee began education with licensed nurses and nurse assistants on Pressure Injury Prevention/Management Policy which details definitions of avoidable and unavoidable, compliance guidance, interventions for prevention, promote healing, treatments, and monitoring. This was completed at 6:00 pm on 7/27/2023, and no licensed nurse or nurse assistant was allowed to work until they had completed this education. On 8/18/2023 the facility administrator notified the Medical Director of Immediate Jeopardy the facility received regarding Abuse and Neglect related to skin management. POR verification: During a phone interview on 8/18/2023 at 4:02 p.m. RN D stated she had received education on Skin Management policy regarding . physician notification . from the Regional Nurse Consultant on 7/28/2023 and on 7/30/2023. Record review of form titled In-service Program Attendance Records dated 7/28/2023 and 7/30/2023 with RN D's signature of attendance. During an interview on 8/18/2023 at 3:59 p.m. LVN B stated she had received education on Skin Management policy regarding . physician notification . from the Regional Nurse Consultant on 7/28/2023 and on 7/30/2023. Record review of form titled In-service Program Attendance Records dated 7/28/2023 and 7/30/2023 with LVN B's signature of attendance. During a telephone interview on 8/18/2023 at 3:58 p.m. LVN II stated she had received education on Skin Management policy regarding . physician notification . from the Regional Nurse Consultant on 7/28/2023 and on 7/30/2023. Record review of form titled In-service Program Attendance Records dated 7/28/2023 and 7/30/2023 with LVN II's signature of attendance. Record review of Skin assessment/shower sheets revealed 100 residents checked for skin issues. Record review of Resident #15's EMR revealed a progress note with 7/27/2023 06:40 Skin/Wound Note skin sweep done this shift, no new skin impairments. Record review of Resident #15's EMR revealed a progress note with 7/27/2023 19:01 Skin/Wound Note skin sweep completed this shift, new change to skin dry scab .5x.5 area to right ankle, tolerated skin assessment well. 7/27/2023 06:49 Skin/Wound Note skin sweep completed this shift, new change to skin noted, skin wrinkly, and lightened in color noted to buttocks, New order for moisture barrier applied q shift and prn after each incontinent care. tolerated skin assessment well. Record review of Resident #16's EMR revealed a progress note with 7/27/2023 07:28 Skin/Wound Note skin sweep completed this shift, new change to skin noted, dry scab with mild redness noted. recent visit with podiatrist due to ingrown toenail being removed and callus resolved. tolerated skin assessment well. Record review of Resident #7's EMR revealed a progress note with 7/27/2023 08:50 Skin/Wound Note skin sweep completed this shift, no new change to skin noted. require podiatrist visit due to elongated toenails. tolerated skin assessment well. Record review of Resident #3's EMR revealed a progress note with 7/28/2023 10:18 Skin/Wound Note Skin sweep completed on 7/26/2023, resident presents with Stage 4 to sacrum - 2.5x2.5x.4 - show signs of improving. 1+ BLE edema noted. dry scab area to right forearm. Resident #3 is on hospice services. Weight has been stable. appetite is good. No s/s of dehydration noted. No s/s of infection noted. continue with wound care order. Record review of Resident #14's EMR revealed a progress note with 7/28/2023-skin sweep. Record review of Resident 17's EMR revealed a progress note with 7/28/23-skin sweep. Interviews with LVNs/RNs on 6am-6pm and 6pm-6am shifts to include weekends revealed 8 6pm-6am LVNs/RNs, 6 6am-6pm LVNs/RNs inservices done on Skin Management policy which included . physician notification . Record review of Inservice signature sheets for Skin Management policy which details . physician notification . 20 of 20 LVNs/RNs signed for attendance. Interviews with LVNs/RNs, CNAs, CMAs on 6am-6pm and 6pm-6am shifts to include weekends revealed 12 of 20 nurses were inserviced. On 8/18/2023 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Abuse and Neglect and reviewed plan to sustain compliance. On 8/19/23 at 6:46 p.m., the Administrator and Interim DON were notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity of harm with a potential for more than minimal harm due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: The City Health Inspector suspended the facilities kitchen license to operate and closed the facility kitchen on 8/31/2021 due to a roach infestation and poor sanitation. This failure resulted in identification of Immediate Jeopardy (IJ) on 9/01/2021 at 6:39 p.m. While the immediacy was removed on 9/05/2021, the facility remained out of compliance at serious potential for actual harm that was not immediate jeopardy with a scope of widespread due to the need to monitor the implementation and effectiveness of its Plan of Removal (POR). This deficient practice placed residents at risk for food contamination and transmission of diseases to humans, an increase in allergy and asthma symptoms and could affect the health and well-being of all residents. The findings were: Record review of a Food Nutrition Services Consultation Report, dated 8/16/2021-8/17/2021 and signed by the Registered Dietician, revealed: Kitchen Maintenance Needs identified as several cracked and loose tiles in kitchen, moisture in wall around ware washing area needs repair, and all walls need to be cleaned . Sanitation Pest Control needs to be addressed, fly in kitchen. Summary of Activities: In-Service Training Program not in place. Record review of a City Health Department inspection report, titled Retail Food Establishment Inspection Report, dated 8/31/2021 beginning at 8:50 a.m. and ending at 9:50 a.m., revealed the facility was out of compliance with Prevention of Food Contaminants: Observations: Evidence of pests can be observed in the establishment. Contact your licensed exterminator and adhere to the following: controlling pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by routinely inspecting incoming shipments of food and supplies. Routinely inspecting the premises for evidence of pests. Using methods, if pest are found, such as trapping devices or other means of pest control. Observations: Insect frass (excrement or other refuse left by insects and insect larvae) seen on walls of kitchen. All frass must be removed and area disinfected. Further review of the document revealed the facility was out of compliance with Physical Facilities which included: Detailed cleaning in kitchen was required. Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Observations: physical facility was in poor condition. The physical facility shall be maintained in good repair. Correct by 11/29/2021. Record review of a City Health Department inspection report, titled Retail Food Establishment Inspection Report, dated 8/31/2021 at 9:50 a.m. and ending 10:40 a.m., revealed the facility license was suspended. License has been suspended-roach infestation and poor sanitation. Establishment will be allowed to serve food if food cannot be obtained by lunch. Food must come from an approved vendor. Documentation must be provided. After lunch all food preparation must stop until infestation has been eliminated. Contact a licensed pest company and follow the recommended plan to control infestation. The following must be corrected before license can be reinstated and food preparation can resume. No live roaches present. Walls and baseboards repaired. No dead roaches present. Copy of pest control invoice. Information documented as given to the Administrator. Record review of a Pest Control Inspection Report, dated 8/31/2021, revealed: Documented time in the facility 1:30 p.m. to 2:06 p.m. Applied duster and pellets (pesticide) for German roaches. Facility requested additional service. Spoke with Administrator upon arrival. Clean out of rear storage area of kitchen. Flushed and vacuumed German roaches from void in wall. Dusted voids and outlets in storage room of kitchen. Record review of the computerized maintenance log, from 6/05/2021 to 9/1/2021, revealed no kitchen concerns or maintenance issues logged or addressed with the exception of routine documentation of the Fire Suppression system marked as kitchen exhaust hood marked as all good. Record review of a Pest Control Inspection Report, dated 9/01/2021, revealed: Documented time in the facility: 10:00 a.m.-12:54 p.m. Open Condition: found 8/27/2019, severity: High Kitchen dish room: gaps in baseboard tiles There are large gaps along the baseboards that are providing excellent areas for these German cockroaches to harbor and breed. Recommended action: Please seal these cracks/gaps to prevent further infection. Open Condition: found 1/04/2020, severity: Medium Kitchen dish room: gaps along wall behind dish room sink Gaps along wall behind dish room sink provide excellent harborage points for German cockroaches. Please seal all gaps on the wall to discourage pest entry into the wall voids. Open Condition: found 1/04/2020, severity: Medium Drain under dish equipment: The drain underneath the dish equipment has food debris/organic matter build up that provides a source of attraction and feeding for small flies. Please thoroughly scrub the drains up to 2 feet down to discourage small fly attraction. Open Condition: found 3/10/2020, severity: High Gaps along baseboards/walls Gaps present along the wall/baseboards are providing excellent harborage points for German cockroaches to harbor and breed out of sight. The gaps in the wall behind the standing cooler immediately to the left of the kitchen entry door were where a majority of the activity was observed directly harboring inside. Seal/repair these areas to discourage pest entry and harborage inside of the wall voids. Food debris/organic matter Food debris/organic matter noted along floor under most stationary equipment providing excellent feeding and attraction points for German cockroaches. Please ensure all food debris/organic matter is thoroughly cleaned each night to limit attraction and feeding points for pests. Immobile kitchen equipment Immobile equipment in kitchen limits inspection and treatment opportunities in areas under the cooler where German cockroach infestation was noted previously. Service 9/01/2021: Bait placement for German roaches Pellets for German roaches Aerosol (insecticide) for German roaches Facility requested additional service. Spoke with Administrator upon arrival. Did full kitchen clean out. Inspected, dusted, sprayed, baited throughout kitchen. Dusted wall voids, cracks and crevices. Flushed hot spot areas. Sprayed walls and floors with liquid chemical. Baited around outlets, water heater and areas where roach activity is heaviest. Vacuumed up any roaches seen. Record review of a City Health Department inspection report, titled Retail Food Establishment Inspection Report dated 9/02/2021 at 3:50 p.m. revealed: License has been reinstated. Improvement has been made in repairing kitchen. Majority of openings have been sealed and damaged tiles have been reattached. Roach activity has been reduced dramatically. Two live roaches were identified in the investigation. Both were immobile. Pest company staff has stated they will do one final treatment this afternoon. Establishments management team has been instructed to clean and disinfect kitchen before preparing food. Record review of a Pest Control Inspection Report dated 9/2/2021 revealed: Service 9/02/2021: Applied gel cockroach bait to cracks and crevices of cabinets, kitchen, office, outlets, pantry, retaining wall, wall voids for German roaches. Applied product to cracks and crevices for flies. Applied pellets to kitchen, pantry, storage room for German cockroaches. Applied aerosol (insecticide) to cabinets, kitchen, pantry, storage room for ants, flies, German roaches, gnats. Inspected and treated the kitchen. During my inspection, I sighted some German cockroach activity in pantry area along the electrical conduit pipe above. Also found some behind the stove, in the partition bean, underneath the dishwasher sink, (unknown) trays, and cabinets in dining room. I performed a flushing treatment in these areas where activity was found. This technique consists of applying a residual insecticide and using a fogging agent to force the cockroaches out the walls and voids. Sometimes after these types of treatments you can see an increase in activity, this is normal. If you experience an increase in activity this should decrease in a week or less. During an observation on 9/01/2021 at 12:17 a.m. upon entry to the facility, a Pest Control staff member was observed speaking to the Administrator in the Administrators office. During an observation on 9/01/2021 at 12:25 p.m., the kitchen doors (2) were closed and the dietary staff had pushed 3 dining room tables together and were preparing ham and cheese sandwiches on the tables in the dining room. During an observation on 9/01/2021 at 4:28 p.m. with the Dietary Supervisor following pest control treatment and fogging revealed dead roaches on the floors of the kitchen preparation area, dry storage and washroom floor which ranged in size from a grain of rice to the approximate size of a nickel. There were 8 dime sized roaches in a sink in the washroom and 1 dead roach was observed of a stainless-steel kitchen preparation surface. A separate stainless-steel kitchen preparation surface was noted to have dried sticky food residue and crumbs identified by the Dietary Manager as the table normally held the toaster and microwave. There was an accumulation of dirt/grease in areas under sinks, behind the freezer cabinets and near baseboards which had not been cleaned. A hole in the wall underneath a sink in the wash area which was approximately 3-4 inches in diameter was observed. Further observation revealed a large section of the wall in the dry storage area was newly repaired area of sheet rock had been replaced with a smooth surface panel approximately 3 feet x 5 feet with new baseboard and coved which were caulked and sealed. Further observation on 9/01/2021 at 4:37 p.m. of the kitchen washroom area revealed Dietary Aide A swept a small portion of the washroom in an area of approximately 4 foot by 6 foot into two piles of roaches, dirt and other debris. During an observation on 9/02/2021 at 12:01 p.m., the Pest Control Company staff member was inside the kitchen with the Dietary Manager. The Pest Control staff inspected equipment and sprayed an insecticide behind the freezers, on the walls on the kitchen, near baseboards, along electric conduit along the walls and ceiling of the kitchen and just outside the kitchen in a long set of cabinets which ran along the wall of the kitchen. The only equipment in the kitchen at the time of the observation were immovable appliances, warming table and stainless-steel counters. All small appliances, kitchen utensils, supplies and dry food product remained out of the kitchen area. The kitchen remained closed. During an observation on 9/02/2021 at 12:13 p.m. kitchenware was found sitting on dining room tables and stacked in a resident hallway and in a room marked employee break room. The dry goods food supplies in the original cardboard boxes, kitchen supplies, small appliances and additional kitchen ware was stored in an empty resident room while the kitchen remained closed. During an observation of the kitchen on 9/03/2021 at 3:37 p.m. 6 dead roaches were observed on the floor of the kitchen. During an observation on 9/03/2021 at 5:35 p.m. revealed the facility served the evening meal service out of the kitchen utilizing the kitchen steam table using food prepared from a sister facility. During an observation on 9/04/2021 at 9/04/2021 at 12:50 p.m. revealed the kitchen was fully operational. Several dead roaches were observed on the floor of the kitchen dry storage area. During an observation of the kitchen on 9/05/2021 at 8:19 a.m. there were 3 live roaches in the dish cleaning area of the kitchen. One roach was under the handwashing sink where the baseboard and wall met and was actively moving along the baseboard. One roach was seen under the ware wash machine and ran across the open floor and then under the equipment. One roach which appeared to have previously been stepped on was moving slowing across the floor in the sink/ware wash area. All three roaches appeared to be adult German roaches. Further observation of the kitchen food preparation and dry storage area revealed dead roaches too numerous to count. During an interview on 9/01/2021 at 12:30 p.m., the Dietary Manager (DM) stated an inspector with the Health Department came to the facility on [DATE], saw two roaches and shut the kitchen down. The Dietary Manager stated the Health Department Inspector returned to the facility again on 9/01/2021, saw two additional roaches and kept the kitchen closed. The DM further stated the Health Department Inspector was due to return for a 3rd inspection on 9/02/2021 and had warned the facility that if he saw even one roach, he would keep the kitchen closed. The Dietary Manager confirmed the roaches seen by the inspector were live roaches. The DM stated only the Health Inspector saw the roaches and denied seeing any himself. He stated the Health Inspector used a flashlight in an unknown location to locate the live roaches. The DM stated all kitchen supplies that were movable were removed from the kitchen area and were stored in an empty resident room and on the resident hallway. The DM stated the facility was providing box lunches to residents and a sister facility provided pureed textured food to 2 residents who required a pureed diet. The DM confirmed the facility was not following the menu for meal service because they had no access to the kitchen following the Health Department closure. During an interview on 9/01/2021 at 12:49 p.m., a Pest Control staff member confirmed the kitchen had been closed down by someone (unknown to him) who came to the facility due to roaches in the kitchen wall. The Pest Control staff confirmed the facility kitchen had a significant roach infestation which he described as pretty bad that encompassed approximately 5 feet of the kitchen wall behind the sheetrock. He stated there was a gap near the coved (base board) where roaches entered the kitchen. The Pest Control staff stated he removed the base plate and sprayed (insecticide) up into the wall to flush the roaches out. He stated roaches too numerous to count started running up the wall. The Pest Control staff stated the kitchen was not accessible at the time of the interview due to fogging. He stated the kitchen would be suitable for entry at 4:10 p.m. on 9/01/2021. The Pest Control staff stated he would be back the morning of 9/02/2021 to inspect and re-retreat the wall and kitchen and would return one time a week until all residual roaches were killed. He further stated the Pest Control Company had a contract to supply pest control to the facility in which he went to the facility on e time a month to treat the premises. During these monthly treatments he baited and sprayed the kitchen for pests. During an interview on 9/01/2021 at 1:45 p.m., the Administrator confirmed the City Health Department went to the facility and inspected the kitchen. The Administrator stated at approximately 11:20 a.m.-11:30 a.m. on 8/31/2021 the City Health Department notified him of concerns included in a written report which included pests found in the kitchen. The Administrator stated the City Health Inspector stated the facility could serve the lunch meal service but needed to close afterwards. The Administrator stated he closed the kitchen down on 8/31/2021 at 2:30 p.m. He stated Pest Control had come to the facility and treated the facility for pests. He further stated the City Health Inspector returned to the facility on [DATE] at 7:00 a.m. and found additional pests so he kept the kitchen closed. The Administrator stated the City Health Inspector would come again on 9/02/2021 at 9:00 am. To re-inspect the kitchen. During an interview on 9/01/2021 at 3:47 p.m , Dietary Aide A (DA A) stated the kitchen had a roach problem. She stated the roach infestation which resulted in the kitchen closure could have been avoided if the kitchen and facility management had listened to the staff complaints about the kitchen. DA A stated staff in the kitchen were feeling really frustrated. She stated there were only two people working in the kitchen and it wasn't enough staff to cook and clean. DA A further stated, It didn't have to get to this point. DA A stated she first noticed the roach problem 4 years ago when she first began working at the facility, but it had recently gotten bad. She stated, I knew it was bad. I asked the Dietary Manager if we could order some spray or do something to fix the [roach] problem. DA A stated she saw 3-5 roaches a day in one-hour time. She stated she saw them on the cook table while cooking, but mostly she saw them on the wall where the cook table was located, coming from a crack low down on the wall. DA A stated she didn't think the exterminator would be able to solve the problem. She stated she felt like the walls were in such bad condition they needed to be torn down and rebuilt. DA A stated there were several holes in the walls of the kitchen, by the cook table, in the dry storage and behind the freezers. The dry storage area had a larger hole than the rest of them. She described water leakage from the floor sewage coming up from drains in the floor in the dishwasher room. DA A stated the drain was fixed 2-3 months ago but the roaches remained. DA A stated she notified the Maintenance Supervisor of the water and roach concerns. She stated the Maintenance Supervisor told her the exterminator was coming. She stated the exterminator did come and he sprayed the kitchen, but the roaches were still a problem. DA A stated she last told the Dietary Supervisor and Maintenance Director roaches were coming out of the walls while she was cooking and told them the roaches were bad. DA A stated the Dietary Manager stated he was going to get on it and he was going to talk to the Administrator about getting the exterminator. The Dietary Manager stated he tried but nobody wanted to work at the facility. DA A stated she had also spoken directly with the Administrator about the roaches and lack of staff in the kitchen. She stated in July 2021 she had a crying melt in front of the Administrator who acknowledged her concerns about the kitchen, including needing additional staff and the roaches. The Administrator had responded by having the exterminator come to the facility and he stated, we are trying to get you some staff. During further interview on 9/01/2021 at 4:30 p.m., the Dietary Manager stated he was new to the facility. He stated he knew there were roaches in the kitchen when he started 60-days-ago. The DM stated he saw roaches here or there but didn't know how bad the problem was until identified by the City Health Inspector. The Dietary Manager stated, I though the Health Inspector was kidding when he said he was closing us down. The DM stated the Health Inspector told him he would shut the kitchen down for a couple of roaches and he did. The DM stated they started pulling the kitchen apart on 8/31/2021 and saw more roaches than he expected, 10-15 roaches in the cracks and near the baseboards. He stated he sprayed bleach and saw 1-2 coming out of the wall, a couple here and a couple there which turned into more than 10. The DM stated when he first identified the roach problem in the kitchen, he would spray the roaches with comet or bleach or kill them with a cleaning rag. He stated he was just dealing with it as he went along because he was new to the facility. The Dietary Manager stated the roach issues in the kitchen were a common topic of the management morning meetings. He further stated, they did not talk about it every day, but pest control had been to the facility before to address the pest issues. The Dietary Manger stated he wasn't really concerned about it because pest control went regularly and because he didn't see the infestation. The DM stated none of his employees had expressed any concerns for pests and the roaches weren't running around the kitchen; they were in the walls. He further stated, Really, it wasn't that big of a deal. The DM stated approximately 2-3 weeks ago the Administrator had called in the department heads to assist with cleaning the kitchen on a Saturday. He stated for 2 hours they scrubbed and organized the kitchen. The Dietary Manager stated he didn't know if he spoke to the Administrator about the roaches, it's was not documented, and they didn't write it down. He further stated, he walked through the kitchen when he accepted the job and took full responsibility for what went wrong. During an interview on 9/01/2021 at 5:17 p.m., the Maintenance Supervisor (MS) stated the kitchen staff rarely reported maintenance concerns until the last minute. He stated they were constantly clogging the drain and the disposal, but his main concern was the kitchen staff did not clean. The MS stated a few weeks ago the department heads went into the kitchen and deep cleaned and now the kitchen was back to the same condition it was before they cleaned. He further stated he witnessed kitchen staff sitting in the kitchen on their phones and not cleaning. The MS stated he has discussed with the staff as a one of the department managers they needed to clean. The dietary staff said they were paid to cook, not clean. He stated they were a contract company, but they were still responsible for cleaning. The MS stated he talked to the Dietary Manager several times about the kitchen cleanliness. The DM response was he tried his best. The Maintenance Supervisor stated pest control went to the facility again and again, but the kitchen staff continued to feed the roaches by not cleaning. The staff were sweeping stuff under the freezers instead of cleaning it up. The MS stated he documented everything on the maintenance log and got maintenance issues completed immediately. The Dietary Manager stated he knew about the roaches before this current incident. He stated he walked around with Pest Control and they sprayed everything, but these freezers were inundated and infested with roaches. The Maintenance Supervisor stated he discussed kitchen concerns 3 week ago with the Administrator when the department heads went in to clean. The MS stated he discussed concerns for kitchen staff being on their phones and not cleaning and he had also discussed seeing a lot of roaches. The MS stated he didn't get a response from the Administrator. During an interview on 9/01/2021 at 5:54 p.m. the Housekeeping/Laundry Supervisor (HLS) confirmed the housekeeping staff had expressed concerns for pests in the facility, mostly big cockroaches, not the small ones (German) identified in the kitchen. The HLS stated last month (August 2021) he came in to help assist with the kitchen cleaning. The HLS stated he didn't think the kitchen staff were cleaning the kitchen because it didn't look like the kitchen was getting wiped down after meal service. He further stated, when he came in on that Saturday in August to help clean, he saw roaches but could not quantify the amount seen. The HLS stated when the freezers were pulled back away from the walls there were a lot of little dead roaches everywhere. He stated he could tell the kitchen had a roach problem. The HLS stated he didn't discuss his concerns with the Dietary Supervisor because everyone else had told he and he didn't feel the need. He further stated he did not discuss the concerns with the Administrator because he felt like it was a well-known problem. The HLS stated, I don't know why they aren't cleaning properly. He stated he didn't feel like the Dietary Supervisor gave the kitchen staff proper directions and they were always worried about prepping for the next meal. During an interview on 9/01/2021 at 4:30 p.m., the Dietary Manager confirmed the facility made repairs to the wall of the dry storage area. The DM further stated he wasn't sure what area of the kitchen the Inspector found the roaches. During an interview on 9/01/2021 at 4:38 p.m., Dietary Aide A confirmed the dead roaches in the kitchen were too numerous to count. She stated there were approximately 15 dead roaches in one of the two debris piles in the washroom. During an interview on 9/02/2021 at 10:22 a.m., Lead Dietary Aide B (DA B) stated she had worked for the kitchen contract service in the facility kitchen for 4 years. DA B confirmed the kitchen had issues with roaches and sanitation. DA B stated roaches in the kitchen was not a new situation, but as time went on it had gotten worse. She stated the infestation was throughout the building, but right now it was focused on the kitchen. DA B stated the building was old and needed to be torn down otherwise the situation would reoccur. DA B stated the employees had tried their best to address the situation and felt like it was an administration issue which wasn't being addressed. DA B stated while in the kitchen, she saw roaches throughout the day because they came out now and then. She stated she would try to kill them by stepping on them and sweeping them up but had to keep on working. DA B stated she had notified the Dietary Manager when she saw the roaches which were mainly on the floors and occasionally on the walls. She stated she saw both big water roaches and small roaches and saw roaches in the food storage room but denied seeing roaches in the food. DA B stated on 8/30/2021 and 8/31/2021 she spoke with the Dietary Supervisor about the roach concerns. She stated the DS responded by saying, I realize we have a roach issue. DA B stated she witnessed the exterminator spray the kitchen previously and the roaches would come out of the wall and die, but then they came back. DA B stated the kitchen was experiencing staffing issues and had only two kitchen staff per meal. She stated she had discussed the staffing shortage with the Dietary Supervisor, and he acknowledged the staffing issue. DA B stated the kitchen staff did not have a cleaning schedule. DA B stated she had not brought any of these concerns up with the Administrator. Further interview on 9/02/2021 at 10:45 a.m., the Dietary Manager confirmed the kitchen staff did not have access to a cleaning schedule and he had not implemented a cleaning schedule with staff. He stated he had one on his computer but had not printed it out or given it to staff yet. The Dietary Manager stated he verbally instructed staff on what section they were assigned to clean. He stated he verified staff cleaning was done by knowing which staff member he had assigned to the task and he would hold them accountable. He stated he would hold them accountable by giving them an in-service training. The Dietary Manager confirmed he had not given his staff any in-service training on cleaning or sanitation since he started 60-days-ago. He further stated he gave new employees expectations which included: clean up at the end of shift and empty bus tubs. The Dietary Manager stated he did not provide any staff training to new staff. During an interview on 9/02/2021 at 1:19 p.m., the Pest Control Company staff member stated the facility was old and had a lot of structurally conducive conditions to roaches. The Pest Control Staff also stated the kitchen had sanitation issues. He further stated while observing and inspecting the kitchen today (9/02/2021) he found live German cockroach activity behind wire conduit in pantry, in the kitchen area itself and in the cabinet immediately outside of the kitchen. The Pest Control Company staff member stated he saw approximately 25-30 live German Cockroaches, most in the adult roaches. He stated roaches were hitchhikers and the food boxes from the kitchen likely contained roaches. He further stated the facility would need to clean the kitchen after the insecticide treatment. At this time the kitchen remained closed. During an interview on 9/02/2021 at 4:11 p.m., the City Health Inspector (Sanitarian II) stated he came to the facility (on 8/31/2021) for a routine health inspection and identified a roach problem and a kitchen with poor sanitary conditions. Based on the findings he suspended the facility kitchen license. The Inspector stated everything in the kitchen was dirty and there was insect frass and insect waste on the kitchen walls. The Inspector also identified a lot of damage to the kitchen such as holes in the walls. The Inspector stated upon re-inspection (9/01/2021) the kitchen was not ideally repaired but the facility had made lots of improvements from the original inspection (8/31/2021). The Inspector stated he closed the kitchen because roaches carry diseases and transmit the diseases on their feet to kitchen surfaces, so they kitchen needed to be closed to prevent disease spread. During further interview on 9/02/2021 at 4:13 p.m., the City Health Inspector stated on his second facility kitchen inspection on 9/01/2021 there were still live roaches observed, so the kitchen had to remain closed. The Inspector stated he saw the same thing he saw the first day with the live roaches so he couldn't allow them to re-open. He stated the facility had made some improvement, but the kitchen needed to be deep cleaned to remove food debris and grease. The Inspector stated during his 3rd inspection on 9/02/2021 he noted the kitchen had made major improvements and had reinstated the license for the kitchen to re-open on 9/03/2021. He stated the kitchen could reopen after the facility had a final pest control treatment, deep cleaning and sanitization of the kitchen. The Inspector stated there was still a lot of damage to the kitchen, but they had sealed the holes in the walls and ceiling where the roaches could hide and had completed pest control treatments to eliminate roach activity to an acceptable level. During an interview on 9/03/2021 at 8:52 a.m., the Administrator stated the City Health Department had given approval for the kitchen to be re-opened. The Administrator stated after the City Health Inspector completed the inspection on the evening of 9/02/2021 the facility had pest control re-treat the kitchen on 9/02/2021. The facility plan was to clean and sanitize the kitchen and all equipment before reopening the kitchen for evening meal service on 9/03/2021. During an interview on 9/03/2021 at 9:15 a.m., the District Manager of Culinary Services (DMCS) stated she was the direct supervisor of the Dietary Manager who was the employee of a contract food service company utilized by the facility. The DMCS stated she provided oversite to the facility and visited 2-3 times per month, in person. She stated she was aware of the kitchen had sanitation and maintenance issues but was not aware of concerns for roaches. The DMCS stated she had wanted to see more cleaning of the kitchen equipment and the floor. She stated they could only do so much with the floor because of the cracks in the tile. The DMCS stated the Dietary Manager had not reported to her any concerns for roaches. She stated when she made visits to the facility kitchen, she identified concerns and documented them in a company application and provided the Dietary Manager with a handwritten copy of concerns which needed to be address by in-servicing staff. The DMCS stated all in-services should be documented and kitchen staff should sign a copy of the in-service to indicate they understood the training. The DMCS confirmed the Contract Company had a system in place which included policies and procedures and on-boarding training to address kitchen sanitation. The DMCS confirmed both the Dietary Manager and the DMCS had communicated sanitation and maintenance concerns with the facility Administrator. During further interview on 9/03/2021 at 10:48 a.m., the District Manager of Culinary Services confirmed she had not verified in-service training was completed. The DMCS sta [TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases to include COVID-19 infections for 66 of 84 (Residents #1 - #64, #70 and #71) residents reviewed for infection control in that: A. The facility did not prevent six staff members (ADON JJ, Med Aide A, RN E, and LVNs B, F, and J) who were listed on a document provided by the facility that indicated they were exposed to Resident #1 who was positive for COVID-19, from returning to work to provide care for residents after the facility indicated they had exposure to COVID-19 from Resident #1. The facility allowed four staff (ADON JJ, LVN F, RN E and Med Aide A) who were pending their COVID-19 test results to continue to work in the facility from 03/28/2020 - 04/06/2020. This deficient practice resulted in the identification of an Immediate Jeopardy (IJ) on 04/03/2020 due to the following: - The facility allowed staff to continue working while pending their COVID-19 test results. - The facility policy for COVID-19 read if staff were ill they were to self-isolate at home. Based on interviews, this did not occur. - Not all competent residents and/or responsible parties were notified of their positive COVID-19 status per the order issued by the City of San Antonio on 03/30/2020. While the IJ was removed on 04/06/2020, the facility remained out of compliance at a level of potential harm with a scope identified as widespread. These deficient practices could affect all residents and place the residents at risk for mental anguish, COVID-19 infections, and possible death. B. ADON JJ was observed on 04/12/2020 donning two pairs of gloves and only removing the first set of gloves to sanitize his gloved hands. C. Dietary Aide OO did not don clean PPE before she entered Davis Hall, walked half-way down the hall to deliver snacks to residents who were negative for COVID-19. These deficient practices placed residents at risk for mental anguish, COVID-19 infections, and possible death. The findings were: During an observation on 04/06/2020 at 1:06 p.m. the facility had not separated the residents into a dedicated hallway for isolation to separate the negative and positive residents. Interviews throughout the duration of the investigation revealed that on 03/26/2020 Texas Health and Human Services (HHSC) received a complaint and self-reported incident which revealed there was one positive resident, Resident #1, who was confirmed to have COVID-19 and one staff member, CNA H, who was identified as being positive for COVID-19. On 03/28/2020 HHSC surveyors were notified of a 2nd resident, Resident #2, who was identified as being positive for COVID-19, and who was at the facility at the time. On 03/30/2020 at 11:31 AM, HHSC surveyors were notified by the Administrator of a 3rd resident, Resident #64, who was identified as being positive for COVID-19, and who was at the facility at the time. At the time of this notification, the Administrator was asked to provide a list of positive staff members. The Administrator stated, There are no staff members who are showing signs and symptoms, but we sent staff who were listed on the medium exposure list to get tested . During the course of the investigation it was revealed through observation, interviews and record reviews that the facility was not following CDC guidance. According to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fhcp-return-work.html, last revised 3/16/2020. Title:Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19 (Interim Guidance), revised on 04/30/2020: Under the section titled, Return to Work Criteria for HCP with confirmed of suspected COVID-19: Use of the below strategies to determine when HCP may return to work in healthcare settings. 1. Test-based strategy. Exclude from work until: Resolution of fever without the use of fever-reducing medications and Improvement in respiratory symptoms (e.g., cough, shortness of breath), and Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab (a swab of the nasal passageway to test for infectious organisms) specimens collected >24 hours apart (total of two negative specimens). Footnotes: All test results should be final before isolation is ended. Record review of the facility policy titled, Infection Outbreak Response and Investigation, dated 3/10/2020, revealed as its policy: The facility promptly responds to outbreaks of infectious disease to stop transmission of pathogens and prevent additional infections. Fundamental Information: Outbreak generally refers to the occurence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. Some infections are so rare that a single case would constitute an outbreak. 2. Implementation of infection control measures: b. Symptomatic employees will be screened by the Infection Preventionist, or designees, and referred to appropriate medical provider and removed from the facility. Record review of the facility policy titled, Infection Control Guidelines COVID-19, revised on 3/16/2020 read: To minimize exposures and spread of respiratory pathogens including 2019-nCoV. Admission of COVID-19 Resident and Non COVID-19 Residents: If possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usually on short-term rehab floor or returning to long stay original room. Employees: 3) If they are ill, have them put on a facemask and self-isolate at home. A. Resident #1 was sent to the hospital on [DATE] and was confirmed as being positive for COVID-19 on 03/25/2020. Throughout the course of the investigation it was revealed that staff members were allowed to work in the facility without knowing their COVID-19 test results. Facility management did not adhere to CDC guidelines and relied on local health authorities for guidance on allowing staff members to return to work. During a telephone interview on 3/28/2020 at 11:19 AM, the Administrator was asked to send staff sign in sheets which captured their temperatures and the answers to questionnaires regarding signs and symptoms of COVID-19 prior to staff beginning their shift. The Administrator stated she would send the staff sign-in sheets. At the time of lifting the first IJ the Administrator did not send those staff sign in sheets that included their temperatures and answers to the questionnaire. During an interview on 3/27/2020 at 2:27 PM, the Administrator stated the city Health Department had not arrived at the facility. The Administrator and DON were asked to provide a list of all staff members who signed into work for the last two weeks and the DON stated she would provide that list. That list at the time of lifting the first IJ on 04/06/2020 was not provided by the facility. During a telephone interview on 03/30/2020 at 2:33 PM, LVN B stated he was sent home on 3/26/2020 due to possible exposure to Resident #1. LVN B stated he was tested for COVID-19 on 3/28/2020 and was awaiting his results. An interview was attempted on 03/31/2020 at 8:40 AM with CNA H. A telephone voicemail message was left for CNA H and at the time of the exit, CNA H had not returned any voicemail messages. During an interview on 3/30/2020 at 3:17 PM, LVN I stated she was sent home on 3/26/2020 after possible exposure to Resident #1. LVN I stated she received a COVID-19 test on 3/28/2020. LVN I stated the ADON JJ called her to work on 3/29/2020 for the overnight shift from 10:00 p.m. to 6:00 a.m. LVN I stated she did not feel comfortable working at the facility without knowing her results and did not go to work because she did not know her results. During an interview on 3/30/2020 at 4:21 PM, CNA X stated she was tested on [DATE] for COVID-19. CNA X stated she last worked at the facility on 03/20/2020 and confirmed she assisted CNA H provide perineal care to Resident #1 along with CNA H in the days leading up to Resident #1 being sent to the hospital. CNA X stated at the time of the perineal care Resident #1 was coughing. During an interview on 3/31/2020 at 3:05 PM, ADON JJ stated he was tested for COVID-19 on 3/28/2020. ADON JJ confirmed he has been working at the facility despite not knowing his test results because he was considered a low risk for the initial exposure to Resident #1. ADON JJ stated he was considered low risk because he only dropped something off to Resident #1 in her room prior to her identification of being positive for COVID-19. ADON JJ further stated he had fed Resident #2 in the dining room the week of 3/23/2020 but could not recall the dates. ADON JJ stated he did not wear a mask or PPE while he was feeding Resident #2. ADON JJ stated some of the staff were listed as low and medium risk depending on what kind of care they provided to the resident. ADON JJ stated RN E was listed as a low exposure risk due to her only performing a skin assessment on Resident #1. During an interview on 3/31/2020 at 3:24 PM, LVN J stated he was considered a low risk exposure because he had only provided an Accu-Chek (blood sugar test meter) for Resident #1 the day before the resident was sent to the hospital on [DATE]. LVN J stated he did not receive a test on the weekend on 3/28/2020. At the time of this interview, LVN J stated he had received a telephone call from a physician who worked at the city health department immediately prior to this interview and the physician conducted a telephone interview and had stated that his exposure to Resident #1 did not warrant a COVID-19 test. An attempted interview was made on 04/01/2020 at 7:03 PM, with LVN F, a telephone voicemail message was left and at the time of the exit, LVN F did not return the telephone calls. During an interview on 4/2/2020 at 9:43 AM, LVN B stated he was tested on Saturday 3/28/2020 and had not worked in 14 days. LVN B stated, the facility told me I could go back today since it has been 14 days since I had last contact with the resident (Resident #1). I am confused about what to do, and I am being told different things. A corporate lady called me from the staff number, but it wasn't the Administrator. I was one of the first staff members contacted. I was given a form to fill out, but it was already filled out and she wanted me to sign the bottom. It basically said I needed to self-quarantine and notify about symptoms. They asked me to return to work today (04/02/2020), and I am scheduled for 10pm-6am shift (overnight). During an interview on 4/2/2020 at 10:30 AM, LVN I stated she had just received her positive results and her last work day was 3/18/2020. LVN I stated she had a cough on 3/19/2020 with maybe a low-grade temp and was told to self-quarantine for seven days from last symptoms. LVN I stated ADON JJ asked her to work on 3/31/2020 and LVN I stated she told ADON JJ she would not work. During an interview on 4/2/2020 at 10:31 AM, CNA D stated she did not want to go to work on 4/2/2020 because she wanted to get tested . CNA D stated the last day she worked was yesterday (4/1/2020) and she had been coughing for at least three days. CNA D stated she had denied the cough when answering the questionnaire. CNA D stated she had the same residents that CNA H had and has had close contact with many positive residents. During an interview on 4/2/2020 at 2:23 PM, CNA C stated she last entered the facility on 3/26/2020 but was told she was exposed to a resident that tested positive for COVID-19. CNA C stated she last worked on 3/24/2020 and when she arrived at home she was not feeling well. CNA C stated she took her temperature on 3/24/2020 and she had a fever of 101.1 degrees. CNA C stated she called the on-call nurse who she confirmed was ADON JJ, and ADON JJ stated that she could return to work as long as her fever was less than 102 degrees. CNA C stated she returned to work on 3/25/2020 and did not have any fevers. CNA C confirmed she tested positive for COVID-19 on 3/30/2020. During an interview on 4/2/2020 at 1:42 PM, Medication Aide A stated his last day working in the facility was on 4/1/2020. Medication Aide A stated he was sent to get tested on [DATE], and confirmed he received a notification he was positive for COVID-19 on 4/1/2020 at 5:00 PM. Medication Aide A stated the ADON and Administrator told him he could continue working in the facility until he had received his COVID-19 results. During an interview on 4/2/2020 at 1:58 PM, ADON JJ stated he had the test performed on Saturday (03/28/2020) about 3:30 p.m. and was still waiting for his results. ADON JJ stated he did miss several phone calls from the testing facility. ADON JJ stated there was no policy about being tested and coming back to work. ADON JJ further stated, we have had so many people call off and I want to help the residents and the facility. No one asked me to work, I wanted to myself. During an interview on 4/5/2020 at 12:48 PM, ADON JJ stated in order for staff to return to work they would have to check with corporate or the Administrator to see if they could come in for work. ADON JJ further stated, If it's just seasonal allergies [REDACTED]. ADON JJ further stated that he was not aware of staff leaving sick and then returning to work but further stated, You would have to speak with the DON about that. ADON JJ stated, I do not know who the positive staff members are unless they tell me. During an interview on 4/1/2020 at 4:37 PM, Regional Consultant G stated there was an internal IDT (interdisciplinary team) meeting that developed the facility exposure list in accordance with the CDC exposure guidelines. Regional Consultant G stated the facility was not allowing staff who were listed as a medium risk to continue working in the facility. Regional Consultant G was asked why LVN F could continue to work even though she was listed a medium exposure risk, Regional Consultant G stated LVN F's category of a medium exposure listing was done in error and LVN F should have been classified as a low exposure risk. Regional Consultant G stated ADON JJ was considered a low risk exposure. When asked about the test results for the ADON's COVID-19 testing that occurred on 3/28/2020, Regional Consultant G stated ADON JJ went to get tested on his own choice. Regional Consultant G stated, He is all over the place and we need him here, he is our ADON. During an interview on 4/2/2020 at 10:24 AM, the Administrator stated staff who were identified as a medium exposure risk to Resident #1 were not allowed to work. The Administrator stated the staff who were identified as a low risk were not sent home even though they were exposed. The Administrator stated, staff who were considered low exposure risk could continue to work in the building. The Administrator was asked if low exposure risk staff who were pending the results of their COVID-19 test could work, the Administrator stated yes, they could work and then the Administrator followed with a question: Can we allow low risk staff who have not received their COVID-19 test results to continue working? Record review of a signed facility Witness Statement Form, dated 4/6/2020, revealed a statement written by LVN B addressed to the Administrator. It read as follows: I (LVN B) was sent home on 3/26/2020 after the administrator completed a risk assessment that classified me as medium risk related to performing peri care on Resident #1 that tested positive late evening 3/25/2020. I was tested on [DATE]. I remained home on self-quarantine. Then on 4/3/20 I received my results of positive (for COVID-19). On 4/3/20 I spoke to (the Administrator) as my physician stated I could return after 7 days being asymptomatic which would be 4/5/20. The Administrator agreed I could return on 4/5/20 for work. My first shift back was after midnight on 4/5/20. During an interview on 4/2/2020 at 9:43 AM, LVN B stated, They asked me to return to work today (04/02/2020), and I am scheduled for 10pm-6am shift (overnight). During an interview on 4/3/2020 at 10:36 AM, the Administrator and Regional Consultant G stated LVN B has not returned to work at the facility. Regional Consultant G stated the Health Department told her and the Administrator asymptomatic staff members could work in the facility pending their results. When asked if there was documentation of this, Regional Consultant G stated they would provide the information. Regional Consultant G then stated, We have to call the staff to come work, we wouldn't have staff if we didn't. During this interview the Administrator stated that for low exposure staff even if they have been tested , they could work, We have received guidance that low risk and tested staff could continue to work. During an interview on 4/3/2020 at 10:58 AM, ADON JJ stated he had not received his COVID-19 test results. ADON JJ further stated, I have missed their calls. ADON JJ was interviewed as he was assisting residents inside the facility. During an interview on 4/3/2020 at 11:04 AM, RN E stated she had not received her COVID-19 test results. RN E was interviewed as she was working within the facility. According to an email submitted by the facility, dated 4/6/2020 at 2:44 PM, from Epidemiologist R, read: Our Medical Director, (MD L) called the CDC and they stated employees that test positive and have been asymptomatic can return to work seven days after the date tested . (The facility was not following CDC recommendations and were relying on the local health authority to provide guidance) Record review of the facility policy titled, Infection Outbreak Response and Investigation, dated 03/10/2020, revealed as its policy: The facility promptly responds to outbreaks of infectious disease to stop transmission of pathogens and prevent additional infections. Fundamental Information: Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. Some infections are so rare that a single case would constitute an outbreak. 2. Implementation of infection control measures: b. Symptomatic employees will be screened by the Infection Preventionist, or designees, and referred to appropriate medical provider and removed from the facility. On 4/3/2020 at 10:36 a.m., the Administrator and Regional Consultant G were notified of an Immediate Jeopardy (IJ) situation, a completed IJ template was provided to the facility for the above failures, and a Plan of Removal was requested. On 4/6/2020 at 4:25 p.m., the facility's Plan of Removal was accepted, and included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 4/3/20 Administrator reviewed the employee evaluation completed using Table 1 Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19). The Administrator verified that medium exposure level employees had not worked since 3/26/20. Today 4/3/2020 Regional Consultant M identified employees that worked in the facility and tested for COVID-19. Regional Consultant M identified employees who were received COVID-19 test with positive results were self-isolating for 14 days at home and have not returned to work. On 4/3/2020 5 employees were identified as having been tested but with their results pending (LVN F, CNA N, the ADON, LVN J, and CNA P). All employees are adhering to CDC guidelines regarding wearing facemasks. The local health department who is part of City Emergency Management MED COM ordered all employees to be tested even though a COVID-19 exposure event did not occur. Regional Consultant M verified that any staff assisting feeding residents with the potential to choke or cough are wearing gown, eye protection, facemask. Hand sanitizing is completed before PPE is donned, during the meal when assisting residents and after PPE is removed. Administrator reviewed Employee Screening Logs back to 3/26/2020 and no employee has worked with an elevated temperature or cough, shortness of breath or sore throat. Every employee is screened daily prior to working for any s/s of respiratory issues including temp and has been a practice of this center since approximately February 10, 2020. Regional Consultant G validated that all employees were wearing gown, eye protection, mask and gloves while on duty on 4/3/2020. The PPE is donned prior to entering the work area. Monitored by Administrator/designee. Medical Director was notified of immediate jeopardy Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _______4-3-2020__________ 2. Identification of other residents having the potential to be affected was accomplished by Residents were assessed by Regional Consultant G/designee for signs and symptoms of temperature, sore throat, cough and shortness of breath on 4/3/2020 with no negative findings. 3. Actions to Prevent Occurrence/Recurrence The following actions were taken to ensure occurrence or reoccurrence of process/system failure that could lead to serious adverse outcome and when those actions were completed. On 4/3/2020 Regional Consultant G/designee started in-service on 1) Proper use of PPE in clean unit 2) Proper use of PPE on isolation unit 3) Work Restrictions related COVID-19. Daily contact is made by Regional Consultant M or designee to any employee who has a pending COVID-19 to determine if they have received test results that are positive. Those employees are taken off duty for 14 days for self- isolation and do not return to work until the 15th day. All employees are screened daily prior to work for any s/s of respiratory problems, any employee with any s/s of respiratory issue will not be allowed to work and is completed by Administrator/designee. All employees wear gown, eye protection, mask and gloves while on duty. The PPE is donned prior to entering the work area. Monitored by Administrator/designee. Regional Consultant M or designee daily will log any COVID-19 test results the Staff Surveillance log daily. The surveyor verification of this Plan of Removal on 04/06/2020 was as follows: Residents who were identified as being positive for COVID-19 were separated from residents who were identified as negative for COVID-19 and were placed in the D hall of the facility. Observations were made to ensure residents were wearing a mask while outside of their room. There was one instance of an unidentified resident who was outside of their room, this resident was wearing a face mask. Staff observations were made to ensure that all staff were wearing appropriate PPE throughout the facility. Further observations revealed that staff members were washing their hands with soap and water and/or using hand sanitizer. The front entrance to the facility had sufficient PPE supplies for staff or essential personnel to enter the building premises. Further observations revealed that there was an attendant at the front desk who was conducting temperature checks and a questionnaire for COVID-19 symptoms. During an interview on 4/6/2020 at 12:40 PM, Interim DON Z stated she had sat at the front door for the day checking temperatures and asking the questionnaire to all visitors. Interim DON Z stated visitors cannot enter the building with an elevated temperature and they must don PPE prior to entering the resident hallways. On 4/6/2020 at 11:00 AM, a telephone interview attempt was made to interview the DON and a voicemail message was left. At the time of the exit the DON did not return a voicemail message. During an interview on 4/6/2020 at 1:27 PM, ADON JJ stated he had still not received his COVID-19 test results. During an interview on 4/6/2020 at 2:11 PM, the Administrator confirmed LVN B did work on 4/6/2020 and LVN B had received his test results and was positive for COVID-19. The Administrator referred back to a conversation Regional Consultant G had with Epidemiologist R. Further interview with the Administrator revealed she sent a forwarded email to the surveyor dated, 4/6/2020 at 2:44 PM, which read that positive staff members can continue to work at the facility as long as they are asymptomatic for seven days after the test date. During an interview on 4/6/2020 at 2:45 PM, the Administrator stated Epidemiologist R stated there were no restrictions for positive employees to work with residents. This statement was confirmed by Regional Consultant S at the time of this conversation, that there are no restrictions for positive staff members to continue working with any of the resident population. During an interview on 4/6/2020 at 3:04 PM, the Administrator was asked if LVN B had any type of medical clearance to return back to work. The Administrator stated, No he doesn't need anything, per the email, he doesn't need to provide medical clearance. Currently, we do not have a doctor note. On 4/6/2020 at 4:25 PM, the Administrator, Regional Consultant S and Regional Consultant T were informed this IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as widespread. B. During an observation on 04/12/2020 at approximately 11:40 a.m., ADON JJ was observed to have two sets of gloves on. ADON JJ removed the outer layer of gloves and sanitized his gloved hands. During an interview on 04/12/2020 at approximately 11:40 a.m., ADON JJ stated the facility staff were advised by Metropolitan Health Department to don 2 sets of gloves and when the outer layer of gloves were removed the inner layer of gloves could be sanitized prior to donning a second set of gloves. Record review of the facility's policy titled Surveillance Plan: Infection Control Surveillance COVID-19, revised on 04/21/2020, revealed as its policy: To minimize exposures and spread of respiratory pathogens including 2019-nCoV. Further review revealed: Gloves: Perform hand hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. According to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html, CDC Guidance does not recommend double gloves when providing care to suspected or confirmed 2019-COVID patients. C. Interview on 4/15/2020 at 2:54 PM during the entrance conference with the Interium Administrator revealed the residents who were negative for COVID-19 were on Davis Hall and that was considered a clean hall. He reported any employee who enters Davis hall has to don fresh PPE since all the residents on the hall were negative for COVID-19. Observation on 4/18/2020 at 10:07 AM revealed LVN II, stood at the medication cart parked half-way down Davis Hall while the surveyor asked her questions when a dietary employee (Dietary Aide OO) entered Davis Hall from the dining room side door, which did not have PPE supplies for the dietary employee to don, and entered Davis Hall, walked over to the medication cart and handed the LVN a disposable tray that had assorted snacks on it. In an interview on 4/18/2020 at 10:12 AM LVN II reported the kitchen is supposed to be a clean area and they can come through this door (referring to the door to the dining room). In an interview on 4/18/2020 at 10:45 AM with Dietary Aide OO she confirmed she had delivered snacks to Davis Hall through the dining room door and walked into the hall to the nurse's cart with the same PPE. Dietary Aide OO reported she did leave the kitchen to go to the nurse's station to deliver snacks to the other halls and to deliver the hall trays. Dietary Aide OO reported when she enters the facility she would be screened at the front door, temperature taken, dons PPE, then would g to the kitchen to start her shift. Dietary Aide OO stated she would be in the kitchen for 1 hour before she leaves the dining room to deliver trays to the nurse's station through Crocket Hall which had no residents. For Davis Hall she would push the meal cart through the dining room door to the hall and would not have to enter the hall. Dietary Aide OO reported there had been a purple cart next to the dining room door on Davis Hall that she would place the snacks on but it was not there today which was the first day it was not there. The Aide confirmed she had not changed her PPE before entering Davis Hall. Observation on 4/18/2020 at 10:50 AM of the dining room door leading to Davis Hall revealed there were no PPE supplies for dietary staff to don. Interview on 4/18/2020 at 11:20 AM with Regional Director NFA reported the dietary staff would push the meal cart for Davis Hall through the dining room door so they would not have to walk around and staff on Davis Hall would take the meal cart. When informed of the Dietary Aide OO who walked half-way down Davis Hall to the med cart to deliver snacks without doning new PPE, the Regional Director NFA reported she would re-educate the dietary staff. Record review of the Contracted Dietary (undated) policy titled Infection Control Overview & Policy revealed employees can be exposed to or expose residents to diseases through: .c. Contact with clothing, uniforms, laboratory coats, or isolation gowns used as PPE may become contaminated with potential pathogens after care of a resident colonized or infected with an infectious agent .

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 6 of 10 residents (Resident #72, #59, #17, #66, #7, and #16) reviewed for quality of care related to COVID-19, in that: 1. a. LVN F failed to notify MD when Resident #72 had a change in condition in which blood pressure dropped, oxygen saturation was low on 5 liters on oxygen. b. Resident #72's Magnesium level was not drawn as ordered prior to [MEDICATION NAME] treatment an EKG was not completed on day 5 of [MEDICATION NAME] treatment as ordered. c. Resident #72 was not being monitored for COVID-19 signs and symptoms every shift as per facility policy. 2. Resident #59 was not being monitored for COVID-19 signs and symptoms every shift as care planned. 3. Residents #17, #66 and #7 did not have vital signs completed as ordered by the physician. These failures resulted in identification of Immediate Jeopardy (IJ) on 4/16/2020. While the IJ was removed 4/24/2020, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to ensure residents were being assessed for a change in condition and physician was being notified. These deficient practices can affect all residents and place them at risk of not receiving the necessary care and a decline in health and/or death. The findings were: Record review of facility's policy on Notification of Changes, revised 2/10/2020, revealed, The facility will immediately inform the resident; consult with the resident's physician; and if known the resident's legal representative or appropriate family member(s) of the following: . 3. A significant change in the physical, mental or psychosocial status of the resident. 6. The facility documents resident assessment(s), interventions, physician and family notification(s) on SBAR (Situation Background Assessment Recommendation), Nurses Progress Note or Telephone Order Form (physician/family notice) as appropriate). Record review of facility's policy on Notification of Changes, revised 2/10/2020, revealed, The facility will immediately inform the resident; consult with the resident's physician; and if known the resident's legal representative or appropriate family member(s) of the following: . 3. A significant change in the physical, mental or psychosocial status of the resident. 6. The facility documents resident assessment(s), interventions, physician and family notification(s) on SBAR (Situation Background Assessment Recommendation), Nurses Progress Note or Telephone Order Form (physician/family notice) as appropriate). 1. a. Record review of Resident #72's nurse's progress note dated 4/13/2020 at 10:15 PM written by LVN F read blood pressure 88/44, pulse 71, respirations 18, and oxygen saturation 90 % on 5 liters will continue to monitor. Record review of facility's COVID-19 Monitoring Tool dated 4/14/2020 on 6:00 AM-2:00 PM shift revealed Resident #72 had a temperature of 100.5 with a note under other symptoms that read, Notified MD see electronic records. Further review revealed cough, sore throat, shortness of breath, vomiting, diarrhea and headache sections were left blank. Record review of Resident #72's progress notes revealed no documentation of a note for 4/14/2020 on 6:00 AM-2:00 PM shift. During an interview on 4/15/2020 at 5:39 PM, the Regional Director NFA stated if there was a change in condition the nurses should be documenting. Regional Director NFA stated if the issue was respiratory the RT would do a treatment, if that did not resolve, the RT would then notify nurse and MD. The Regional Director NFA stated if the vital signs were abnormal the RT should report to the nurse. The Regional Director NFA further stated V/S logs and COVID-19 Monitoring tools were reviewed by the nurses and regional nurses since April 10 for abnormalities and inconsistencies. The Regional Director NFA further stated nurses on the night shift were assessing for symptoms on the COVID-19 monitoring tool or when the RT was not on schedule. During an interview on 4/15/2020 at 5:40 PM, the Regional Nurse Consultant EE confirmed nurses should be documenting every shift in progress notes on alert charting for residents with a change in condition and COVID-19 positive symptomatic residents. The Regional Nurse Consultant EE further confirmed residents on [MEDICATION NAME] should be documented for 72 hours for any adverse reactions. During an interview on 4/15/2020 at 5:45 PM, Regional Nurse Consultant EE and Regional Director NFA confirmed there was no documentation the RT notified nursing of changes in condition for Resident #72. The Regional Nurse Consultant EE confirmed there was no documentation in Resident #72's clinical record on 4/14/2020 indicating physician had been notified. During an interview on 4/15/2020 at 6:54 PM, Dr. BB stated she had not sent in her progress notes as she was waiting to receive labs and vital signs from the facility. Dr. BB stated she used electronic medical records and when she submits the records, the records needed to go to the facility, but the records were currently set to go to the facility's corporate office. Dr BB further stated the facility do not give her exact vital sign numbers when she completed rounds but facility staff would tell her if residents' vital signs were normal or abnormal and she reviewed the vital signs later. Dr. BB further stated she was notified of Resident #72's elevated temp on 4/14/2020 at 5:10 AM and IV fluids were re-started. Dr BB confirmed the facility should have called her when Resident #72 began having a change in condition on 4/13/2020 and became non-responsive, had an elevated blood pressure, decreased oxygen saturation and increased respirations. Dr. BB further stated Resident #72 was the sickest resident in the facility. During an interview on 4/16/2020 at 11:13 AM, LVN B confirmed Resident #72 did not have a consent form for the off-label use of [MEDICATION NAME]. LVN B further sated he was not aware one was needed. During an interview on 4/16/2020 at 11:34 AM, the Regional Nurse Consultant EE confirmed they did not have any consent forms for any of the residents receiving [MEDICATION NAME] to treat COVID-19. The Regional Nurse Consultant EE further stated physician spoke to residents' families but did not know if it was documented in the residents' records. During an interview on 4/23/2020 at 9:13 AM ADON CC revealed Resident # 72 was alert and able to make needs known. ADON CC further stated Resident # 72 is able to communicate with the physician during tele heath rounds. She further sated Resident # 72 required lots of supervision as his condition had been deteriorating. During an interview on 4/24/2020 at 5:17 AM, LVN F confirmed she did not notify the physician of Resident #72's condition and should have. b. Record review of Resident #72's telephone order, dated 4/9/2020, revealed orders for EKG (electrocardiogram)today, EKG on 4/10/2020, EKG on 4/13/2020. CMP (complete metabolic panel) and Magnesium today. Record review of Resident #72's MAR for April 2020 revealed Resident #72 received initial dose of [MEDICATION NAME] on 4/10/2020 and last dose (day 5) on 4/14/2020. Record review of Resident #72's medical records revealed EKG results for 4/9/2020 and 4/11/2020 and no EKG results found for 4/13/2020. Further review revealed no pre-treatment Magnesium level was drawn prior to treatment of [REDACTED]. During an interview on 4/18/2020 at 12:00 PM, the RD NFA provided a typed sheet that read: On 4/18/2020 I spoke with Dr. BB, who stated the following diagnostics and labs are completed for [MEDICATION NAME] treatment: EKG-Pretreatment, Day 2 and Day 5, Magnesium, CMP- Pretreatment, Post-Repeat Magnesium and CBC. During an interview on 4/23/2020 at 9:35 AM, the RD NFA confirmed there was no pre-treatment Magnesium level for 4/9/2020 and EKG for 4/14/2020, which was day 5 of [MEDICATION NAME] treatment. During an interview on 4/24/2020 at 12:52 PM, Dr. BB stated the following diagnostics and labs are completed for [MEDICATION NAME] treatment: EKG-Pretreatment, Day 2 and Day 5, Magnesium, CMP- Pretreatment and, Post-treatment repeat Magnesium, CMP and CBC. During an interview on 4/25/2020 at 12:47 PM, Regional Nurse Consultant FF confirmed Resident # 72 did not have a pre-treatment, Magnesium level drawn as ordered. Record review of facility's COVID-19 Treatment Guidelines (no date) revealed, Review existing CMP or EKG if available, strongly recommend ordering a pre-treatment EKG, CMP, Mg. Monitoring during treatment; Vital signs every 6 hours during treatment and for one day after, daily provider visits, via telehealth or in person, to monitor patient and to assess treatment efficacy, strongly recommend repeat EKG on day 2 and Day 5. c. Record review of the facility's COVID-19 Monitoring Tool forms, dated 4/11-4/15/2020, revealed there was no COVID 19 Monitoring Tool for 4/11/2020 6 AM -2 PM shift, 4/13/2020 2-10 PM shift form was blank, 4/13/2020 missing one shift (one form did not specify shift), 4/14/2020 2-10 PM shift, and 4/15/2020 was missing one shift (one form did not specify shift). During an interview on 4/15/2020 at 5:45 PM, the Regional Nurse Consultant EE and Regional Director NFA confirmed they were missing COVID-19 Monitoring Tools. They further the confirmed COVID-19 Monitoring Tool on 4/13/2020 2-10 PM shift was left blank. During further interview Regional Nurse Consultant EE and Regional Director NFA stated the COVID-19 Monitoring Tool should be completed every shift. 2.Record review of Resident #59's care plan, dated 4/1/2020, revealed the resident had a [DIAGNOSES REDACTED]. symptoms of COVID-19 every shift and oxygen saturation every 4 hours. Record review of the facility's COVID-19 Monitoring Tool forms, dated 4/11-4/15/2020, revealed there was no COVID-19 Monitoring Tool for 4/11/2020 6 AM -2 PM shift, 4/13 2-10 PM shift form was blank, 4/13 missing one shift (one form did not specify shift), 4/14 2-10 PM shift, 4/15 missing one shift (one form did not specify shift). During an interview on 4/15/2020 at 5:45 PM, the Regional Nurse Consultant EE and Regional Director NFA confirmed they were missing COVID-19 Monitoring Tools. They further confirmed the COVID-19 Monitoring Tool on 4/13/20 2-10 PM shift was left blank. During further interview Regional Nurse Consultant EE and Regional Director FA stated the COVID-19 Monitoring Tool should be completed every shift. 3. Record review of Resident #17's face sheet revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #17's telephone order dated 4/11/2020 revealed orders for vital signs every 6 hours. Record review of Resident #17's clinical record revealed Resident # 17 only had vital signs completed once on 4/15/2020. Record review of Resident #66's Face Sheet, dated 4/16/2020, revealed he was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #66 was diagnosed with [REDACTED]. Record review of Resident #66's Physician Telephone Order, dated 4/12/2020, revealed an order for [REDACTED]. Record review of Resident #66's electronic clinical record revealed under the vital signs section, his blood pressure, pulse, respiration, temperature and oxygen saturation was recorded twice on 4/13/2020 and only once on 4/14/2020, 4/15/2020, 4/16/2020 and 4/17/2020 instead of every 6 hours as ordered. Record review of Resident #7's face sheet revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's telephone order, dated 4/10/2020, revealed an order for [REDACTED]. Record review of Resident #7's Physician's Telephone Order, dated 4/11/2020, revealed an order for [REDACTED].o. bid x 4 days, EKG stat today, EKG Day 2 & 5 with use of [MEDICATION NAME]. Further review revealed there were no orders for vital signs every 6 hours while the resident received [MEDICATION NAME]. Record review of Resident #7's electronic clinical record revealed under the vital signs section his blood pressure, pulse and respirations was only recorded once from 4/13/2020 to 4/16/2020; his oxygen saturation recorded twice on 4/14/2020 and only once on 4/13/2020, 4/15/2020 and 4/16/2020; and temperature was recorded twice on 4/15/2020 and 4/13/2020 and only once on 4/14/2020 and 4/16/2020 instead of every 6 hours as recommended During an interview on 5/1/2020 at 9:39 AM, ADON JJ confirmed Resident # 7 did not have orders for vital signs every 6 hours while on [MEDICATION NAME], in addition to the vitals every four hours for one night. ADON JJ further confirmed vital signs were not done every 4 hours as ordered for one night. During an interview on 4/15/2020 at 5:40 PM, the Regional Nurse Consultant EE and RD NFA confirmed they did not have documentation of vital signs being done for Residents #17, #66 and #7 as ordered by the physician. On 4/16/2020 at 2:50 PM the Interim Administrator and Regional Director NFA were notified of an Immediate Jeopardy (IJ) situation for the above failures, a completed IJ template was provided and a Plan of Removal was requested. An amended IJ Template was provided on 4/21/2020 at 8:30 AM. On 4/19/2020 at 5:41 PM the facility's Plan of Removal was approved. The facility's Plan of Removal included the following steps to be taken by the facility: 1. Immediate Action(s) taken for the residents(s) found to have been affected include: On 4/16/2020 Resident #72 had a comprehensive assessment completed by LVN B. Dr. BB was notified of resident assessment with new orders by physician, as indicated. Care plan was updated. On 4/17/2020 a comprehensive assessment, which included assessment of respiratory status and vital signs of Resident #72 was completed by RN E. Resident will be re-evaluated by physician on 4/17/2020 during MD rounds. Changes to plan of care by physician included medication adjustments and labs. Continued monitoring of respiratory status as resident completed [MEDICATION NAME] treatment. Resident's plan of care was updated to include [MEDICATION NAME] treatment and care on 4/16/2020. On 4/16/2020, Resident #59 is on hospice care and was assessed by the licensed nurse, which included a skin care assessment and notification of MD for new treatment orders, which were added to residents' plan of care. Vitals signs and respiratory status were obtained and documented on COVID-19 monitoring tool with no negative findings. According to physician progress notes [REDACTED]. On 4/17/2020, a comprehensive assessment, which included vital signs and assessment of respiratory status was completed by RN E. Resident #59 will be re-evaluated by physician on 4/17/20 during MD rounds. Care plan updated, including labs and continued monitoring. 2. Identification of other residents having the potential to be affected was accomplished by Residents were reviewed for changes in condition for 4/16/2020 by Regional Nurse Consultant EE. Dr. BB will be notified of any change of condition, orders will be carried out as indicated. There we no negative findings. 3. Actions to Prevent Occurrence / Recurrence The following actions were taken to ensure occurrence or reoccurrence of process/ system failure that could lead to serious adverse outcome and when those action were completed. Documentation and Communication Training: On 4/16/2020 Regional Nurse Consultant EE/ designee started in-service on 1) Notification of physician for changes in residents' change in condition, including timely notifying physician of changes in respiratory status or vital signs 2) Interact 4.0 SBAR Change in condition, 3) Oxygen Administration/Pulse Oximeter, includes parameters of when to call the physician, and 4) Documentation guidelines to ensure completeness and accuracy of documentation, including changes in conditions and vital signs-are in the medical record and/or on COVID-19 monitoring tool. On 4/16/2020 Regional Nurse Consultant EE re-educated RT AA on reporting changes in condition noted on COVID-19 monitoring tool, to ensure licensed nurses are aware of changes in condition for MD notification and further assessment. All residents will be assessed every 4 hours for pulse ox and every shift for S/S of temp and respiratory issues and daily for vital signs by the licensed nurse. On 4/17/2020, the COVID-19 Monitoring Tool was revised to include unit, shift and licensed nurse. Inservice education was started by Regional Director NFA/designee to ensure accuracy and completeness of information on the monitoring tool, including the date, location/room, and all vitals are recorded. In-service included licensed nurses and RT. RT AA was temporary support and is no longer working at the facility. Inservice will be provided to licensed nurses prior to the start of shift until all nurses have been trained; and upon new hires. COVID 19 Monitoring Tool, vital signs, and patient information is available to physicians, IDT, HHSC, providers, and authorized persons electronically and copied upon request. On 4/17/2020 Regional Director NFA started in-service training on Neglect to ensure nursing staff and facility leadership address/monitor changes in condition on the COVID-19 monitoring tool. On 4/18/2020 Regional Director NFA started in-service training on [MEDICATION NAME] treatment guidelines, including obtaining consent from resident/responsible party for [MEDICATION NAME] treatment. Documentation of consents will be noted in the medical record. On 4/18/2020 Regional Nurse Consultant FF started in-service training on Alert Charting, which process includes but is not limited to documentation of patient evaluation findings, physician notification and response, any new orders or instructions, implement acute care plan-which will be documented in the nurses' notes. Documentation for alert charting occurs daily and as indicated. Alert charting continues for a minimum 72 hr. or until resolution of the change of condition. Communication: The alert charting process will be used as the system that guides documentation of a resident's condition, and response to interventions implemented. Documentation for alert charting occurs daily and as indicated. Alert Charting continues for a minimum 72 hr. or until resolution of the change of condition Licensed nurses reference the Alert Charting Log at the start of each shift to identify residents requiring continued evaluation/assessment, follow-up and documentation Documentation related to the alert charting process may include, but is not limited to a) -patient evaluation pertinent to the condition identified as the acute event; b) -vital signs; c) -level of consciousness; d) -complaints and, or behavior symptoms; e) -respiratory evaluation; f) -patient response or outcomes The Licensed nurses uses the Alert Charting Log during shift to shift report to communicate to the oncoming nurse the resident's current status, and associated events that occurred during the shift The RNC/designee reviews that Alert Charting Log at a minimum of daily to discuss with the Licensed nurse the residents with a change of condition, status, need for additional interventions and to determine if the resident has returned to baseline functional status. Monitoring: RNC or designee will review monitoring tool daily to ensure completion and verify that any changes in condition is reported to the physician with interventions as indicated. RNC or designee will validate physician notification was completed by reviewing the clinical record daily and ensure plan of care is updated. Issues identified will be immediately addressed and re-education provided. RNC or designee will review Alert Charting Log daily and validate follow up in clinical record. Issues identified will be immediately addressed and re-education provided. Results of findings will be reviewed weekly by facility QAPI committee for further corrective action and/or continued monitoring. The surveyor verification of the Plan of Removal on 4/24/2020 was as follows: 1. Record review revealed Resident #72 had a comprehensive assessment was completed by LVN B. Care plan was updated on 4/16 to include [MEDICATION NAME] treatment. Resident #72 had a comprehensive assessment completed by RN E on 4/17/2020. Record review revealed Resident #59 had a comprehensive assessment completed by RN E on 4/17/2020. Resident # 59 was seen by MD on 4/17/2020. 2. During an interview on 4/20/2020 at 4:00 PM, Regional Nurse Consultant EE stated she reviewed all residents for a change in condition by reviewing vital signs and COVID-19 Monitoring Tool and communicating with nurses and Dr. BB. 3. Documentation and Communication Training- Record review of facility's in-service records dated 4/16/2020 - 4/23/2020 revealed all nursing staff received training on: Notification of physician change in resident's condition/ Interact 4.0 SBAR Oxygen Administration, pulse oximeter Documentation Guidelines COVID-19 Monitoring Tool Neglect [MEDICATION NAME] ([MEDICATION NAME]) Treatment Alert Charting During an interview on 4/20/2020 at 1:50 PM, LVN II revealed she received in-service training on residents needing consent for [MEDICATION NAME], completing COVID-19 Monitoring Tool every shift, Vital Sign daily and using the 24-hour report to relay any changes. LVN II further stated she was in-serviced on abuse and neglect last week and discussed the importance of checking residents and meeting their needs. During an interview on 4/21/2020 at 5:25 AM, RN GG stated she had continuous in-service training recently. She stated she was in-serviced on Third Eye notification of physician change of condition and provided me a copy of the guideline given to her. RN GG further stated she was in-serviced on charting accurately and documenting changes. She was last in-serviced on abuse/neglect last week. RN GG discussed rounding frequently making sure residents are hydrated keeping up with vital signs and residents' needs. Stated currently the policy is to do vital signs q shift, and oxygen saturations and temperature checks every 4 hours. During an interview on 4/23/2020 at 8:40 AM, LVN DD revealed today was his first day and was in-serviced on tr PPE (personal protective equipment), neglect, documentation, and alert charting. During an interview on 4/23/2020 at 9:07 AM, the ADON JJ revealed they had a lot of in-service training recently on neglect, documentation, alert charting, COVID-19 Monitoring Tool and use of [MEDICATION NAME]. He further stated they received training and were asked to repeat what they learned. During an interview on 4/23/2020 at 9:18 AM, ADON CC revealed she was in-serviced on neglect, COVID-19 Monitoring tool, alert charting and how they are supposed to use them for hand off report. ADON CC stated they complete the COVID-19 Monitoring Tool, vital signs every shift, and oxygen saturations every 4 hours. Record review of facility's COVID-19 Monitoring Tool, dated 4/21/2020 and 4/23/2020, revealed assessment was completed every shift. Further review revealed sheet was dated, shift and nurse signature was on each form. Record review of facility's Vital Sign Sheet dated 4/21/2020 - 4/23/2020, revealed vitals were completed on all residents once per day. Further review revealed the sheet was dated, shift and nurse signature was on each form. During an interview on 4/23/2020 at 10:51 AM, the Regional Nurse Educator revealed she reviews the vital sign sheets, COVID-19 Monitoring Tools, Alert Charting and 24-hour report sheets. The Regional Nurse Educator stated she then followed up with the nurses to ensure the physician was notified and the event was documented on the nurses' progress note. The Regional Nurse further stated they kept track of what they have reviewed by making copies and placing it in a binder and the Regional Nurse Consultant or designee follows up daily. During an interview on 4/24/2020 at 5:17 AM, LVN F confirmed she received in-services on notifying physician for resident change of condition and filling out the SBAR form. LVN F further confirmed she had in-services on oxygen administration, alert charting, COVID-19 monitoring tool, neglect. During an interview on 4/24/2020 at 5:30 AM, LVN B confirmed he received in-services on notifying the physician with any resident change of condition, reports to receiving nurse, and documents on SBAR and nursing progress note. LVN B confirmed oxygen saturations were to be checked every 4 hours and to notify MD if an oxygen saturation was less than 90%. LVN B confirmed he received an in-service training on completing the COVID-19 monitoring tool. LVN B also confirmed he was in-serviced on [MEDICATION NAME] to include adverse effects, EKG, need for consent written/verbal prior to administered the medication and follow up on the residents' post treatment of [REDACTED]. LVN B confirmed he received in-service on the different types of neglect by Regional Nurse Consultant FF. During an interview on 4/24/2020 at 5:37 AM, RN E stated she received in-service training on notifying MD on change of condition, completing SBAR form, alert charting, and oxygen administration. RN E stated oxygen saturation is checked every 4 hours and to notify MD if O2 sat 90% or below. She stated she was further in-serviced on completing the COVID 19 monitoring tool. RN E was in-serviced on obtaining consent form for [MEDICATION NAME] before giving the medication, and completing vital sign every 6 hours, EKG, and Magnesium level. RN E was also in-serviced on neglect. Record review of the facility in-service record revealed all licensed staff completed training on 4/23/2020 regarding Notification of physician change in resident's condition/ Interact 4.0 SBAR, Oxygen Administration, pulse oximeter, Documentation Guidelines, COVID-19 Monitoring Tool, Neglect, [MEDICATION NAME] ([MEDICATION NAME]) Treatment, and Alert Charting. Record review of facility's Alert Charting and 24-hour report dated 4/20/20 - 4/24/20, revealed event change in condition was back tracked to 4/14/2020. On 4/24/2020 at 11:12 AM Regional Consultant M and Regional Director NFA were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as a pattern due to residents on-going need for assessments for signs and symptoms of COVID-19.

Based on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 2 of 10 residents (Residents #11 and #72), in that: 1. LVN F failed to notify MD when Resident #72 who was COVID-19 positive and was on [MEDICATION NAME] for the off-label treatment of [REDACTED]. Resident # 72's in blood pressure dropped, oxygen saturation was low on 5 liters on oxygen. 2. Resident #11's COVID-19 status was not reported to the resident's legal guardian. These deficient practices could affect residents with a change in condition and place them at risk for a decline in health and or death. The findings were: 1. Record review of Resident #72's face sheet revealed an admission date of [DATE], and readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident # 72's Quarterly MDS, dated [DATE], revealed the resident understands and was understood. BIMS score of 6 (severely cognitive impaired). Record review of Resident #72's care plan, revised 3/16/20, revealed the resident was at risk for alteration in psychosocial well-being related to possible restriction on visitation due to COVID-19. Further review revealed the resident's care plan did not address care or treatment for [REDACTED]. Record review of Resident #72's physician progress notes [REDACTED].#72) is actively declining. Has fever, cough, shortness of breath, antibiotics not helping at this time, likely due [MEDICAL CONDITION] infection . Plan to start [MEDICATION NAME] .Vital signs every 6 hours, close monitor, given resident's advanced age, history of cardiac [MEDICAL CONDITION] disease, recent emergency room visit, high risk to deteriorate. Record review of Resident #72's telephone order, dated 04/09/2020, revealed orders for [MEDICATION NAME] 400 mg oral twice daily today then [MEDICATION NAME] 200 mg oral twice daily for 4 days. Record review of facility's Vital Signs Sheet, dated 4/13/2020 (shift or time unspecified), revealed Resident #72 had a temperature of 97.8, oxygen saturation 92 at 3 liters, B/P 139/109, pulse 61 respirations 28 room air 85% placed on oxygen at 2 liters. Record review of facility's COVID-19 Monitoring Tool, dated 4/13/20 (shift or time unspecified), revealed Resident #72 had a temperature of 97.8 under cough, sore throat, shortness of breath, vomiting, diarrhea, headache read patient nonverbal/non-responsive. During an interview on 4/15/20 at 4:10 PM, RT AA stated he took care of the residents by addressing their respiratory needs, he instructs them on taking deep breathes, administered respiratory treatments or oxygen as needed. RT AA further stated he did notify the nursing staff of Resident #72's change in condition. Resident # 72 became non-responsive, had an elevated blood pressure, decreased oxygen saturation and increased respirations. RT AA stated he only documented on the Vital Sign Sheet and COVID Monitoring Tool. Record review of Resident #72's nurses' progress notes revealed no progress notes from 4/12 at 10:51 PM until 4/13/20 at 10:15 PM. Record review of Resident #72's progress note, dated 4/13/20 at 10:15 PM written by LVN F, revealed, blood pressure 88/44, pulse 71, respirations 18, and oxygen saturation 90 % on 5 liters will continue to monitor. Record review of facility's COVID-19 Monitoring Tool, dated 4/14/20 on 6 AM -2 PM shift, revealed Resident #72 had a temperature of 100.5 with a note under other symptoms that read, Notified MD see electronic records. Further review revealed cough, sore throat, shortness of breath, vomiting, diarrhea and headache section were left blank. Record review of Resident # 72's vital sign sheet from 4/9/2020 to 4/14/2020 revealed blood presure ranges from 103/58 -145/62, respirations 16-20 and oxygennn saturation from 91-96 and has used oxygen from 2-3 liters. Record review of Resident # 72's nurses' progress notes revealed no documentation for 4/14/20 on 6 AM -2 PM shift. During an interview on 4/15/2020 at 5:39 PM, Regional Director NFA stated a change in condition of someone they were monitoring should be documented in alert charting. Regional Director NFA stated if the issue was respiratory the RT would do a treatment, if that did not resolve, the RT would then notify nurse and MD. Regional Director NFA stated if the RT discovered an elevated B/P it should be reported to the nurse. Regional Director NFA further stated V/S logs and COVID-19 Monitoring tools were reviewed by the nurses and regional nurses since April 10 for abnormalities and inconsistencies. Regional Director NFA stated nurses were documenting pulse saturation every 4 hours, and nurses on the night shift were assessing for symptoms on the COVID-19 Monitoring Tool when the RT was not on schedule. During an interview on 4/15/20 at 5:40 PM, Regional Nurse Consultant EE confirmed nurses should be documenting every shift in progress notes on alert charting for residents with a change in condition and COVID-19 positive symptomatic residents. Regional Nurse Consultant EE further confirmed residents on [MEDICATION NAME] should be documented for 72 hours for any adverse reactions. During an interview on 4/15/20 at 5:45 PM, Regional Nurse Consultant EE and Regional Director NFA stated RT AA should have notified the nurse and physician of Resident #72's change in condition. The Regional Nurse Consultant confirmed there was no documentation in Resident #72's clinical record for 4/14/20 indicating physician had been notified. During an interview on 4/15/2020 at 6:54 PM, Dr. BB stated she had not sent in her progress notes as she was waiting to receive labs and vital signs from the facility. Dr. BB stated she used electronic medical records and when she submits the records, the records needed to go to the facility, but the records were currently set to go to the facility's corporate office. Dr BB further stated the facility do not give her exact vital sign numbers when she completed rounds but facility staff would tell her if residents' vital signs were normal or abnormal and she reviewed the vital signs later. Dr. BB further stated she was notified of Resident #72's elevated temp on 4/14/2020 at 5:10 AM and IV fluids were re-started. Dr BB confirmed the facility should have called her when Resident #72 began having a change in condition on 4/13/2020 when Resident # 72 became non-responsive, had an elevated blood pressure, decreased oxygen saturation and increased respirations. Dr. BB further stated Resident #72 was the sickest resident in the facility. During an interview on 4/23/2020 at 9:13 AM ADON CC revealed Resident # 72 was alert and able to make needs known. ADON CC further stated Resident # 72 can communicate with the physician during tele health rounds. She further sated Resident # 72 required lots of supervision as his condition had been deteriorating. During an interview on 4/24/2020 at 5:17 AM, LVN F confirmed she did not notify the physician of Resident #72's condition and should have. 2. Record review of Resident #11's face sheet, dated 4/6/2020, with an original admission date of [DATE], revealed [DIAGNOSES REDACTED]. Record review of Resident #11's Annual MDS, dated [DATE], revealed a BIMS score of 99, which indicated the resident was unable to complete the interview. Further review revealed Resident #11 was moderately impaired for cognitive skills for daily decision making. During an interview on 4/20/2020 at 12:01 PM, ADON JJ confirmed the facility did not notify the legal guardian of Resident #11 testing COVID positive. ADON JJ read through all of the progress notes for Resident #11 and stated, Yeah, I don't see where anyone called. During an interview on 4/21/2020 at 8:31 AM, the legal guardian for Resident #11 confirmed the facility did not notify her of Resident #11's COVID-19 status. Record review of facility's policy on Notification of Changes, revised 2/10/20, revealed, The facility will immediately inform the resident; consult with the resident's physician; and if known the resident's legal representative or appropriate family member(s) of the following: . 3. A significant change in the physical, mental or psychosocial status of the resident. 6. The facility documents resident assessment(s), interventions, physician and family notification(s) on SBAR (Situation Background Assesmsnet Recommendation), Nurses Progress Note or Telephone Order Form (physician/family notice) as appropriate).

Based on interview and record review, the facility failed to provide pharmaceutical services to assure the accurate administering of PRN medications for 1 of 1 resident (Resident #3) reviewed for pharmacy services, in that: Resident #3 was not administered PRN [MEDICATION NAME] (laxative) and [MEDICATION NAME] (ammonia reducer and laxative) medications for constipation. The facility did not assess, respond in a timely manner, or consult Resident #3's attending physician when the resident did not have a bowel movement for 13 days, which resulted in fecal impaction with the need for a [MEDICAL CONDITION]. The facility failed to assess and administer medications to Resident #3 for bowel movements This deficient practice could place residents at-risk for significant abdominal pain, bloating, hemorrhoids, urinary incontinence, perforated colon, rectal bleeding, fecal impaction and the inability to achieve evacuation of the bowel. The findings were: Record review of the Resident's #3's face sheet, dated 02/21/2019, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had both short-term and long-term memory loss with impaired decision making skills. Record review of Resident's Plan of Care (P[NAME]) last updated 02/14/2019 revealed Constipation was addressed as a measurable goal; with an intervention to monitor and record bowel movements (BM) daily. For absence of BM for 3 days or more to follow physicians' orders. Record review of Residents #3's Resident Bowel and Bladder by Shift Chart revealed it was documented that the resident had not had a bowel movement for 13 days from 02/05/2019 to 02/18/2019. Resident #3 had a bowel movement on 2/19/2019. Record review of Resident #3's (MONTH) and (MONTH) 2019 MARs, revealed orders for: [MEDICATION NAME] Suppository 10 mg Insert 1 suppository rectally every 24 hours as needed for constipation and [MEDICATION NAME] Solution 20 GM/30 ml, give 30 ml by mouth every 24 hours as needed for constipation, related to constipation unspecific. Further review of the same document revealed [MEDICATION NAME] was administered to Resident #3 on 02/21/2019 at 12:45 a.m. with unsuccessful results, and [MEDICATION NAME] was not administered. Further review revealed that on no other occasion were these medications administered to Resident #3 in the months of (MONTH) or February. Record review of Residents #3's progress note, dated 02/21/2019 at 2:28 AM, revealed: Review of Nurses Progress Note, in part revealed Certified Nurses Aide (CNA) reported noticing abdominal distention. Assessed and noted abdomen, distended with left side protruding out, diminished bowel sounds. Resident noted to be grimacing and moaning. Administered PRN [MEDICATION NAME] Suppository 10 mg rectally at 2445, resident having difficulty allowing placement. Call placed to facility after hours medical consulting company. Spoke with MD H. Received orders to send resident to ED for evaluation and treatment Call placed to admitting facility to giver report RN K. Call placed to ambulance company for transfer to ED. DON informed of transfer to ED. Call place to emergency contact, no answer. Resident left facility via stretcher, alert and responsive. Record review of Resident #3's, facility's after duty hours medical consulting company note, dated 02/21/2019 at 1:12 AM, revealed the facility's after duty hours medical consulting company was contacted from the facility to assist with consultation and assessment. Record review Residents #3's Medical Consultation Progress Note, dated 02/21/2019 and signed at 5:31 AM, revealed: Chief Complaint Abdominal Pain, Pt has not had BM for several days and noted that her Abdomen has gotten more distended, painful to palpate. Nausea, but no vomiting. VS 178/100, P 100, R 18, lying in bed clear to ausculatory bilaterlly , regulate rate and rhythem, Distended, decreases BS, + tenderness Plan: Abdominal pain with distention - no BM for several days-likely constipation but need to r/o obstruction; offered X-ray but Pt. would rather go to the ER to get imaging quickly to r/u obstruction (CT etc.) Pt to transfer to ER. Signed, (physician). Record Review of Resident #3's revealed resident was transferred to hospital 02/21/2019 via ambulance; ambulance run sheet not available per facility. Record review of Resident #3's ED record revealed: CT Abdomen and Pelvis w/ IV Contrast 02/21/2019, reveals, the bowel is significantly compressed due to colonic findings described. There is a normal caliber appendix. Fluid filled moderately distended cecum and ascending colon. Moderately distended air-filled [MEDICATION NAME] colon. Rectosigmoid colon is significantly distended, with the rectum measuring up to 16 cm. associated rectal wall thickening. Record review of Resident #3's ED record revealed: General Surgery Consult Note, 02/21/2019 at 7:27 PM. HPI, [AGE] year old female admitted through the ER with abdominal pain, distention and massive fecal impaction. Elderly with dementia, lives in nursing home was found writhing in pain. P[NAME]: If need to disimpaction, will need to go under anesthesia, will need to discuss possible [MEDICAL CONDITION] if continues due to its massive amount and threat to colon wall. Admit resident to unit for further treatment and observation. Record review of Resident #3's record revealed, Inpatient, CT of Abdomen and Pelvis, follow up fecal impaction, 02/23/2019. Impression: Persistent severe fecal impression with large 11 cm ball in dilated rectum and persistent marked dilatation and stool content in mid-distal sigmoid colon. Slight improvement from 02/21/2019 exam. Record review of Resident #3's record revealed, Inpatient ICU, Diagnosis, Assessment and Plan, 02/25/2019, revealed Resident #3 needed surgical intervention for her fecal impaction. [AGE] year old woman, with past medical history of [REDACTED]. Patient was managed medically initially, unfortunately with no improvement, today patient comes to the ICU status [REDACTED]. Patient now comes to the ICU to continue medical management. Record review of Resident #3's discharge instructions, dated 03/01/2019, revealed the resident was discharged and returned to the nursing facility on 03/01/2019 with a discharge [DIAGNOSES REDACTED]. During an interview with CNA C on 02/22/2019 at 10:00 AM, CNA C stated that all output, to include bowel movement gets documented in the resident's electronic record per shift. CNA C stated consistency and size of output is also annotated on this report. Any concerns are reported to the LVN on shift. CNA C stated Resident #3 could make her needs know. CNA C stated that she had taken care of the resident on numerous occasions. During an interview with ADON B on 02/22/2019 at 10:30 AM, ADON B stated that nursing was made aware of those residents who were flagged or on a bowel program such as Resident #3 was. ADON B stated that the electronic charting system was supposed to alert the nurse on those residents who have gone without bowel movements after three days. During a telephone interview with APRN G on 02/22/2019 at 3:00 PM, APRN G stated he had visited with Resident #3 in her room on 02/14/2019. APRN G confirmed that at the time of the resident's exam he had noted no specific findings. APRN G confirmed that facility nursing staff had not brought any concerns regarding Resident #3 to his attention, and further confirmed that he had not asked facility nursing staff if there had been any pertinent changes in Resident #3's condition that he needed to be aware of since his last visit with the resident on 01/06/2019. APRN G confirmed that he had not reviewed Resident #3's available documentation at the facility during his visit with the resident on 02/14/2019 (by 02/14/2019 Resident #3 had gone ten days without a bowel movement). APRN G stated that it was difficult to communicate with the resident due to her hearing loss. During an interview with DON A on 02/22/2019 at 03:30 PM stated that every CNA was supposed to document the resident's bowel movement daily and per shift, into the electronic chart. DON A confirmed there were numerous missing entries for bowel movement monitoring on Resident #3's (MONTH) Bowel and Bladder Shift Chart after review. DON A further confirmed Resident #3 went 13 days without having a bowel movement, confirmed the nursing staff did not acknowledge this, nor was the resident treated for [REDACTED]. DON A stated they were unsure why staff did not implement the facility's policy after three days without documented bowel movements per facility policy. Record review of the facility policy for Bowel Monitoring, dated 03/11/2016, revealed: - Bowel movements are monitored by nursing staff observation that a patient has had a bowel movement or a report from a patient that bowel movement has occurred - If the patient has not had a bowel movement for 4-7 days monitor for signs and symptoms of constipation; abdominal pain, nausea/vomiting, loss of appetite, decrease bowel sounds - Notify the physician of the abnormal symptoms - Provide the patient with fluids and juice a indicated - Administer stool softener, suppositories, enemas and fibers as ordered - Continue to monitor the patient during 4 to 7 days for bowel movement, adverse signs and symptoms - Notify the Physician if there is increase tenderness, rigidity, distention, absence or decrease bowel sounds or abnormal bowel movements e.g. blood or mucus in stool. - Monitor Care Tracker reports Record review of Resident # 3's clinical record revealed no evidence that nursing staff was monitoring Resident #3's impaction and complying with physician's orders. Record review of facility's Abuse and Neglect policy,dated 09/13/2017, revealed that the resident has the right to be free from .neglect .

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident (Resident #3) reviewed for quality of care - bowel monitoring, in that: The facility did not assess Resident #3 and provide medications per physician's orders when the resident did not have a bowel movement for 13 days. Resident #3 experienced a severe fecal impaction requiring surgical intervention and placement of a [MEDICAL CONDITION]. This deficient practice could place residents at-risk for significant abdominal pain, bloating, hemorrhoids, urinary incontinence, perforated colon, rectal bleeding, fecal impaction and the inability to achieve evacuation of the bowel. The findings were: Record review of the Resident's #3's face sheet, dated 02/21/2019, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had both short-term and long-term memory loss with impaired decision making skills. Record review of Resident's Plan of Care (P[NAME]) last updated 02/14/2019 revealed Constipation was addressed as a measurable goal; with an intervention to monitor and record bowel movements (BM) daily. For absence of BM for 3 days or more to follow physicians' orders. Record review of Residents #3's Resident Bowel and Bladder by Shift Chart revealed it was documented that the resident had not had a bowel movement for 13 days from 02/05/2019 to 02/18/2019. Resident #3 had a small bowel movement on 2/21/19. Record review of Resident #3's (MONTH) and (MONTH) 2019 MARs, revealed orders for: [MEDICATION NAME] Suppository 10 mg Insert 1 suppository rectally every 24 hours as needed for constipation and [MEDICATION NAME] Solution 20 GM/30 ml, give 30 ml by mouth every 24 hours as needed for constipation, related to constipation unspecific. Further review of the same document revealed [MEDICATION NAME] was administered to Resident #3 on 02/21/2019 at 12:45 a.m. with unsuccessful results, and [MEDICATION NAME] was not administered. Further review revealed that on no other occasion were these medications administered to Resident #3 in the months of (MONTH) or February. Record review of Resident #3's progress note, dated 02/14/2019, revealed APRN G visited with the resident on 02/14/2019 and documented under abdominal findings NTND (non-tender non-distended), No new problems, and Cont. Plan of Care. Record review of Resident #3's physician progress notes [REDACTED]. with P[NAME]. Record review of MD's medication orders dated 04/25/2011 and 08/29/18 revealed that Resident #3 had to be medicated according for constipation. Record review of Resident #3's facility progress note, dated 02/22/2019, revealed the resident had not been assessed for any type of abdominal complaints or pain or problems related to constipation from 02/01/2019 until 02/21/2019. Further review revealed the resident was transferred to the ED at the hospital on [DATE] for treatment. Record review of Residents #3's progress note, dated 02/21/2019 at 2:28 AM, revealed: Review of Nurses Progress Note, in part revealed Certified Nurses Aide (CNA) reported noticing abdominal distention. Assessed and noted abdomen, distended with left side protruding out, diminished bowel sounds. Resident noted to be grimacing and moaning. Administered PRN [MEDICATION NAME] Suppository 10 mg rectally at 2445, resident having difficulty allowing placement. Call placed to facility after hours medical consulting company. Spoke with MD H. Received orders to send resident to ED for evaluation and treatment Call placed to admitting facility to giver report RN K. Call placed to ambulance company for transfer to ED. DON informed of transfer to ED. Call place to emergency contact, no answer. Resident left facility via stretcher, alert and responsive. Record review of Resident #3's, facility's after duty hours medical consulting company note, dated 02/21/2019 at 1:12 AM, revealed the facility's after duty hours medical consulting company was contacted from the facility to assist with consultation and assessment. Record review Residents #3's Medical Consultation Progress Note, dated 02/21/2019 and signed at 5:31 AM, revealed: Chief Complaint Abdominal Pain, Pt has not had BM for several days and noted that her Abdomen has gotten more distended, painful to palpate. Nausea, but no vomiting. VS 178/100, P 100, R 18, lying in bed clear to ausculatury bilateraly, regular rate and rhythem , Distended, decreases BS, + tenderness Plan: Abdominal pain with distention - no BM for several days-likely constipation but need to r/o obstruction; offered X-ray but Pt. would rather go to the ER to get imaging quickly to r/u obstruction (CT etc.) Pt to transfer to ER. Signed, (physician). Record Review of Resident #3's clinical record revealed resident was transferred to hospital 02/21/2019 via ambulance; ambulance run sheet not available per facility. Record review of Resident #3's ED record revealed: CT Abdomen and Pelvis w/ IV Contrast 02/21/2019, reveals, the bowel is significantly compressed due to colonic findings described. There is a normal caliber appendix. Fluid filled moderately distended cecum and ascending colon. Moderately distended air-filled [MEDICATION NAME] colon. Rectosigmoid colon is significantly distended, with the rectum measuring up to 16 cm. associated rectal wall thickening. Record review of Resident #3's ED record revealed: General Surgery Consult Note, 02/21/2019 at 7:27 PM. HPI, [AGE] year old female admitted through the ER with abdominal pain, distention and massive fecal impaction. Elderly with dementia, lives in nursing home was found writhing in pain. P[NAME]: If need to disimpaction, will need to go under anesthesia, will need to discuss possible [MEDICAL CONDITION] if continues due to its massive amount and threat to colon wall. Admit resident to unit for further treatment and observation. Record review of Resident #3's hospital record revealed, Inpatient, CT of Abdomen and Pelvis, follow up fecal impaction, 02/23/2019. Impression: Persistent severe fecal impression with large 11 cm ball in dilated rectum and persistent marked dilatation and stool content in mid-distal sigmoid colon. Slight improvement from 02/21/2019 exam. Record review of Resident #3's hospital record revealed, InpatientICU, Diagnosis, Assessment and Plan, 02/25/2019, revealed Resident #3 needed surgical intervention for her fecal impaction. [AGE] year old woman, with past medical history of [REDACTED]. Patient was managed medically initially, unfortunately with no improvement, today patient comes to the ICU status [REDACTED]. Patient now comes to the ICU to continue medical management. Record review of Resident #3's discharge instructions, dated 03/01/2019, revealed the resident was discharged and returned to the nursing facility on 03/01/2019 with a discharge [DIAGNOSES REDACTED]. During an interview with CNA C on 02/22/2019 at 10:00 AM, CNA C stated that all output, to include bowel movement gets documented in the resident's electronic record per shift. CNA C stated consistency and size of output is also annotated on this report. Any concerns are reported to the LVN on shift. CNA C stated Resident #3 could make her needs known. CNA C stated that she had taken care of the resident on numerous occasions. During an interview with ADON B on 02/22/2019 at 10:30 AM, ADON B stated that nursing was made aware of those residents who were flagged or on a bowel program such as Resident #3 was. ADON B stated that the electronic charting system was supposed to alert the nurse on those residents who have gone without bowel movements after three days. During a telephone interview with APRN G on 02/22/2019 at 3:00 PM, APRN G stated he had visited with Resident #3 in her room on 02/14/2019. APRN G confirmed that at the time of the resident's exam he had noted no specific findings. APRN G confirmed that facility nursing staff had not brought any concerns regarding Resident #3 to his attention, and further confirmed that he had not asked facility nursing staff if there had been any pertinent changes in Resident #3's condition that he needed to be aware of since his last visit with the resident on 01/06/2019. APRN G confirmed that he had not reviewed Resident #3's available documentation at the facility during his visit with the resident on 02/14/2019 (by 02/14/2019 Resident #3 had gone ten days without a bowel movement). APRN G stated that it was difficult to communicate with the resident due to her hearing loss. During an interview with DON on 02/22/2019 at 03:30 PM stated that every CNA was supposed to document the resident's bowel movement daily and per shift, into the electronic chart. DON confirmed there were numerous missing entries for bowel movement monitoring on Resident #3's (MONTH) Bowel and Bladder Shift Chart after review. DON further confirmed Resident #3 went 13 days without having a bowel movement, confirmed the nursing staff did not acknowledge this, nor was the resident treated for [REDACTED]. DON stated they were unsure why staff did not implement the facility's policy after three days without documented bowel movements per facility policy. Record review of the facility policy for Bowel Monitoring, dated 03/11/2016, revealed: - Bowel movements are monitored by nursing staff observation that a patient has had a bowel movement or a report from a patient that bowel movement has occurred - If the patient has not had a bowel movement for 4-7 days monitor for signs and symptoms of constipation; abdominal pain, nausea/vomiting, loss of appetite, decrease bowel sounds - Notify the physician of the abnormal symptoms - Provide the patient with fluids and juice a indicated - Administer stool softener, suppositories, enemas and fibers as ordered - Continue to monitor the patient during 4 to 7 days for bowel movement, adverse signs and symptoms - Notify the Physician if there is increase tenderness, rigidity, distention, absence or decrease bowel sounds or abnormal bowel movements e.g. blood or mucus in stool. - Monitor Care Tracker reports Record review of Resident # 3's clinical record revealed no evidence that nursing staff was monitoring Resident #3's impaction and complying with physician's orders. Record review of facility's Abuse and Neglect policy,dated 09/13/2017, revealed that the resident has the right to be free from .neglect .

Based on interview, and record review, the facility failed to ensure residents were free from neglect for 1 of 1 resident (Resident #3) reviewed for neglect, in that; The facility did not assess, respond in a timely manner, or consult Resident #3's attending physician when the resident did not have a bowel movement for 13 days, which resulted in fecal impaction with the need for a [MEDICAL CONDITION]. The facility failed to assess and administer medications to Resident #3 for bowel movements. This deficient practice could place residents at-risk for significant abdominal pain, bloating, hemorrhoids, urinary incontinence, perforated colon, rectal bleeding, fecal impaction and the inability to achieve bowel movements. The findings were: Record review of the Resident's #3's face sheet, dated 02/21/2019, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had both short-term and long-term memory loss with impaired decision making skills. Record review of Resident's Plan of Care (P[NAME]) last updated 02/14/2019 revealed Constipation was addressed as a measurable goal; with an intervention to monitor and record bowel movements (BM) daily. For absence of BM for 3 days or more to follow physicians' orders. Record review of physician's order revealed that staff needed to monitor and record bowel movements (BM) daily; and give PRN medications. Record review of Residents #3's Resident Bowel and Bladder by Shift Chart revealed it was documented that the resident had not had a bowel movement for 13 days from 02/05/2019 to 02/18/2019. The last recorded a medium bowel movement according to the clinical record was 2/19/19. Record review of Resident #3's (MONTH) and (MONTH) 2019 MARs, revealed orders for: [MEDICATION NAME] Suppository 10 mg Insert 1 suppository rectally every 24 hours as needed for constipation and [MEDICATION NAME] Solution 20 GM/30 ml, give 30 ml by mouth every 24 hours as needed for constipation, related to constipation unspecific. Further review of the same document revealed [MEDICATION NAME] was administered to Resident #3 on 02/21/2019 at 12:45 a.m. with unsuccessful results, and [MEDICATION NAME] was not administered. Further review revealed that on no other occasion were these medications administered to Resident #3 in the months of (MONTH) or February. Record review of Resident #3's of APRN G progress note, dated 02/14/2019, revealed APRN G visited with the resident on 02/14/2019 and documented under abdominal findings NTND (non-tender non-distended), No new problems, and Cont. Plan of Care. Record review of Resident #3's physician progress notes [REDACTED]. with P[NAME]. Observation on 2/21/2019 of Resident #3 in the hospital revealed that resident was not interviewable. Record review of Resident #3's facility progress note, dated 02/22/2019, revealed the resident had not been assessed for any type of abdominal complaints or pain or problems related to constipation from 02/01/2019 until 02/21/2019. Further review revealed the resident was transferred to the ED at the hospital on [DATE] for treatment. Record review of Residents #3's progress note, dated 02/21/2019 at 2:28 AM, revealed: Review of Nurses Progress Note, in part revealed Certified Nurses Aide (CNA) reported noticing abdominal distention. Assessed and noted abdomen, distended with left side protruding out, diminished bowel sounds. Resident noted to be grimacing and moaning. Administered PRN [MEDICATION NAME] Suppository 10 mg rectally at 2445, resident having difficulty allowing placement. Call placed to facility after hours medical consulting company. Spoke with MD H. Received orders to send resident to ED for evaluation and treatment Call placed to admitting facility to giver report RN K. Call placed to ambulance company for transfer to ED. DON informed of transfer to ED. Call place to emergency contact, no answer. Resident left facility via stretcher, alert and responsive. Record review of Resident #3's, facility's after duty hours medical consulting company note, dated 02/21/2019 at 1:12 AM, revealed the facility's after duty hours medical consulting company was contacted from the facility to assist with consultation and assessment. Record review Residents #3's Medical Consultation Progress Note, dated 02/21/2019 and signed at 5:31 AM, revealed: Chief Complaint Abdominal Pain, Pt has not had BM for several days and noted that her Abdomen has gotten more distended, painful to palpate. Nausea, but no vomiting. vital signs blood pressure 178/100, Pulse rate 100, respirations 18, lying in bed. clear to ausculatory, regular rate and rhythm, Distended, decreases Bowel Sounds, increase tenderness Plan: Abdominal pain with distention - no BM for several days-likely constipation but need to r/o obstruction; offered X-ray but Pt. would rather go to the ER to get imaging quickly to r/u obstruction (CT etc.) Patient to transfer to ER. Signed, (physician). Record Review of Resident #3's medical record revealed resident was transferred to hospital 02/21/2019 via ambulance; ambulance run sheet not available per facility. Record review of Resident #3's ED (emergency department) record revealed: CT Abdomen and Pelvis w/ IV Contrast 02/21/2019, reveals, the bowel is significantly compressed due to colonic findings described. There is a normal caliber appendix. Fluid filled moderately distended cecum and ascending colon. Moderately distended air-filled [MEDICATION NAME] colon. Rectosigmoid colon is significantly distended, with the rectum measuring up to 16 cm. associated rectal wall thickening. Record review of Resident #3's ED record revealed: General Surgery Consult Note, 02/21/2019 at 7:27 PM. HPI (history pathological individual), [AGE] year old female admitted through the ER with abdominal pain, distention and massive fecal impaction. Elderly with dementia, lives in nursing home was found writhing in pain. P[NAME]: If need to disimpaction, will need to go under anesthesia, will need to discuss possible [MEDICAL CONDITION] if continues due to its massive amount and threat to colon wall. Admit resident to unit for further treatment and observation. Record review of Resident #3's radiology report revealed, Inpatient, (CT) of Abdomen and Pelvis, follow up fecal impaction, 02/23/2019. Impression: Persistent severe fecal impression with large 11 cm ball in dilated rectum and persistent marked dilatation and stool content in mid-distal sigmoid colon. Slight improvement from 02/21/2019 exam. Record review of Resident #3's hospital record revealed, Inpatient(ICU) and , Diagnosis, Assessment and Plan, 02/25/2019, revealed Resident #3 needed surgical intervention for her fecal impaction. [AGE] year old woman, with past medical history of [REDACTED]. Patient was managed medically initially, unfortunately with no improvement, today patient comes to the ICU status [REDACTED]. Patient now comes to the ICU to continue medical management. Record review of Resident #3's discharge instructions, dated 03/01/2019, revealed the resident was discharged and returned to the nursing facility on 03/01/2019 with a discharge [DIAGNOSES REDACTED]. During an interview with CNA C on 02/22/2019 at 10:00 AM, CNA C stated that all output, to include bowel movement gets documented in the resident's electronic record per shift. CNA C stated consistency and size of output is also annotated on this report. Any concerns are reported to the LVN on shift. CNA C stated Resident #3 could make her needs known. CNA C stated that she had taken care of the resident on numerous occasions. During an interview with ADON B on 02/22/2019 at 10:30 AM, ADON B stated that nursing was made aware of those residents who were flagged or on a bowel program such as Resident #3 was. ADON B stated that the electronic charting system was supposed to alert the nurse on those residents who have gone without bowel movements after three days. During a telephone interview with APRN G on 02/22/2019 at 3:00 PM, APRN G stated he had visited with Resident #3 in her room on 02/14/2019. APRN G confirmed that at the time of the resident's exam he had noted no specific findings. APRN G confirmed that facility nursing staff had not brought any concerns regarding Resident #3 to his attention, and further confirmed that he had not asked facility nursing staff if there had been any pertinent changes in Resident #3's condition that he needed to be aware of since his last visit with the resident on 01/06/2019. APRN G confirmed that he had not reviewed Resident #3's available documentation at the facility during his visit with the resident on 02/14/2019 (by 02/14/2019 Resident #3 had gone ten days without a bowel movement). APRN G stated that it was difficult to communicate with the resident due to her hearing loss. During an interview with DON A on 02/22/2019 at 03:30 PM stated that every CNA was supposed to document the resident's bowel movement daily and per shift, into the electronic chart. DON confirmed there were numerous missing entries for bowel movement monitoring on Resident #3's (MONTH) Bowel and Bladder Shift Chart after review. DON further confirmed Resident #3 went 13 days without having a bowel movement, confirmed the nursing staff did not acknowledge this, nor was the resident treated for [REDACTED]. DON stated they were unsure why staff did not implement the facility's policy after three days without documented bowel movements per facility policy. Record review of the facility policy for Bowel Monitoring, dated 03/11/2016, revealed: - Bowel movements are monitored by nursing staff observation that a patient has had a bowel movement or a report from a patient that bowel movement has occurred - If the patient has not had a bowel movement for 4-7 days monitor for signs and symptoms of constipation; abdominal pain, nausea/vomiting, loss of appetite, decrease bowel sounds - Notify the physician of the abnormal symptoms - Provide the patient with fluids and juice a indicated - Administer stool softener, suppositories, enemas and fibers as ordered - Continue to monitor the patient during 4 to 7 days for bowel movement, adverse signs and symptoms - Notify the Physician if there is increase tenderness, rigidity, distention, absence or decrease bowel sounds or abnormal bowel movements e.g. blood or mucus in stool. - Monitor Care Tracker reports Record review of Resident # 3's clinical record revealed no evidence that nursing staff was monitoring Resident #3's impaction and complying with physician's orders. Record review of facility's Abuse and Neglect policy,dated 09/13/2017, revealed that the resident has the right to be free from .neglect .