Every finding on record at Southland Rehabilitation and Healthcare Center

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #3 and Resident #7) and 3 of 5 staff (CNA A, CNA B and ADON) reviewed for infection control.1.The facility failed to ensure CNA A wore the appropriate PPE when she provided care to Resident #3 who was on EBP on 5/13/2026.2.The facility failed to ensure CNA B and the ADON wore the appropriate PPE when they provided care to Resident #7 who was on enhanced barrier precautions (EBP) on 5/13/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:1.Record review of a Face Sheet for Resident #3 dated 5/13/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of UTI (urinary tract infection), extended spectrum beta lactamase (ESBL) resistance (bacteria that is resistance to many common antibiotics), and chronic kidney disease (a condition where the kidneys are damaged or lose function over time).Record review of active physician orders for Resident #3 dated 5/13/2026 indicated a physician order for catheter care every shift that started on 5/8/2026.Record review of an admission MDS Assessment for Resident #3 dated 5/12/2026 indicate it was in progress and not completed.Record review of a care plan for Resident #3 dated 5/11/2026 indicated she had bowel/bladder incontinent related to disease process. She had a foley catheter secondary to the ESBL sepsis.During an observation on 5/13/2026 at 8:48 am, CNA A entered the room of Resident #3 and put gloves on her hands. There was not a sign on the door or PPE noted in the hallway or hanging on the door. Resident #3 was in bed awake. CNA A pulled the linens down and opened the brief. Resident #3 had a urinary catheter that was draining into a drainage bag. CNA A looked and asked Resident #3 to roll onto her left side so she could check to make sure she was dry. CNA A told Resident #3 she was dry and closed her brief. CNA A went into the restroom and brought out a urinal, drained the urinary bag, flushed the urine in the toilet, and placed the urinal in a plastic bag in the bathroom. CNA A removed her gloves and placed them in the trash and washed her hands in the bathroom and exited the room.2. Record review of a Face Sheet for Resident #7 dated 5/13/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (a group of lung diseases that affect breathing), gastrostomy status (tube placed in the stomach for feeding) and chronic atrial fibrillation (an irregular heartbeat).Record review of active physician orders for Resident #7 dated 5/13/2026 indicated an order for enteral feedings dated 5/8/2026. He had unstageable wounds to his left and right heels that started on 5/8/2026.Record review of a Quarterly MDS Assessment for Resident #7 dated 4/2/2026 indicated he did not have any impairment in thinking with a BIMS score of 14. He required partial/moderate assistance with personal hygiene. He was frequently incontinent of urine/bowel.Record review of a care plan for Resident #7 dated 12/2/2025 indicated he had wound management. Interventions included to monitor for signs of infection. The care plan did not reflect the need for EBP.During an observation on 5/13/2026 at 9:58 am, at the room of Resident #7 there was a sign on the door for EBP and PPE was hanging on the outside of the door. The ADON and CNA B were in the room to provide incontinent care. Resident #7 was sitting in a wheelchair with a lift pad under his buttocks with his g-tube infusing. The ADON disconnected his feeding, and both staff sanitized their hands and put on gloves. A mechanical lift was used to transfer Resident #7 from his chair to his bed by both staff. Neither staff put on a gown before the transfer. Resident #7 was positioned in bed and CNA B removed her gloves and placed them in the trash and sanitized her hands. The ADON removed her gloves and placed them in the trash and sanitized her hands and applied gloves. Resident #7 was rolled and the lift pad was removed along with his pants, and both were placed in a plastic bag. Resident #7's brief was opened and pulled down between his thighs. CNA B removed her gloves and placed them in the trash and sanitized her hands. The ADON assisted with turning and positioning Resident #7. CNA B placed gloves on her hands and removed a wipe from the plastic bag and wiped across his lower abdomen and placed the wipe in the trash. CNA B removed another wipe and wiped down both inner thighs and placed the wipes inside the brief. The ADON removed her gloves and placed them in the trash and exited the room to get more wipes. CNA B removed her gloves and placed them in the trash and sanitized her hands. The ADON reentered the room with wipes in a plastic bag and placed gloves on her hands. CNA B placed gloves on her hands and removed a wipe and wiped down his inner thighs again and placed the wipes in the brief. Resident #7 was rolled onto his right side and CNA B removed her gloves and placed them in the trash and sanitized her hand. CNA B applied gloves and rolled the brief underneath Resident #7's buttocks and removed it and placed it in the trash. CNA B removed her gloves and placed them in the trash and sanitized her hands. CNA B applied gloves, removed wipes, and wiped Resident #7's buttocks and a small amount of fecal material was present. CNA B removed her gloves; placed them in the trash; sanitized her hands and applied gloves. A clean brief was applied under Resident #7's buttocks and barrier cream was applied to his buttocks. CNA B removed her gloves and placed them in the trash; sanitized her hands; and applied gloves. Resident #7 was rolled onto his back, and brief was secured and he covered back up with his linens. The ADON and CNA B both removed their gloves and placed them in the trash. The ADON gathered the trash, exited the room, and placed the trash in the dirty linen barrel. The ADON and CNA B both washed their hands in the bathroom.During an interview on 5/13/2026 at 10:32 am, CNA B initially said she did not know what residents were on EBP and did not know what EBP was for. She said there was a sign for EBP on the door of Resident #7's room that she read and said it indicated staff to wear a gown and gloves for high contact. She said Resident #7 had a wound dressing and a feeding tube. She said she should have worn a gown during the care she provided to him. She said there was PPE on the door that included gowns. She said when she saw the sign after care was completed, she recognized it and had seen the signs in the facility and followed the precautions. She said there was a risk of spreading infections to other residents if they did not follow EBP. She said she had been at the facility for 6 months and was trained on EBP.During an interview on 5/13/2026 at 11:16 am, CNA A said she should have put on a gown when she provided care to Resident #3 because she had a urinary catheter. She said they were supposed to wear a gown and gloves when caring for a resident that was on EBP. She said there was usually signage on the doors and PPE should have been on a shelf outside of the door. She said there was a risk of infections if they did not wear gowns and gloves.During an interview on 5/13/2026 at 11:26 am, the ADON said she had been employed at the facility since December 2025. She said the DON was the IP for the facility but they both trained the staff on infection control. She said during the care that was provided to Resident #7 she did not wear the appropriate PPE that included a gown and gloves. She said Resident #7 was on EBP and it just slipped her mind. She said residents on EBP included any that had tubes such as urinary catheters, PICC lines, g-tubes, colostomies, or any tube coming out or going into the resident's body. She said staff were supposed to wear a gown and gloves when a resident was on EBP during contact care. She said the nurse aides would have knowledge about which residents were on EBP and they had signs and PPE on the doors. She said Resident #3 did not have a sign on her door earlier that morning, but a sign had been placed since then. She said there could be a risk of infections being spread to other residents if the appropriate PPE was not worn to protect the residents and staff.During an interview on 5/13/2026 at 2:34 pm, the DON said she was the IP for the facility. She said but she along with the ADON trained staff often with random checks. She said EBP was for residents who had urinary catheters, tubes, colostomies, wounds, or IVs. She said any resident who was in isolation staff were to wear a gown and gloves also. She said there could be a risk of infections if staff did not follow facility policy and procedures.During an interview on 5/13/2026 at 3:23 pm, the Administrator said the clinical staff and nurse administrators were responsible for training staff on infection control. He said EBP included residents with certain types of infections, wounds, g-tubes, or urinary catheters. He said staff should wear the appropriate PPE that was on the doors of the rooms according to policy. He said there was a risk of spreading contaminants.Record review of a facility policy titled Enhanced Barrier Precautions revised 1/2026 indicated, .The facility implements Enhanced Barrier Precautions to reduce transmission of multidrug-resistant organisms (MDROs) in residents, while maintaining quality of life and minimizing unnecessary isolation. 1. Enhanced Barrier Precautions (EBP): expand the use of PPE and refer to the use of gowns and gloves during high contact resident care activities. a. PPE: the use of gown and gloves for high contact resident care activities is indicated with: i. wounds and/or indwelling medical devices regardless of MDRO colonization as well for residents. C. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: iii. Transferring; iv. Providing hygiene; vi. Changing briefs or assisting with toileting; vii. Device care or use-indwelling urinary catheter. 3. Implementation a. The facility will implement a system to alert staff, residents, and visitors that a resident is on TBP. ii. For Enhanced Barrier Precautions, signage should also clearly indicate high contact resident care activities that require the use of gowns and gloves. B. Make PPE including gowns and gloves, available immediately outside of the resident room.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections for 1 of 3 (Resident #4) reviewed for incontinent care.The facility failed to ensure Resident #4 received proper incontinent care on 5/13/2026.This failure could place residents at risk of embarrassment, discomfort, and skin breakdown.Findings included:Record review of an admission Record for Resident #4 dated 5/13/2026 indicated he was [AGE] years old with diagnoses of BPH (enlarged prostate), UTI (infection in the urinary tract), dementia (a decline in thinking, behavior, and ability to perform everyday activities), and malignant neoplasm of prostate (cancer in the prostate).Record review of an admission MDS Assessment for Resident #4 dated 5/5/2026 indicated he did not have any impairment in thinking with a BIMS score of 15. He required substantial/maximal assistance with personal hygiene. He was always incontinent of urine/bowel.Record review of a care plan for Resident #4 dated 5/8/2026 indicated he had bowel/bladder incontinence related to disease process. Interventions included to check as required for incontinence. Wash, rinse, and dry perineum.During an observation on 5/13/2026 at 10:41 am, Resident #4 was in his room in bed. Staff had just placed him in bed to provide incontinent care. The ADON and CNA A were in the room, and both washed their hands and put on gloves. They removed his pants and Resident #4 said they were wet. Both staff said the pants were wet and they placed them in a plastic bag. CNA A opened Resident #4's brief and pulled it down between his thighs. CNA A removed her gloves, placed them in the trash, sanitized her hands, and put on clean gloves. Resident #4 had feces present inside the brief. CNA A removed wipes from a plastic bag and wiped his inner thighs using multiple wipes and placed the wipes inside the brief. CNA A removed her gloves and placed them in the trash, sanitized her hands, and applied clean gloves. The ADON removed her gloves and placed them in the trash and exited the room to get more gloves. The ADON reentered the room, sanitized her hands, and applied clean gloves. The ADON assisted with positioning Resident #4 onto his right side. CNA A did not clean Resident #4 properly around his penis which was uncircumcised and his inner thighs and left feces on his inner thighs. CNA A removed wipes from the plastic bag and wiped Resident #4's buttocks. Feces were still present on Resident #4's inner thighs and buttocks. CNA A removed Resident #4's brief and placed it in the trash. CNA A sanitized her hands and applied clean gloves. Resident #4 was not clean and had dried feces noted to his scrotum. CNA A applied a clean brief and placed barrier cream on her fingers to apply to his buttocks. Surveyor intervened and had staff look at Resident #4 to see if he was cleaned properly. CNA A with the help of the ADON completed care of Resident #4. CNA A secured the brief on Resident #4 and removed her gloves and placed them in the trash. CNA A removed the trash from the room and placed it in the dirty linen barrel that was in the hallway. The ADON removed her gloves and placed them in the trash. Both staff washed their hands and exited the room.During an interview on 5/13/2026 at 11:07 am, Resident #4 was sitting in a wheelchair in the room. He was alert to person and place. He said he had been at the facility for 3 weeks. He said he had been changed by staff earlier that morning but had been up since a little before breakfast. He said he could not remember how often staff changed him during the day or night.During an interview on 5/13/2026 at 11:16 am, CNA A said she had been employed at the facility since January 2026. She said her shift was from 6 am to 6 pm. She said she should have paid more attention to how Resident #4 was cleaned. She said his pants were wet and had a bowel movement. She said she provided care for him that morning a little after 7 am. She said they were supposed to make rounds every 2 hours for incontinent care, but she had not gotten a chance to check on everyone that was assigned to her again. She said the feces were hard to see on Resident #4 during the care she provided to him. She said it would make her feel icky-disgusted if she was left dirty. She said he was uncircumcised and she should have cleaned his penis properly with pulling his foreskin back and cleaning and then placing the skin back in place.Record review of a CNA Comprehensive Clinical Competency Review Skills Checklist dated 1/6/2026 indicated she was observed by the ADON, and perineal care skills were met.During an interview on 5/13/2026 at 11:26 am, the ADON said she had been employed at the facility since December 2025. She said Resident #4 was really saturated in urine because his pants were wet. She said staff should check residents every 2 hours. She said there were two lines on the briefs they used to help indicate how saturated the briefs were. She said if the color change was not above 75%, they did not have to change the residents. She said the lines on the briefs were yellow and when they were wet, they changed to blue. She said Resident #4's brief was 100% saturated with urine and should have been changed before the time it was changed. She said feces were stuck to him and that indicated he had been sitting in it for a while. She said she did not notice it at the time that he was still dirty before the Surveyor intervened. She said a male resident should be cleaned in the front and back and both inner thighs. She said Resident #4 was uncircumcised and she did not clean his penis. She said she would expect the staff to take care of her timely and not be left in feces or urine. She said residents could be at risk of skin break down or infections if they were left dirty.During an interview on 5/13/2026 at 2:34 pm, the DON said the facility had invested money in a different brand of briefs and if the lines on the briefs were 75% or less, then they would not change the briefs. She said ADL care should be done every 3-4 hours because of the briefs the facility used. She said residents should be cleaned properly when incontinent care was provided and a male resident that was uncircumcised should cleaned properly. She said there could be risk of infections if staff did not follow policy and procedures.During an interview on 5/13/2026 at 3:23 pm, the Administrator said the clinical staff and nurse administrators were responsible for training staff in the facility. He said it would not make him feel great if staff left him dirty or did not clean him properly. He said he expected the staff to follow policy and procedures.Record review of a facility policy titled Incontinence Care dated 3/2017 indicated, .It is the policy of this facility to provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence. Staff 4. Wash peri-area using front to back strokes, rinse, pat dry.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 16 residents reviewed for quality of care. (Resident #3 and Resident #6) The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #3 and #6 on 2/26/26. The facility failed to ensure CNA B locked the brakes for safety during a transfer of Resident #3 on 2/26/26. These failures could result in a loss of quality of life due to injuries.Findings include: 1.Record review of a facility face sheet dated 2/26/26 for Resident #3 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of intervertebral disc degeneration, lumbar region with discogenic back pain only (Intervertebral disc degeneration in the lumbar region can lead to discogenic back pain and lower extremity pain due to the breakdown of spinal discs, which may compress nerves and cause discomfort).Record review of Resident #3 clinical record revealed the admission MDS assessment had not been completed . Record review of a baseline care plan dated 2/24/26 for Resident #3 indicated he had an ADL self-care performance deficit and had an intervention requiring staff participation for transfers. During an observation on 2/26/26 at 9:30 a.m., CNA A and CNA B were observed transferring Resident #3 from bed to wheelchair using a mechanical lift. A lift sling was observed in room on overbed table for use with transfer. The sling loops were observed to be faded in color. CNA B said she did not think they were faded in color. When asked what color the sling loops were , she said, well, yes, they are faded from when they were new. She went and got another lift sling to use for transfer. During the transfer, after securing the loops on the hooks and prior to lifting resident from the bed, CNA B did not lock the brakes on the mechanical lift. CNA B also did not lock brakes before lowering Resident #3 onto his wheelchair. During an interview on 2/26/26 at 1:35 pm CNA B said she did not lock the brakes when transferring Resident #3, she said she must have forgotten. She said the lift could tip over and residents could get hurt if the brakes were not locked. She said she would check the lift slings for wear and tear, rips, tears, and faded colors before use. She said if unsafe slings were used, they could break, and the resident could fall. During an interview on 2/26/26 at 10:10 am ADON said she expected her staff to follow proper policy and procedures when using the mechanical lift, which included locking the brakes for resident safety. She said a resident could fall and be injured if brakes were not locked. 2.Record review of a facility face sheet dated 2/26/26 for Resident #6 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of cerebral palsy (a neurological condition that affects muscle movement and development). Record review of a quarterly MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 00, which indicated she was severely cognitively impaired. She was dependent with transfers. Record review of a comprehensive care plan dated 4/19/22 for Resident #6 indicated she had an ADL self-care performance deficit and required assistance of 2 staff members for transfers using a mechanical lift. During an observation on 2/26/26 at 10:00 am Resident #6 was observed sitting in a wheelchair in the common area near nurse's station. She was observed to have a mechanical lift sling underneath her with loops that were observed to be fraying. During an interview on 2/26/26 at 1:20 pm Laundry Director said lift slings were laundered with no bleach and air dried. She said if she noticed a sling with discoloration or fading, rips, or tears, she would show it to the DON so it could be removed if needed. She said residents could get hurt if a sling broke during a transfer. During an interview on 2/26/26 at 1:40 pm Resource RN said she expected her staff to follow policy and procedures when using the mechanical lift to transfer residents using the mechanical lift. She said if brakes were not locked when lifting or lowering resident, the lift could go off balance and fall, possibly injuring the resident. She said if an unsafe sling was used, it could break causing resident injury. She said they would be providing in-services and education regarding the use of mechanical lift and inspection of lift slings. Record review of a Clinical Competency Review dated 1/6/26 for CNA B indicated she had been demonstrated proficiency using the hydraulic lift on 1/6/26. Record review of a facility policy titled Mechanical Lift undated read: .Ensure that the mechanical lift equipment is in good working condition, and safety checks performed as per manufacturer recommendations. and .Inspect the sling for any damage or wear before use. and .Position the mechanical lift, ensuring that the base is stable and locked.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #3) and of 1 of 4 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A washed or sanitized their hands between glove change during incontinent care provided to Resident #3 on 2/26/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings include: Record review of a facility face sheet dated 2/26/26 for Resident #3 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of intervertebral disc degeneration, lumbar region with discogenic back pain only (Intervertebral disc degeneration in the lumbar region can lead to discogenic back pain and lower extremity pain due to the breakdown of spinal discs, which may compress nerves and cause discomfort). Record review of Resident #3 clinical record revealed the admission MDS assessment had not been completed. Record review of a baseline care plan dated 2/24/26 for Resident #3 indicated he had an ADL self-care performance deficit and had an intervention requiring staff assistance for toileting. During an observation on 2/26/26 at 9:30 am CNA A was observed providing incontinent care on Resident #3. After cleaning feces from rectal area, she was observed removing the glove from her right hand and without washing or sanitizing her hands, she then put a clean glove on her right hand. She did not change the glove on her left. She then proceeded to put clean brief on Resident #3 and assisted with transferring him from bed to chair. During an interview on 2/26/26 at 1:05 pm CNA A said she did not sanitize her hands during peri care and said she did only [NAME] the one glove on her right hand after cleaning rectal area. She said when she went in there, she did not know she would need to perform incontinent care on him and was not really prepared. She said it could put residents at risk for infections if proper handwashing or sanitizing was not done. During an interview on 2/26/26 at 10:10 am ADON said she expected her staff to perform hand hygiene when providing incontinent care for residents. She said if proper hand hygiene was not followed, residents could be at increased risk for infections. During an interview on 2/26/26 at 1:40 pm Resource RN said she expected her staff to follow policy and procedures when providing incontinent care to residents and to always perform hand hygiene, especially when going from dirty to clean. She said residents could get an infection if hand hygiene was not performed. She said, going forward, staff would receive education and more checkoffs to ensure compliance. Record review of a facility policy titled Hand Hygiene dated 10/2022 read: .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: .h. Before moving from a contaminated body site to a clean body site during resident care; .m. After removing gloves.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pest control. The facility failed to ensure the kitchen remained free from roaches. On 1/05/2026 roaches were observed crawling on the wall behind the bags of cereal in the dry pantry area, and crawling on the floor in the main kitchen prep and cooking area. This failure could place residents at risk for reduced quality of life and poor sanitary environment.Findings included: During the initial tour of the kitchen dry pantry area on 1/05/2026 at 9:00 AM, a live roach was seen crawling up the wall behind the cereal, upon moving the bags of cereal dried roach excrement was observed on the wall. During the initial tour of the kitchen main cooking and preparation area on 1/05/2026 at 9:05 AM, a live roach was observed crawling on the floor under the stove and oven area. During an interview on 1/5/2026 at 9:00am the DM said the food delivery company had delivered a box of potatoes that contained roaches and that was where the roaches originated from. She said they had the roach problem for about a month. She said now they opened all boxes of vegetables outside to make sure they do not bring any additional roaches into the kitchen. During an interview on 1/5/2026 at 9:10am [NAME] A said the roaches had been a problem for about a month. She said the food delivery company had delivered some potatoes in a cardboard box that had roaches in it. During an interview on 01/06/2026 at 10:19 AM the DM said she verbally notified the Administrator sometime within the last week that there was still a roach problem in the kitchen. She said that roaches could possibly get in the food and make the residents sick. She said going forward her expectations were for food to be stored and served under sanitary conditions. During an interview on 01/07/2026 at 9:31 AM [NAME] B said she had seen roaches in the kitchen since about November 2025. Said she had reported the roaches to the DM. She said when the exterminator sprayed the roaches would get worse. She said since they changed exterminators the roaches had been better, but she had still seen them. She said roaches could get in the residents' food and make them sick. During an interview on 01/07/2026 at 9:36 AM the Dietary Aide said he had seen roaches in the kitchen for about 2 weeks. He said he had reported the roaches to the DM. He said the exterminator had been out and sprayed for the roaches right before 12/25/2025. He said roaches could carry diseases and they could get in the residents' food and make them sick. During an interview on 01/07/2026 at 9:39 AM the Dishwasher said he had seen roaches in kitchen since about November 2025 when the new exterminator started coming and spraying. He said roaches carry diseases and are a menace to the residents and could possibly make the residents sick. During an interview on 01/07/2026 at 9:45 AM the Administrator said he knew about the roach problem in the kitchen. He said in November 2025 the facility changed pest control companies in an effort to address the roach problem. He said he was aware that there were still roaches in the kitchen but felt like the facility was addressing the problem appropriately. He said the roaches could possibly make the residents sick. During an interview on 01/07/2026 at 10:25 AM the Maintenance Director said he was aware there was a pest problem in the kitchen. He said they contracted a new exterminator company in November 2025. He said they came and sprayed the facility the first time on 11/17/25 and then told him they would come back and spray again 12/1/25. He said they did not return on 12/1/25 to spray the second time. He said the next time they sprayed the kitchen was on 12/19/25. Record review of the facility's Quality Team Tracking Form dated 11/13/2025 indicated a problem area of Roach Activity. Interventions included: .8. Pest control vendor will provide twice every two weeks for a month then monthly. 9. Dietary/Designee will monitor for any new or worst sightings and pest control vendor will be notified same day for treatment. Record review of contracted pest control company invoice dated 11/13/2025 indicated live roaches found in the cafeteria and were treated. Record review of contracted pest control company invoice dated 11/17/2025 indicated live roaches found in the cafeteria and were treated. Record review of contracted pest control company invoice dated 12/19/2025 indicated live roaches found in the cafeteria and were treated. Record review of the facility's Pest Control Policy/Procedure undated indicated: Policy: It is the policy of this facility to provide an environment free of pests. Procedures: 1. The facility will have a Pest Control vendor contract that provides treatment of the environment for pests. 2. The pest control visits will occur at least monthly. 3. It will allow for additional visits when a problem is detected. 4. Monitoring of the environment will be done by the facility's staff. 5. Pest Control problems will be reported promptly.

Based on interviews, observations and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 4 residents (Resident #3) reviewed for care plans.The facility failed to ensure Resident #3's comprehensive care plan revision date 11/10/2025 reflected problems, goals or interventions for congestive heart failure and vascular insufficiency including application of compression stockings daily and their removalThis failure could place residents at risk of not receiving appropriate care to meet their current needs. The findings included: Record review of a face sheet dated 01/05/26 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included congestive heart failure (inability of the heart to pump effectively), venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Record review of a Quarterly MDS assessment dated [DATE] for Resident #3 indicated he had intact cognition with a BIMS score of 15. Section I - Active diagnosis indicated Resident #3 had heart failure and venous insufficiency-chronic peripheral.Record Review of a comprehensive care plan on 01/06/2026 revision date 11/10/2025 indicated no problem area related to congestive heart failure, no goals for congestive heart failure and no interventions for congestive heart failure, such as application of compression stockings, monitoring edema and administration of diuretic therapy.During a record review on 01/05/2026 at 3:21 PM physician order dated 08/29/2025 indicated: apply light to moderate compression stockings above the knees every morning and remove at bedtime, one time a day and remove per schedule. During an interview and observation on 01/06/2026 at 09:15 am Resident # 3 said he had not had any compression stockings applied to his lower legs by staff in months. He said he did not have any compression stockings in his room. He said it was too difficult for him to apply the compression stockings by himself, so he had not thought about it too much. Resident #3 said he was not aware that the staff were to put his compression stockings on every day and that the medical doctor had ordered for them to be applied every morning and be removed every evening by nursing staff. Resident #3 was observed at 09:15 am sitting in his wheelchair in his room with no compression stockings on. His legs appear dark pink and have edema. During an interview on 01/07/2026 at 11:30 AM the MDS Coordinator said she was responsible for revising and updating the care plans. The MDS Coordinator said she was new to the MDS process for the facility. The MDS Coordinator said the risk to the residents could include all members of the IDT not knowing what was going on with the residents or any needed change in interventions not being addressed as an example Resident #3 not having his compression stockings applied and coordination with staff to ensure the application occurred each morning and what needed to be monitored due to his congestion heart failure and venous insufficiency, in example: skin condition, increased swelling. The MDS Coordinator said she would update the care plan to address Resident #3's problem of congestive heart failure. During an interview on 01/07/2026 at 10:00 AM, the DON said the MDS Coordinator was responsible for updating and revising the comprehensive care plans. She said other staff would update them as well, whenever needed. She said she would get communications during the morning meetings if there was something about a resident that needed to be updated on the care plan. She said the MDS Coordinator also does reviews quarterly and after each MDS assessment such as a change of condition. She said if interventions for congestive heart failure including application of compression stockings were not included in the care plan , staff may not know resident needs and changes in care provided. She said that if a resident was refusing an ordered intervention, it should be included on the comprehensive care plan.During an interview on 01/07/2026 at 10:30 am the Administrator said he was aware that Resident #3 had a problem with his care plan and interventions for congestive heart failure. He said MDS Coordinator was responsible for updating and revising the comprehensive care plans and the care plan would be updated. He said if interventions were not included in the care plan, staff may not know about resident needs and changes in care provided. Record review of a facility policy titled Comprehensive Care Plan Revision dated 01/2022 reflectedPolicy Statement:It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.Procedure:1. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care.2.The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to:a) Initial goals based on admission orders,b) Physician orders,c) Dietary orders,d) Therapy services,e) Social services; andf) PASARR recommendations, if applicable.3. The facility team will provide a written summary of the baseline care plan to the residents and their representatives that includes the initial goals of the resident, a summary of medications and dietary instructions, and any services and treatments to be administered. This summary will be in a language and conveyed in a manner the residents and/or their representatives can understand. This summary will be provided by the time of the completion of the comprehensive care plan.s. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify.Page 1 of 2-Title: Comprehensive Person-Centered Care Planning care or service declined, the associated risks, IDT's effort to educate the residents and resident representative and any alternate means to address risk.6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.7. The facility IDT includes, but is not limited to the following professionals:A. Registered Nurse with responsibility for the resident.B. Nurse Aide with responsibility for the resident; .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.Policy Interpretation and ImplementationI. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.2. The Interdisciplinary Team documents in the CAT (Care Area Triggers) summary sheet and/or records in the clinical record: a. The residents' status in triggered CAT areas; b. The team's rationale for deciding whether to proceed with care planning; and c. Evidence that the team considered the development of care planning interventions for all CAT's triggered by the MDS.3.Each resident's Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas, b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d .Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care; f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program.4. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MOS).5. Care plans are revised as changes in the residents' condition dictate. Care plans are reviewed at least quarterly and any significant change in status.6. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies.Record Review of a facility policy dated 10/2007Resident Rights- Refusals:POLICY:It is the policy of this facility to honor a resident's request not to receive medical treatment as prescribed by his/her physician, as well as care routines outlined on the resident's assessment and plan of care.PROCEDURES:1. The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician.2. An IDT team member will assess the reasons for the resident's refusal of treatment and attempt to educate the resident/family as to the consequences of such refusal and update plan of care as needed.3. Should the resident refuse to accept treatment, the refusal must be entered into the resident's medical record. The attending physician will be notified of such refusal and orders updated and followed as warranted. Care plan will be updated related to refusal of treatment/care.

Based on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality for 1 of 4 residents reviewed for following physician orders. (Resident #3) The facility did not ensure that Resident #3's compression stockings were applied every morning as ordered by the physician on 01/05/2026 and 01/06/2026. This failure could place the residents at risk for increasing edema or worsening of vascular insufficiency (inability to return blood back into circulation). Findings included:Record review of a face sheet dated 01/05/26 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included congestive heart failure (inability of the heart to pump effectively), venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During observations on 01/05/2026 Resident #3 was observed sitting in his wheelchair at 10:00 am in common area, 12:30 pm in hallway D and 3:00 pm in the dining area during resident council meeting with no compression stockings on his lower extremities. During a record review on 01/05/2026 at 3:21 PM physician order dated 08/29/2025 indicated: apply light to moderate compression stockings above the knees every morning and remove at bedtime, one time a day and remove per schedule. During an interview and observation on 01/06/2026 at 9:15 am Resident # 3 said he had not had any compression stockings applied to his lower legs by staff in months. He said he did not have any compression stockings in his room. He said it was too difficult for him to apply the compression stockings by himself, so he had not thought about it too much. Resident #3 said he was not aware that the staff were to put his compression stockings on every day and that the medical doctor had ordered for them to be applied every morning and be removed every evening by nursing staff. Resident #3 was observed at 9:15 am sitting in his wheelchair in his room with no compression stockings on. His legs appear dark pink and have edema. During an observation on 01/06/2026 at 2:00 pm Resident #3 was participating in an activity in the dining room. He had compression stockings on both lower legs. During a record review of a Medication and Treatment Administration Summary for January 2026 indicated on 01/05/2026 LVN D indicated she had completed application of compression stockings as ordered. During a record review of a Medication and Treatment Administration Summary January 2026 indicated on 01/06/2026 LVN E indicated she had completed application of compression stockings as ordered.Record Review of a comprehensive care plan on 01/06/2026 revision date 11/10/2025 indicated no problem area related to congestive heart failure, no goals for congestive heart failure and no interventions for congestive heart failure such as, application of compression stockings, monitoring edema and administration of diuretic therapy. During an interview on 01/06/2026 at 9:45 am LVN B said she had signed the Medication/treatment administration record on Resident #3's application of compression stockings, but she had not put them on him. LVN B said that she should not have signed the task off without completing it as ordered by the medical doctor. LVN said that not following MD orders could result in swelling and decreased circulation of Resident #3's lower extremities. LVN B said that she would obtain compression stockings from the supply room and complete application for Resident #3. During an interview of 01/06/2026 at 10:15 am the DON said that orders should not be signed off by the nursing staff if not completed. She said that not completing MD orders could result in negative outcomes for the residents. The DON said she had been informed that Resident #3 was refusing application of his compression stockings but there was no documentation in the progress notes and refusals were not included in Resident #3's current care plan. During an interview on 01/07/2026 at 10:30 am the Administrator said orders should not be signed off by the nursing staff if not completed. He said that not completing MD orders could result in negative outcomes for the residents. Record Review of a facility Policy dated 3/2023 Pharmacy Services/Nursing ServicesSubject: Physician OrdersPharmacy Services/ Nursing Services Physician Orders POLICY:It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.PROCEDURES:1.No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses.2.All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The signing of orders shall be by signature or a personal computer key. Signature stamps may not be used.3.admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly. There is a double check system to verify accuracy of order transcription. Verify resident name on hospital paperwork matches the resident's name.4.Verbal orders for drugs, treatments, procedures shall be received only by licensed nurses, psychiatric technicians, pharmacists, nurse practitioners, physicians, physicians' assistants (from their supervising physician only), and certified respiratory therapists when the orders relate specifically to respiratory care.5.Verbal orders must be recorded immediately in the residents' chart by the person receiving the order and must include the date and time of the order.6.Medication, treatment or related orders are transcribed in the Medication Administration Record or the Treatment Administration Record.

Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 2 of 6 residents reviewed for respiratory care (Residents #11 and #44). The facility failed to ensure the external filters of Resident #11's and #44's oxygen concentrators were free of dust build up on 1/7/26. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.Findings included: Record review of a facility face sheet dated 1/5/26 for Resident #11 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of dementia and chronic respiratory failure with hypoxia (occurs when the lungs cannot effectively exchange oxygen and carbon dioxide, leading to low oxygen levels in the blood). Record review of a comprehensive MDS dated [DATE] for Resident #11 indicated a BIMS score of 00, which indicated severe cognitive impairment. She was dependent for all ADLs. She received oxygen therapy while a resident in the facility. Record review of a physician's order summary report dated 1/5/26 for Resident #11 indicated she had the following physician's order dated 5/30/23: .O2 (oxygen) at 2-4L/min per NC (nasal cannula) . Record review of a comprehensive care plan dated 9/24/25 for Resident #11 indicated she received oxygen therapy related to chronic respiratory failure with hypoxia. Record review of a facility face sheet dated 1/5/26 for Resident #44 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (uncontrolled blood sugar) and COPD (chronic obstructive pulmonary disease - a progressive lung disease characterized by obstructed airflow and breathing difficulties). Record review of a Quarterly MDS assessment dated [DATE] for Resident #44 indicated a BIMS score of 13, which indicated she was cognitively intact. She was dependent for most ADLs. She received oxygen therapy while a resident in the facility. Record review of a physician's order summary report dated 1/5/26 for Resident #44 indicated the following physician order dated 3/25/25: .O2 (oxygen) at 2-5L/min continuously per NC (nasal cannula) . Record review of a comprehensive care plan dated 4/15/22 for Resident #44 indicated she received oxygen therapy related to COPD and chronic respiratory failure. During an observation on 01/05/2026 at 10:04 am Resident #11 was observed lying in bed sleeping. She did not awaken to voice. She was wearing oxygen via nasal cannula. Oxygen concentrator outer filter was observed to be dirty with a thick buildup of dust. During an observation on 01/05/2026 at 10:21 am Resident #44 was observed lying in bed. She did not speak when spoken to. She was wearing oxygen via nasal cannula. Oxygen concentrator outer filter was observed to be dirty, with a buildup of thick dust and hair. During an interview on 01/06/2026 at 9:30 AM DON said administrative staff are supposed to check concentrator filters during department head rounds because the nurses are too busy to check them. She said angel rounds are supposed to do be done every day. During an interview on 01/07/2026 at 9:15 am DON said their staff had just been pulled short with having to work the weekends so often lately that the concentrator filters just got missed. She said they would do a better job going forward and she would ensure staff did a better job of keeping them clean. She said there was really no risk for the filters having dust buildup and that the concentrator would just quit working if it got clogged. During an interview on 01/07/2026 at 9:25 am Administrator said he would be making the ADON responsible going forward to monitor and ensure the concentrator filters were cleaned. He said he expected his staff to provide the best quality of care that they could and if the concentrator filters were allowed to have dust buildup, the residents were not going to be getting the best quality of care. Record review of a facility policy titled Oxygen Administration dated 3/2025 read: .Nursing staff is responsible for cleaning filters .

Based on interviews, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 2 of 6 residents (Resident #1 and Resident #2) reviewed for a change of condition. The facility failed to follow their skin and wound policy by not notifying the Medical Director of the changes to Resident #1 and Resident #2's wounds. Resident #1 was admitted to the hospital on 10/31/2024 with sepsis (infection in the blood) and osteomyelitis (bone infection). Resident #2 had an unstageable pressure ulcer wound that was identified on 11/10/2024. An Immediate Jeopardy was identified on 11/10/2024 at 11:15 AM. While the Immediate Jeopardy was removed on 11/11/2024 at 2:15 PM, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than mininal harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, and death. Findings included: 1.Record review of an Admission Record dated 11/9/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, heart failure (heart's inability to pump blood effectively), and benign prostatic hyperplasia (enlarged prostate). Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he has severe impairment in thinking with a BIMS score of 1. He was dependent on staff for all ADLs except for upper body dressing which he required substantial/maximal assistance. He was always incontinent of urine and bowel. He was at risk of developing pressure ulcers/injuries. He did not have any unhealed pressure ulcers/injuries. Other ulcers, wound and skin problems indicated he had moisture associated skin damage (incontinence-associated dermatitis, perspiration, drainage). Treatments included applications of ointments/medications. Record review of an Admission MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 6. He required supervision or touching assistance with toileting hygiene and personal hygiene. He was always continent of urine and bowel. He was not at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. Record review of a care plan for Resident #1 dated 2/28/2024 indicated he had pressure ulcer or potential for pressure ulcer development related to impaired mobility with interventions to notify nurse immediately of any new areas of skin breakdown. Record review of a Consultation Note for Resident #1 dated 11/1/2024 from the hospital indicated he had been admitted to the hospital on account of worsening changes involving his sacrococcygeal wound (a pressure injury also known as a bedsore that occurs in the sacrum) with features suggestive of an infected stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) sacrococcygeal decubitus ulcer (bedsore). Record review of a Nurse Progress Note for Resident #1 dated 10/31/2024 indicated, .patient out of the facility, went to appointment with Infectious Disease Specialist on this AM, and transportation received notice per RP that patient was being admitted to the hospital . Record review of a History and Physical for Resident #1 dated 10/31/2024 from hospital indicated, Resident #1 was sent to the hospital from Infectious Disease Specialist office for infection sacral decubitus ulcer. Assessment and plan of treatment revealed infection with some necrosis decubitus ulcer sacral . Record review of a skin evaluation for Resident #1 dated 10/24/2024 by the Treatment Nurse indicated, .excoriation to sacral region (bottom of spine) and bilateral buttock, stage 3 (loss of tissue) to sacrum 3.8 x 4.4, stage 3 to left ischial tuberosity 3.0 x 3.0 x 0.2 . Record review of a Skin/Wound Note for Resident #1 dated 10/24/2024 by the Treatment Nurse indicated, sacrum has deteriorated now presents as a stage 3 measures 3.8 x 4.4 x 0.2 with serous exudate small amount no odor wound bed 50% non-granulated tissues 50% yellow slough peri wound pink and stage 3 to left ischial tuberosity measures 3.0 x 3.0 with serous exudate small amount no odor wound bed 70% granulated tissues 30% yellow slough peri wound pink excoriated. C/o pain during treatment. No new orders at this time. NP notified. RP notified . Record review of a care plan for Resident #1 dated 10/18/2024 indicated he had impairment to skin related to stage 2, updated 10/29/24, now a stage 3. Interventions included air mattress, clean sacrum with normal saline, pat dry and apply calcium alginate to wound bed, and cover with dry dressing daily. Multivitamins with minerals, zinc sulfate, and vitamin c to be given daily for wound healing. Record review of a care plan for Resident #1 dated 10/18/2024 indicated he had impairment to skin related to stage 2 to right ischial tuberosity. Interventions included air mattress, cleanse left ischial tuberosity (bone that makes up the bottom of the pelvis) with normal saline, pat dry, and apply exuderm (thin protective dressing to provide a protective barrier for wounds) q 3 days. Multivitamins with minerals, zinc sulfate, and vitamin c to be given daily for wound healing. Record review of a Skin/Wound Note for Resident #1 dated 10/18/2024 by the Treatment Nurse indicated, Excoriation to sacrum had deteriorated and presented as a stage 2 (top layer of skin is broken) measures 3.0 x 4.0 x 0.2 with serous (bloody) exudate (drainage) small amount no odor wound bed pink and stage 2 to left ischial tuberosity measures 2.7 x 3.0 with serous exudate small amount no odor wound bed pink peri wound pink excoriated (redness). C/o pain during treatment. Pain meds given. NP notified. New order: cleanse left ischial tuberosity ulcer with normal saline, pat dry, apply exuderm q3 days. Exuderm to left ischial. RP notified. Record review of skin evaluations for Resident #1 dated 9/12/2024 to 10/17/2024 by the Treatment Nurse indicated he had excoriation to bilateral buttock and no other skin issues noted. During a phone interview on 11/8/2024 at 4:55 PM, RP for Resident #1 said he was at the hospital. She said he was admitted to the hospital on 10/31/2024 from an appointment with an infectious disease physician. She said the facility had been checking labs for him and he had elevated WBC's and the facility Medical Director was giving orders. She said on 8/31/2024 he was admitted to the hospital with altered mental status, and it was documented the beginning of a wound. He discharged from the hospital 9/6/2024 back to the nursing home. She said he was on antibiotics, and they sent him to see a blood physician and was told by her she could not find anything and was told he needed to see an infectious disease doctor. She said he saw the infectious disease doctor on 10/31/2024 and he immediately saw an area on Resident #1's bottom and sent him to the hospital and said that was the source of his infection. She said there was a huge hole that you could place your fist in it, and she did not see it until Resident #1 was at the hospital. She said she was told by the nursing facility that they were using some type of saline spray in the wound. She said she visited her father daily and the last time she saw the wound before the last hospital stay it looked like raw meat. She said it was not open at that time, but it looked bad. She said he had one debridement (surgical removal of damaged tissue) of the wound since admission to the hospital and he had a colostomy (a surgical opening in the large intestine for stool which collects into a bag outside of the body) to keep feces from getting into the wound. She said they were planning on another debridement sometime next week. 2. Record review of an Admission Record for Resident #2 dated 11/9/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, malignant neoplasm of prostate (cancer of the prostate), and atherosclerosis (buildup of plaque in the artery walls that can block blood flow). Record review of a Quarterly MDS Assessment for Resident #2 dated 9/30/2024 indicated he had severe impairment in thinking with a BIMS score of 1. He was dependent on staff with all ADL's except for eating which he required supervision or touching assistance. He was always incontinent of urine and bowel. He was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries. Other ulcers, wounds, and skin problems indicated moisture associated skin damage (incontinence-associated dermatitis, perspiration, drainage). Skin and ulcer/injury treatments were nutrition or hydration intervention to manage skin problems and application of ointments/medications. Record review of a care plan for Resident #2 dated 7/18/2023 indicated he had pressure ulcer and potential for pressure ulcer development related to poor mobility and weakness. Interventions included to encourage fluid intake and assist to keep skin hydrated. Record review of active physician orders dated 11/9/2024 for Resident #2 indicated an order to cleanse scar tissue to sacrum with normal saline, pat dry, and apply exoderm q3 days every day shift every 3 days that started on 10/18/2024. Record review of a facility Skin Report for the month of October 2024 did not have Resident #2 listed as having a wound or other skin issues. During an interview on 11/9/2024 at 3:56 PM, the Treatment Nurse said she had been the treatment nurse at the facility for 8 1/2 years and was an LVN. She said she was responsible for skin assessments weekly and responsible for surgical and pressure wounds, venous stasis wounds, and the charge nurses were responsible for the other ones. She said if a new wound were observed if the nurse aide found it during the day, they would notify her. She stated if it were after she left for the day, the nurse aides would let the charge nurse know and put it on the 24-hour report. She said it depended on the type of wound and the severity for if she would be notified the same day or not. If it were a skin tear, she may not be notified until the next day but if it were pressure, they would notify her immediately. She said if a new wound were present for pressure, she would contact the physician, and notify them. She said excoriation looked like redness, scratches, or some type of minor injury without any skin breakage. She said pressure wounds varied according to the stage, stage 1 was non blanchable skin (when touched stays red), stage 2 top layer of skin was missing, stage 3 slough might be present, or it could be a stage 4. She said she staged the wounds. She said she had a lot of education on it and had been to different classes and seminars. The DON would come behind her and look at the wounds and then would notify the physician. She said she would assess the wound, stage it, and let the DON and physician know. She said they did not have a wound care physician that visited the facility and had not had one since she had been employed for 8 1/2 years. She said she was responsible for all the pressure wound treatments for the residents in the facility. She said Resident #1's buttocks started as a scratch from the hospital with excoriation, had small opens on his bottom that were sporadic, and they were using barrier cream after incontinent care episodes. She said the wound was close to his rectum and he continued to have frequent bowel movements throughout the day. She said the interventions started as barrier cream, then an order for exuderm to keep feces out of it, then got wedges to turn q2 hrs, and chair cushion when up. She said she noticed slough, it was a stage 3, and it was about a size of a 50-cent piece. She said he had an appointment in Houston in October, he was gone all day, and noticed he started getting slough on his bottom. She said when the slough started, she got an order for an air mattress to try and relieve pressure on his bottom and a wheelchair cushion, supplements for wound healing, and wound care treatment order changed. She said the treatments were being done daily. She said the wound had gotten worse before he left the faciity on [DATE]. She said the wound was so close to his rectum and it was hard to keep the feces out of it. She said they used waterproof nonadherent bandages, but when he had a bowel movement, it would get underneath the bandage, and she had a hard time keeping it out. She said they were contacting the NP and the Medical Director about the wound for Resident #1. She said the NP and the Medical Director would make rounds at about 6 am in the facility and never made rounds with her to see the wound on Resident #1 or any of the other residents. She said if they asked to see the wound it would have been with the charge nurses. She said she was not wound care certified. She said there was a RN weekend supervisor that performed wound care on the weekends. She said there were standing orders for certain types of wounds, if stage 2 would use exoderm, if stage 3 with minimal drainage would use collagen, moderate drainage calcium alginate, if it had depth she could pack, and use collagen powder. She said there was a book that was kept at the nurse desk. During an interview on 11/9/2024 at 4:29 PM, RN A said she was one of the weekend supervisors and worked every other weekend for the past 2 1/2 years. She said she was responsible for everything that went on in the facility except for staffing. She said she performed wound care on the weekends for the residents. She said she had Resident #1 for daily wound care before he discharged to the hospital. She said the last time she saw Resident #1's wound on his sacrum it was macerated with a dressing, noted the skin looked splotchy, some bleeding, some skin breakdown, and the top layer of skin was missing. She said his left ischium seemed to be deeper about a quarter size in diameter and was open about 1-2 cm. There was no bleeding, he had an exuderm and dressing on the sacrum with collagen, a dry dressing daily, and exuderm every 3 days. She said the sacral wound was right by his rectum and it was very hard to keep the area clean. She said she had been notified before and was told not to stage or classify the wounds because she was not the Treatment Nurse, and the Treatment Nurse would be the one to measure and stage them. She said she could get an order for a dressing for the wound but could not stage it. During a phone interview on 11/9/2024 at 5:06 PM, the PT said he had been employed at the facility for 5 years. He said part of his duties of physical therapy would be administering wound care. He said he did not perform wound care often. He said he used the Ultramist on several patients in the past and it worked well for them. He said he used it recently on Resident #1 who had several pressure wounds. He said he focused on his sacral and coccyx area which were common areas for wounds. He said he had a stage 3 pressure ulcer that had necrotic tissue that was too painful to debride, so the Ultramist was another form of wound care that he could do. He said he performed 5-6 treatments on his wounds before his hospital admission on 10/31/2024. He said initially the entire wound was necrotic and the goal was to decrease the necrotic areas and increase granulated tissue that looked nice and was beefy red with good blood flow. He said the goal was for new skin growth. He said the machine was a small ultrasound machine, if the wound were close to a pacemaker or located close to a cancerous nodule it would be contraindicated. He said it could treat any wounds or ulcers. He said there were subtle changes on the outside of the wound, as it started to have granulation buds that you could visibly see and that was how granulation started. He said when you started to see buds on the skin that was a good thing. He said the location of the wound was close to feces. He was incontinent of bowel/bladder and that could slow things at times. He said the Ultramist was in addition to traditional nursing care, changing dressings, pat dry, and the nurse would apply a new dressing after the treatment was completed. He said due to the location, it always had a foul odor because it was near the rectum but could be a combination of dead tissue or feces and had to be cleaned prior to treatment. He was not sure if he was on antibiotics. He said he gets the wound information from the nurses. He had a stage 3 that ate through the skin, subcutaneous fat, and tissue but no bone was exposed. Record review of Physical Therapy Notes dated 10/21/2024, 10/23/2024, 10/25/2024, 10/29/2024 and 10/30/2024 for Resident #1 indicated .an additional skill of initial treatment of MIST therapy (low frequency, non-contact, non-thermal ultrasound) using sterile water to patient's sacrococcygeal wound due to sharp debridement being contraindicated in order to facilitate perfusion to ischemic areas of wound and decrease risk for infection . During an interview on 11/9/2024 at 5:27 PM, CNA B said she had been employed at the facility for September 2023 and worked 6 am - 6 pm and worked on all halls in the facility. She said on the weekends she helped with wound care by holding and positioning with the weekend RN supervisor. She said she found a wound on Resident #1 about a month ago and informed the weekend RN that he had a bad wound. It started out as two small red, circled areas in the butt crack on the weekend and she told the weekend RN and a charge nurse about it. She said the weekend RN put a bandage on it and put a note for the Treatment Nurse about the wound. She said sometime after observing the new area on Resident #1, she had been off for a few days, and came back and observed no bandage on his buttocks and the wound had started getting bigger. She said the area was bigger than the size of a 4 x 4 gauze. She said the last day she saw the wound was on 10/31/2024 before he left for a physician appointment, and he did not come back. She said the wound on 10/31/2024 was bad, both sides of his buttocks were open, he could put at least three fingers inside, and it smelled like dying flesh that was yellow and green in color. She said a charge nurse put a dressing on the wound before he left for that appointment on 10/31/2024. During an observation on 11/10/2024 at 8:55 AM, Resident #2 was in his room in bed with CNA B and CNA C present to provide incontinent care. CNA B and CNA C removed a dressing to his sacrum as the dressing had stool present that had gotten underneath the dressing to the wound. The DON entered the room and said she needed to look at the wound after they cleaned him because she was informed that the nurse on 11/9/2024 had performed wound care and when the dressing was removed, skin came off with it. Staff provided incontinent care and a large wound to his sacrum was observed with the wound bed black in color with eschar, surrounding skin pink and white, borders irregular, and some skin missing with redness and small open areas. CNA B and CNA C both said the wound had been that way for a while. During an observation and interview on 11/10/2024 at 9:10 AM, the DON and CNA C were in the room of Resident #2. The DON was present to assess the area to his sacrum and provide wound care treatment. The DON said the wound was unstageable. The DON placed collagen in the wound bed and covered with dry dressing temporarily. She said they had some protocols that they could go by and would notify the physician. RN A entered the room and said the wound looked like it was unstageable with necrotic tissue but could not say if it looked that way on 11/9/2024 because the wound had a lot of barrier cream. She said on 11/9/2024 when she tried to remove the cream, Resident #2 was in pain and she could not see the wound bed and she placed an exoderm over the area per the orders. During a follow-up interview and observation on 11/10/2024 at 9:32 AM, RN A said on 11/9/2024 she provided wound care for Resident #2 and the wound was open without a dressing. She said the wound was close to his anus and they cleaned him up and the area had zinc cream on it. She said the wound was very moist and there was an order for exuderm to be applied to the scar tissue, so she placed a 4x4 exuderm per the orders. She said she was told to let the Treatment nurse know of any changes to any wounds in the facility or skin issues. She said the wound had been present since October 7, 2024. RN A still had the text message where she sent the Treatment Nurse a message to inform her that the zinc was not helping Resident #2. The State Surveyor observed the text message that was sent to the Treatment Nurse and the Treatment Nurse response was Ok, with a thumbs up emoji. She said there was not a dressing on Resident #2's sacrum on 11/9/2024 and it only had an order for exoderm. She said the skin did not come off because there was not dressing on it, and it only had zinc oxide present. She said they had standing orders for wound care at the nurse station and then would contact the physician with any new skin issues. During a phone interview on 11/10/2024 at 9:47 AM, the RP of Resident #2 said when he admitted to the facility it was to the secured unit. She said he had been at the facility for 2 years. She said he had been discharged from the secured unit for about 2 months. She said she tried to visit him at least three times out of the month. She said most of the time they keep her updated. She said she had been at the facility on the days of his showers. She said she was present one day this past week and observed staff change him. She said she did not get to see his bottom, she was used to him having his privacy, and when she thought about asking to see his bottom, it was too late. She said they told her he had a bed sore on his bottom when she visited this past week and asked why no one called her to inform her before then. During a follow-up interview and observation on 11/10/2024 at 10:05 AM, the Treatment Nurse said the last time she observed Resident #2's wound it had a lot of scar tissue from a previous wound which made it easier for skin break down. She said the wound started to crack open and it looked like excoriation and received an order to put exuderm on it. She said Resident #2 would hold his urine and when he urinated, he would saturate the brief. She said they tried to keep the exuderm on the wound and keep urine and feces out of it. She said she observed the area that day and it looked like it was starting to try to open, and she did contact the physician. She observed a picture of the wound of Resident #2 that was taken by the State Surveyor, and she said the wound looked like an unstageable wound with black tissue noted. She said they have had issues with the wound bleeding in some areas. She said an exuderm would not be appropriate for his wound at that time. During a phone interview on 11/10/2024 at 10:11 AM, the Medical Director said he was out of town, and he was informed that the State Surveyor had questions about the facility and them contacting him with any changes in the facility. He said he would have to call his NP and call back. During a phone interview on 11/10/2024 at 10:30 AM, the Medical Director said he spoke to his NP and said neither of them were aware of any standing orders for wounds in the facility for them to follow. He said they both received phone calls and were available for the facility and the facility did not mind calling them. He said Resident #1 had elevated white blood cell counts that were going up and down with the highest being about 18. He said it had been going on for about a month and they made him an appointment with an infectious disease physician so they could determine the source of the elevated white blood cells. He said they did not think that the wound for Resident #1 started the elevated white count as they looked at residents with leukocytosis more closely and they could not pinpoint the cause. He said he was not aware that Resident #1 was at the hospital but was glad to hear it because that was the purpose of him seeing the infectious disease physician. He said he was not aware of any skin issues in the facility until that day when the NP was notified about Resident #2. He said skin assessment were the responsibility of the nursing staff. He said he visited the facility twice a week and, in the past, had been asked to look at residents with wounds but not in a long time. He said he left the wound care treatments up to the Treatment Nurse at the facility, as she would evaluate and treat, if not effective then they would work on changing the treatments. He said if he had known about the skin issues, then they would have ordered appropriate treatments at that time. During an interview on 11/11/2024 at 9:43 Am, the DON said the Treatment Nurse and Weekend RN were responsible for wound care treatments. She said the Treatment Nurse was responsible for skin assessments and if the shower techs noticed anything they would tell her, and she did them weekly. She said she conducted a skin assessment about once a week and an overall monthly for the residents in the facility. She said she looked at the skin in the facility once a week because she helped with a lot of incontinent care to make sure the residents had barrier creams because there were a lot of new staff in the facility. She said she staged the wounds and classified them. She said the Treatment Nurse would let her know when a new skin issue was found, and she assessed and staged if appropriate. She said only a RN could stage the wounds, if the staff found something they could only describe the wounds. She said she did a contract with a wound care physician about a few weeks that would start soon. She said she provided care to Resident #2 on Friday 11/8/2024 and did not see any slough in his wound. She said the wound had excoriation but did not have any slough or necrotic tissue present. She said Resident #1's wounds started with minor excoriation, and had elevated WBCs before the wound started, and they checked lab work frequently. She said he had IV therapy, was on antibiotics, constantly doing change in conditions, going to appointments, saw the Medical Director, and his WBCs never went down. She said he was on antibiotics and went to the hospital a while ago and the excoriation to his sacrum continued to get worse. She said he had orders for supplements and therapy started seeing him and he received Ultramist (portable, painless, noncontact, noninvasive, low-frequency ultrasound to the wound. A fluid/saline mist is used to deliver the ultrasound, so there is no direct wound contact) wound therapy in the facility. She said they reported to the physician for any change in condition and if wounds changed. She said the Medical Director was aware of Resident #1's wound and said they changed orders for dressings and started the Ultramist. She said the Medical Director was not aware of Resident #2's wound. She said there was a risk for wound deterioration if the physician was not notified. She said when a new skin issue was identified, they should notify the nurse of any changes so the area would be assessed along with more frequent monitoring, notify the family, and care plan so everyone would be aware. During an interview on 11/11/2024 at 10:20 AM, the Administrator said she was aware that Resident #2 had some excoriation to his buttocks. She said the DON worked the hall where Resident #2 resided on Friday 11/8/2024 and said the area was not excoriated. She said Resident #1's RP had taken him to multiple physicians and took him to and Infectious Disease Specialist for an opinion. She said Resident #1 had elevated wbc's for weeks prior to his hospitalization [DATE]. She said skin assessments were to be done weekly by the Treatment Nurse and the DON was the only one that staged the wounds. She said she was not aware that the Medical Director was not updated of the change in Resident #2's wound. She said the facility was supposed to notify the physician of any change in conditions with the residents and there was a risk for wounds to worsen if they were not notified. Record review of a Skill Checklist-Treatment for the Treatment Nurse sated 5/8/2024 indicated she showed competency of treatments that was observed by the DON. Record review of Standing Orders for skin for the facility indicated orders for general skin protocol indicated any change in the resident's skin condition must be documented, and the physician and responsible party were to be notified dated 4/9/2024 and signed by the Medical Director. Record review of a facility policy titled Skin and Wound Monitoring and Management revised 1/2022 indicated, .It is the policy of this facility that: 1. A resident who entered the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; 7. Communication of changes: a. Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be communicated to: the resident/responsible party, the resident's physician, and others as necessary to facilitate healing . This was determined to be an Immediate Jeopardy (IJ) on 11/10/2024 at 11:15 AM. The facility's Administrator and the DON were notified. The Administrator was provided the IJ template on 11/10/2024 at 12:04 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 11/10/2024 at 4:50 PM. Plan of Removal 11-10-2024 F580 The facility needs to take immediate action to ensure proper physician notification is made to prevent worsening of pressure sores. 1.The Medical Director was notified of IJ on 11/10/2024 at 12:45pm. 2.Review of the 24-hour report was completed for the last 72 hours to ensure family and MDs were notified by DON, ADON on 11/10/24. 3.Education was initiated with Nurses on 11/10/2024 and will be completed on 11/10/2024 by the DON, ADON, and Clinical Resource. The training included Nurse Assessment, Change in Condition Process, documentation of the change in condition, notification to the physician, notification of family, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs, and Clinical Resource used facility policy on change in condition facility procedures on head-to-toe assessment, and notification to family and MD. 4.A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 11/10/2024 and will be completed for all nurses either in-person or via telephone on 11/11/2024at 6pm. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 5. This education and knowledge check will be completed with facility nurses on 11/10/2024 and 11/11/2024 by 6pm, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs, or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency /PRN staff (currently the facility does not utilize agency). 6.An ad hoc meeting regarding items in IJ template will be completed on 11/11/2024 Attendees include Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and will be agreed upon. 7.Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. 8.Knowledge checks were initiated on11/10/ [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 2 of 6 Residents (Resident #1 and Resident #2) reviewed for pressure injuries. The facility failed to prevent Resident #1 from developing a wound to his sacrum that changed from excoriation to a stage 4 pressure ulcer on 10/24/2024. Resident #1 admitted to the hospital on 10/31/2024 with sepsis (infection in the blood) and osteomyelitis (infection in the bone). The facility failed to prevent Resident #2 from developing a wound to his sacrum that changed from excoriation to an unstageable wound on 11/10/2024. The facility failed to follow their skin and wound policy by not notifying the Medical Director of the changes to Resident #1 and #2's wounds. The facility failed to accurately assess Resident #1 and #2's pressure sores. An Immediate Jeopardy was identified on 11/10/2024 at 11:15 AM. While the Immediate Jeopardy was removed on 11/11/2024 at 2:15 PM, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1.Record review of an Admission Record dated 11/9/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of Alzheimer's disease, heart failure (heart's inability to pump blood effectively) and benign prostatic hyperplasia (enlarged prostate). Record review of an Admission MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 6. He required supervision or touching assistance with toileting hygiene and personal hygiene. He was always continent of urine and bowel. He was not at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he has severe impairment in thinking with a BIMS score of 1. He was dependent on staff for all ADLs except for upper body dressing which he required substantial/maximal assistance. He was always incontinent of urine and bowel. He was at risk of developing pressure ulcers/injuries. He did not have any unhealed pressure ulcers/injuries. Other ulcers, wound and skin problems indicated he had moisture associated skin damage (incontinence-associated dermatitis, perspiration, drainage). Treatments included applications of ointments/medications. Record review of a care plan for Resident #1 dated 10/18/2024 indicated he had impairment to skin related to stage 2 updated 10/29/24 now a stage 3. Interventions included air mattress, clean sacrum with normal saline, pat dry and apply calcium alginate to wound bed, cover with dry dressing daily. Multivitamins with minerals, zinc sulfate and vitamin c to be given daily for wound healing. Record review of a care plan for Resident #1 dated 10/18/2024 indicated he had impairment to skin related to stage 2 to right ischial tuberosity. Interventions included air mattress, cleanse left ischial tuberosity (bone that makes up the bottom of the pelvis) with normal saline, pat dry and apply exuderm (thin protective dressing to provide a protective barrier for wounds) q 3 days. Multivitamins with minerals, zinc sulfate and vitamin c to be given daily for wound healing. Record review of a care plan for Resident #1 dated 2/28/2024 indicated he had pressure ulcer or potential for pressure ulcer development related to impaired mobility with interventions to notify nurse immediately of any new areas of skin breakdown. Record review of skin evaluations for Resident #1 dated 9/12/2024 to 10/17/2024 by the Treatment Nurse indicated he had excoriation to bilateral buttock and no other skin issues noted. Record review of a Skin/Wound Note for Resident #1 dated 10/18/2024 by the Treatment Nurse indicated, Excoriation to sacrum had deteriorated and presented as a stage 2 (top layer of skin is broken) measures 3.0 x 4.0 x 0.2 with serous (bloody) exudate (drainage) small amount no odor wound bed pink and stage 2 to left ischial tuberosity measures 2.7 x 3.0 with serous exudate small amount no odor wound bed pink peri wound pink excoriated (redness). C/o pain during treatment. Pain meds given. NP notified. New order: cleanse left ischial tuberosity ulcer with normal saline, pat dry, apply exuderm q3 days. Exuderm to left ischial. RP notified. Record review of a skin evaluation for Resident #1 dated 10/24/2024 by the Treatment Nurse indicated, .excoriation to sacral region (bottom of spine) and bilateral buttock, stage 3 (loss of tissue) to sacrum 3.8 x 4.4, stage 3 to left ischial tuberosity 3.0 x 3.0 x 0.2 . Record review of a Skin/Wound Note for Resident #1 dated 10/24/2024 by the Treatment Nurse indicated, sacrum has deteriorated now presents as a stage 3 measures 3.8 x 4.4 x 0.2 with serous exudate small amount no odor wound bed 50% non-granulated (tissues 50% yellow slough peri wound pink and stage 3 to left ischial tuberosity measures 3.0 x 3.0 with serous exudate small amount no odor wound bed 70% granulated tissues 30% yellow slough peri wound pink excoriated. C/o pain during treatment. No new orders at this time. NP notified. RP notified . Record review of a Nurse Progress Note for Resident #1 dated 10/31/2024 indicated, .patient out of the facility, went to appointment with Infectious Disease Specialist on this AM and transportation received notice per RP that patient was being admitted to the hospital . Record review of an History and Physical for Resident #1 dated 10/31/2024 from hospital indicated Resident #1 was sent to the hospital from Infectious Disease Specialist office for infection sacral decubitus ulcer. Assessment and plan of treatment revealed infection with some necrosis decubitus ulcer sacral . Record review of a Pathology Report dated 10/31/2024 for Resident #1 indicated a bone biopsy of the coccyx had acute osteomyelitis (infection in the bone). Record review of a Consultation Note for Resident #1 dated 11/1/2024 from hospital indicated he had been admitted to the hospital on account of worsening changes involving his sacrococcygeal wound (a pressure injury also known as a bedsore that occurs in the sacrum) with features suggestive of an infected stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) sacrococcygeal decubitus ulcer (bedsore). Record review of a Clinical Documentation Form for Resident #1 dated 11/8/2024 indicated sepsis (blood infection all over the body) was present on admission. During a phone interview on 11/8/2024 at 4:55 PM, RP for Resident #1 said he was at the hospital. She said he was admitted to the hospital on 10/31/2024 from an appointment with an infectious disease physician. She said the facility had been checking labs for him and he had elevated WBC's and the facility Medical Director was giving orders. She said on 8/31/2024 he was admitted to the hospital with altered mental status, and it was documented the beginning of a wound. He discharged from the hospital 9/6/2024 back to the nursing home. She said he was on antibiotics, and they sent him to see a blood physician and was told by her she could not see find anything and was told he needed to see an infectious disease doctor. She said he saw the infectious disease doctor on 10/31/2024 and he immediately saw an area on Resident #1's bottom and sent him to the hospital and said that was the source of his infection. She said there was a huge hole that you could place your fist in, and she did not see it until Resident #1 was at the hospital. She said she was told by the nursing facility that they were using some type of saline spray in the wound. She said she visited her father daily and the last time she saw the wound before the last hospital stay it looked like raw meat. She said it was not open at that time, but it looked bad. She said he had one debridement (surgical removal of damaged tissue) of the wound since admission to the hospital and he had a colostomy (a surgical opening in the large intestine for stool which collects into a bag outside of the body) to keep feces from getting into the wound. She said they were planning on another debridement sometime next week. 2. Record review of an Admission Record for Resident #2 dated 11/9/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, malignant neoplasm of prostate (cancer of the prostate) and atherosclerosis (buildup of plaque in the artery walls that can block blood flow). Record review of a Quarterly MDS Assessment for Resident #2 dated 9/30/2024 indicated he had severe impairment in thinking with a BIMS score of 1. He was dependent on staff with all ADL's except for eating which he required supervision or touching assistance. He was always incontinent of urine and bowel. He was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries. Other ulcers, wounds and skin problems indicated moisture associated skin damage (incontinence-associated dermatitis, perspiration, drainage). Skin and ulcer/injury treatments were nutrition or hydration intervention to manage skin problems and application of ointments/medications. Record review of a care plan for Resident #2 dated 7/18/2023 indicated he had pressure ulcer and potential for pressure ulcer development related to poor mobility and weakness. Interventions included to encourage fluid intake and assist to keep skin hydrated. Record review of a facility Skin Report for the month of October 2024 did not have Resident #2 listed as having a wound or other skin issues. Record review of active physician orders dated 11/9/2024 for Resident #2 indicated an order to cleanse scar tissue to sacrum with normal saline, pat dry and apply exoderm q3 days every day shift every 3 days that started on 10/18/2024. During an interview on 11/9/2024 at 3:56 PM, the Treatment Nurse said she had been the treatment nurse at the facility for 8 1/2 years and was an LVN. She said she was responsible for skin assessments weekly and responsible for surgical and pressure wounds, venous stasis wounds and the charge nurses were responsible for the other ones. She said if a new wound were observed if the nurse aide found it during the day, they would notify her and if it were after she left for the day, the nurse aides would let the charge nurse know and put it on the 24-hour report. She said it depended on the type of wound and the severity if she would be notified the same day or not, if it were a skin tear, she may not be notified until the next day but if it were pressure, they would notify her immediately. She said if a new wound were present for pressure, she would contact the physician and notify them. She said excoriation looked like redness, scratches, or some type of minor injury without any skin breakage. She said pressure wounds varied according to the stage, stage 1 was non blanchable skin (when touched stays red), stage 2 top layer of skin was missing, stage 3 slough might be present, or it could be a stage 4. She said she staged the wounds. She said she had a lot of education on it and had been to different classes and seminars and the DON would come behind her and look at the wounds and then would notify the physician. She said she would assess the wound, stage it, and let the DON and physician know. She said they did not have a wound care physician that visited the facility and had not had one since she had been employed for 8 1/2 years. She said she was responsible for all the pressure wound treatments for residents in the facility. She said Resident #1 buttocks started as a scratch from the hospital with excoriation, had small opens on his bottom that were sporadically, and they were using barrier cream after incontinent care episode. She said the wound was close to his rectum and he continued to have frequent bowel movements throughout the day. She said the interventions started as barrier cream and then an order for exuderm to keep feces out of it and then got wedges to turn q2 hrs and chair cushion when up. She said she noticed slough and it was a stage 3 and was about a size of a 50-cent piece. She said he had an appointment in Houston in October, and he was gone all day and noticed he started getting slough on his bottom. She said when the slough started, got an order for an air mattress to try and relieve pressure on his bottom and a wheelchair cushion, supplements for wound healing and wound care treatment order changed. She said the treatments were being done daily. She said the wound had gotten worse before he left the faciity on [DATE]. She said the wound was so close to his rectum and it was hard to keep feces out of it. She said they used waterproof nonadherent bandages, but when he had a bowel movement, it would get underneath the bandage and had a hard time keeping it out. She said they were contacting the NP and the Medical Director about the wound for Resident #1. She said the NP and the Medical Director would make rounds at about 6 am in the facility and never made rounds with her to see the wound on Resident #1 or any of the other residents. She said if they asked to see the wound it would have been with the charge nurses. She said she was not wound care certified. She said there was a RN weekend supervisor that performed wound care on the weekends. She said there were standing orders for certain types of wounds, if stage 2 would use exoderm, if stage 3 with minimal drainage would use collagen, moderate drainage calcium alginate, if it had depth could pack and use collagen powder. She said there was a book that was kept at the nurse desk. Record review of a Skill Checklist-Treatment for the Treatment Nurse sated 5/8/2024 indicated she showed competency of treatments that was observed by the DON. Record review of Standing Orders for skin for the facility indicated orders for general skin protocol indicated any change in the resident's skin condition must be documented, the physician and responsible party notified dated 4/9/2024 and signed by the Medical Director. During an interview on 11/9/2024 at 4:29 PM, RN A said she was one of the weekend supervisors and worked every other weekend for the past 2 1/2 years. She said she was responsible for everything that went on in the facility except for staffing. She said she performed wound care on the weekends for the residents. She said had Resident #1 for daily wound care before he discharged to the hospital. She said the last time she saw Resident #1's wound on his sacrum it was macerated with a dressing noted the skin looked splotchy, some bleeding, some skin breakdown-top layer of skin missing. She said his left ischium seemed to be deeper about a quarter size in diameter-was open about 1-2 cm-no bleeding and had an exuderm and dressing on sacrum with collagen and dry dressing daily and exuderm every 3 days. She said the sacral wound was right by his rectum and was very hard to keep the area clean. She said she had been notified before and was told not to stage or classify the wounds because she was not, and the treatment nurse would be the one to measure and stage them. She said she could get an order for a dressing for the wound but could not stage it. During an interview on 11/9/2024 at 5:27 PM, CNA B said she had been employed at the facility for September 2023 and worked 6 am-6 pm and worked on all halls in the facility. She said on the weekends she helped with wound care by holding and positioning with the weekend RN supervisor. She said she found a wound on Resident #1 about a month ago and informed the weekend RN that he had a bad wound as it started out as two small red, circled areas in the butt crack on the weekend and told the weekend RN and a charge nurse about it. She said the weekend RN put a bandage on it and put a note for the Treatment Nurse about the wound. She said sometime after observing the new area on Resident #1, she had been off for a few days and came back and observed no bandage on his buttocks and the wound had started getting bigger. She said the area was bigger than the size of a 4 x 4 gauze. She said the last day she saw the wound was on 10/31/2024 before he left for a physician appointment, and he did not come back. She said the wound on 10/31/2024 was bad on both sides of his buttocks were open and could put at least three fingers inside and it smelled like dying flesh that was yellow and green in color. She said a charge nurse put a dressing on the wound before he left for that appointment on 10/31/2024. During an observation on 11/10/2024 at 8:55 AM, Resident #2 was in his room in bed with CNA B and CNA C present to provide incontinent care. CNA B and CNA C removed a dressing to his sacrum as the dressing had stool present that had gotten underneath the dressing to the wound. DON entered the room and said she needed to look at the wound after they cleaned him because she was informed that the nurse on 11/9/2024 had performed wound care and when the dressing was removed, skin came off with it. Staff provided incontinent care and a large wound to his sacrum was observed with the wound bed black in color with eschar, surrounding skin pink and white, borders irregular, some skin missing with redness and small open areas. CNA B and CNA C both said the wound had been that way for a while. During an observation and interview on 11/10/2024 at 9:10 AM, the DON and CNA C were in the room of Resident #2. DON was present to assess the area to his sacrum and provide wound care treatment. The DON said the wound was unstageable. The DON placed collagen in the wound bed and covered with dry dressing temporarily. She said they had some protocols that they could go by and would notify the physician. RN A entered the room and said the wound looked like it was unstageable with necrotic tissue but could not say if it looked that way on 11/9/2024 because the wound had a lot of barrier cream and when she tried to remove the cream, Resident #2 was in pain and she could not see the wound bed and she placed an exoderm over the area per the orders. During a follow-up interview and observation on 11/10/2024 at 9:32 AM, RN A said on 11/9/2024 she provided wound care for Resident #2 and the wound was open without a dressing. She said the wound was close to his anus and they cleaned him up and the area had zinc cream on it. She said the wound was very moist and there was an order for exuderm to be applied to the scar tissue, so she placed a 4x4 exuderm per the orders. She said she was told to let the Treatment nurse know of any changes to any wounds in the facility or skin issues. She said the wound had been present since October 7, 2024. RN A still had the text message where she sent the Treatment Nurse a message to inform her that the zinc was not helping Resident #2. Surveyor observed the text message that was sent to the Treatment Nurse and the Treatment Nurse response was Ok, with a thumbs up emoji. She said there was not a dressing on Resident #2's sacrum on 11/9/2024 and only had an order for exuderm and the skin did not come off because there was not dressing on it, and it had zinc oxide. She said they had standing orders for wound care at the nurse station and then would contact the physician with any new skin issues. During a phone interview on 11/10/2024 at 9:47 AM, the RP of Resident #2 said when he admitted to the facility it was to the secured unit. She said he had been at the facility for 2 years. She said he had been discharged from the secured unit for about 2 months. She said she tried to visit him at least three times out of the month. She said most of the time they keep her updated. She said she had been at the facility on the days of his showers. She said she was present one day this past week and observed staff change him. She said she did not get to see him bottom, and she was used to him having his privacy and when she thought about it asking to see his bottom, it was too late. She said they told her he had a bed sore on his bottom when she visited this past week and asked why no one called her to inform her before then. During a follow-up interview and observation on 11/10/2024 at 10:05 AM, the Treatment Nurse said the last time she observed Resident #2's wound it had a lot of scar tissue from a previous wound which made it easier for skin break down. She said the wound started to crack open and looked like excoriation and received an order to put exuderm on it. She said Resident #2 would hold his urine and when he urinated, he would saturate the brief. She said they tried to keep the exuderm on the wound and keep urine and feces out of it. She said she observed the area that day and it looked like it was starting to try to open, and she would contact the physician. She observed a picture of the wound of Resident #2 that was taken by the Surveyor, and she said the wound looked like an unstageable wound with black tissue noted. She said they have had issues with the wound bleeding in some areas. She said an exuderm would not be appropriate for his wound at that time. During a phone interview on 11/10/2024 at 10:11 AM, the Medical Director said he was out of town, and he was informed that the Surveyor had questions about the facility and them contacting him with any changes in the facility. He said he would have to call his NP and call back. During a phone interview on 11/10/2024 at 10:30 AM, the Medical Director said he spoke to his NP and said neither of them were aware of any standing orders for wounds in the facility for them to follow. He said they both received phone calls and were available for the facility and the facility did not mind calling them. He said Resident #1 had elevated white blood cell counts that were going up and down with the highest being about 18. He said it had been going on for about a month and they made him an appointment with an infectious disease physician so they could determine the source of the elevated white blood cells. He said they did not think that the wound for Resident #1 started the elevated white count as they looked at residents with leukocytosis more closely and they could not pinpoint the cause. He said he was not aware that Resident #1 was at the hospital but was glad to hear it because that was the purpose of him seeing the infectious disease physician. He said he was not aware of any skin issues in the facility until that day when the NP was notified about Resident #2. He said skin assessment were the responsibility of the nursing staff. He said he visited the facility twice a week and, in the past, had been asked to look at residents with wounds but not in a long time. He said he left the wound care treatments up to the Treatment Nurse at the facility, as she would evaluate and treat, if not effective then they would work on changing the treatments. He said if he had known about the skin issues, then they would have ordered appropriate treatments at that time. During an interview on 11/11/2024 at 9:43 Am, the DON said the Treatment Nurse and Weekend RN were responsible for wound care treatments. She said the Treatment Nurse was responsible for skin assessments and if the shower techs noticed anything they would tell her, and she did them weekly. She said she conducted a skin assessment about once a week and an overall monthly for the residents in the facility. She said she looked at skin in the facility once a week because she helped with a lot of incontinent care to make sure the residents had barrier creams because there were a lot of new staff in the facility. She said she staged the wounds and classified them. She said the Treatment Nurse would let her know when a new skin issue was found, and she assess and stage if appropriate. She said only a RN could stage the wounds if the staff found something they could only describe the wounds. She said she did a contract with a wound care physician about a few weeks that would start soon. She said she provided care to Resident #2 on Friday 11/8/2024 and did not see any slough in his wound. She said the wound had excoriation but did not have any slough or necrotic tissue present. She said Resident #1's wounds started with minor excoriation, and had elevated WBCs before the wound started, and they checked lab work frequently. She said he had IV therapy, was on antibiotics, constantly doing change in conditions, going to appointments, saw the Medical Director and his WBCs never went down. She said he was antibiotics and went to the hospital a while ago and the excoriation to his sacrum continued to get worse. She said he had orders for supplements and therapy started seeing him and he received Ultramist wound therapy in the facility. She said they reported to the physician for any change in condition and if wounds changed. She said the Medical Director was aware of Resident #1's wound and said they changed orders for dressings and started the Ultramist. She said the Medical Director was not aware of Resident #1's wound. She said there was a risk for wound deterioration if the physician was not notified. She said when a new skin issue was identified, they should notify the nurse of any changes so the area would be assessed along with more frequent monitoring, notify the family and care plan so everyone would be aware. During an interview on 11/11/2024 at 10:20 AM, the Administrator said she was aware that Resident #2 had some excoriation to his buttocks. She said the DON worked the hall where Resident #2 resided on Friday 11/8/2024 and said the area was not excoriated. She said Resident #1's RP had taken him to multiple physicians and took him to and Infectious Disease Specialist for an opinion. She said Resident #1 had elevated wbc's for weeks prior to his hospitalization [DATE]. She said skin assessments were to be done weekly by the Treatment Nurse and the DON was the only one that staged the wounds. She said she was not aware that the Medical Director was not updated of the change in Resident #2's wound. She said the facility was supposed to notify the physician of any change in conditions with the residents and there was a risk for wounds to worsen if they were not notified. Record review of a facility policy titled Skin and Wound Monitoring and Management revised 1/2022 indicated, .It is the policy of this facility that: 1. A resident who entered the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; 7. Communication of changes: a. Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be communicated to: the resident/responsible party, the resident's physician, and others as necessary to facilitate healing . This was determined to be an Immediate Jeopardy (IJ) on 11/10/2024 at 11:15 AM. The facility's Administrator and DON were notified. The Administrator was provided the IJ template on 11/10/2024 at 12:04 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 11/10/2024 at 4:50 PM. Plan of Removal F 686 11/10/2024 Per the information provided in the IJ Template given on 11/10/24, the facility needs to Take immediate action to ensure prompt identification and interventions for pressure sores are made to prevent serious harm and infection. 1. The Medical Director was notified by the Executive Director on 11/10/2024 at 12:45 pm. 2. The Attending Physician was notified by the Executive Director, of the IJ on 11/10/2024 at 12:45pm. 3. New Braden scales for the total census initiated 11/10/2024 and will be completed 11/10/2024 by Clinical Resources, Clinical Leaders MDS Nurse, ADON, and DON. 4. Audit completed by DON on 11/10/2024 of all residents who are at risk for PU/PI, care plans and care profiles were updated for all residents at high risk to include personalized/individualized interventions/prevention. This was also completed 11/10/2024. 5. Skin assessments were completed on all residents 11/10/2024. These were conducted by the DON, ADON, MDS Nurse, Wound Care Nurse, and Clinical Resource. 6. Education initiated 11/10/2024 by Clinical Resource with, DON, ADON, Nurses, CMAs, and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, turning and repositioning, notification of changes in wounds, interventions, and preventions, as well as communication between Nursing staff and health care professionals; will be completed by 11/11/2024 by 6pm. Any staff unable to attend will not be allowed to work unless they have received their training and knowledge check. 7. All licensed nurses will complete competency on skin assessments initiated on 11/10/24 and will be completed 11/11/2024 by 6pm by DON, ADON, and Clinical Resource. 8. All CNA's will complete competency on skin check initiated on 11/10/2024 and will be completed on 11/11/2024 by 6pm by DON, ADON, MDS Nurse, and Clinical Resource. 9. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 10. An ad hoc QAPI meeting regarding items in the IJ template will be completed on 11/10/2024. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions. 11. The DON, ADON or Clinical Resource will verify staff competency with 10 staff weekly using the skin check competency checklists. 12. All residents with pressure ulcers will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions, as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director, and Wound Nurse. The DON and Administrator will be responsible for ensuring this meeting is held weekly and all residents with pressure ulcers/pressure injury are reviewed. 13.Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90days to ensure ongoing compliance. 14.Resident #1 is no longer a resident in the facility. 15. Wound Care nurse was checked off on wound care, in-serviced on policies and procedures, change of condition, notification of physician, and responsible party on 11-10-2024 at 2pm. The State Surveyors monitored the Plan of Removal as follows: Record review of the POR for F686 was signed by the Medical Director dated 11/11/2024. Record review of Braden Scales (assessment to determine risk for pressure ulcers) for all Residents in the facility dated 11/10/2024 indicated 83 of 83 residents had updated Braden scales. Record review of Braden Scales audit for all residents in the facility dated 11/10/2024 indicated 15 of 83 residents were identified as being high risk for pressure ulcers. All residents care plans were updated. Record review of a care plan for Resident #2 dated 11/102024 indicated he had actual impairment to skin integrity related to unstageable to coccyx. Interventions included air mattress, cleanse coccyx unstageable with normal saline, pat dry, a[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as possible for 4 of 24 residents reviewed for quality of care. (Residents #20, #26, #31, and #47). The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could result in a loss of quality of life due to injuries. Findings included: Record review of a facility face sheet dated 11/05/24 for Resident #20 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: type 2 diabetes (uncontrolled blood sugar), absence of left leg, lack of co-ordination and hypertension (high blood pressure). Record review of a quarterly MDS assessment dated [DATE] for Resident #20 indicated that he had a BIMS score of 13, which indicated that he was cognitively intact. Section GG indicated that he was dependent with transfers. Record review of a comprehensive care plan for Resident #20 indicated that he had an ADL self-care performance deficit. Interventions included .TRANSFER: The resident requires 1-2 staff assistance with transfers . and Last Care Plan Review Completed section reflected .9/23/2024 . Record review of a facility face sheet dated 11/06/24 for Resident #26 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: type 2 diabetes (uncontrolled blood sugar), muscle weakness, lack of co-ordination and hypertension (high blood pressure). Record review of a quarterly MDS assessment dated [DATE] for Resident #26 indicated that she had a BIMS score of 00, which indicated that she had severe cognitive impairment. Section GG indicated that she was dependent with transfers. Record review of a comprehensive care plan for Resident #26 indicated that she had an ADL self-care performance deficit. Interventions included .TRANSFER : The resident requires 1-2 staff assistance with transfers . and Last Care Plan Review Completed section reflected .08/15/2024 . Record review of a facility face sheet dated 11/06/24 for Resident #31 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (deterioration of memory, language, and other thinking abilities), cerebral infarction (stroke), and hypertension (high blood pressure), muscle weakness, and lack of co-ordination). Record review of a quarterly MDS assessment dated [DATE] for Resident #31 indicated that she had a BIMS score of 02, which indicated that she had severe cognitive impairment. Section GG indicated that she was dependent with transfers. Record review of a comprehensive care plan for Resident #31 indicated that she had an ADL self-care performance deficit. Interventions included .TRANSFER : The resident requires 1-2 staff assistance with transfers . and Last Care Plan Review Completed section reflected .10/08/2024 . Record review of a facility face sheet dated 11/06/24 for Resident #47 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia (deterioration of memory, language, and other thinking abilities), muscle weakness, and lack of co-ordination). Record review of a quarterly MDS assessment dated [DATE] for Resident #47 indicated that he had a BIMS score of 06, which indicated that he had severe cognitive impairment. Section GG indicated that he was dependent with transfers. Record review of a comprehensive care plan for Resident #47 indicated that he had an ADL self-care performance deficit. Interventions included .TRANSFER : The resident requires 1-2 staff assistance with transfers . and Last Care Plan Review Completed section reflected .10/16/2024 . During an observation and interview on 11/04/24 at 11:05 AM revealed Resident #26 was sitting in the common area watching TV in a wheelchair. A Hoyer sling with faded straps was underneath her. The straps were all a gray color, and the black main strap was faded to a charcoal color. ADON A said the staff received training to pull slings from use if they had rips, tears, or ravels. She said that the Hoyer sling underneath Resident #29 was faded and should probably be removed from service due to the risk of injury to the resident if it failed. During an observation and interview on 11/04/24 at 11:15 AM revealed Resident #20 was sitting in the dining room in a wheelchair. A Hoyer sling with faded straps was underneath him. The straps were all a gray color, and the black main strap was faded to a charcoal color. LVN B said she worked as needed at the facility and had been in-serviced on when to remove slings from service at the other facility she works at. LVN B said the staff should have received training to pull slings from use if they have rips, tears, ravels and faded. She said that the Hoyer sling underneath Resident #20 was faded and should probably be removed from service due to the risk of injury to the resident if it failed. She said the sling was very faded which could indicate it was bleach or had deteriorated. During an observation on 11/04/24 at 11:25 AM revealed Resident #47 was sitting in the dining room in a wheelchair. A Hoyer sling with faded straps was underneath him. The straps were all a gray color, and the black main strap is faded to a charcoal color. During an observation and interview on 11/06/24 at 09:10 am revealed Resident #31 was sitting in the common area in a wheelchair. A Hoyer sling with faded straps was underneath her. The straps were all a gray color, and the black main strap was faded to a charcoal color. Physical Therapy Assistant C said the staff have received training to pull slings from use if they have rips, tears, or ravels. He said that the nursing staff was responsible for removing the slings, but all staff should be trained and be actively involved in keeping all resident safe. He said the risk to the resident would be a fall and injury if the sling failed during transfer. During an interview on 11/05/24 at 10:07 AM the DON said the staff had been in-serviced on Hoyer lift safety that included taking damaged slings out of service. She said the risk to the resident of the slings failed was an injury from a fall. During an observation and interview on 11/06/24 at 9:09 AM revealed a Hoyer sling with a torn attachment loop was in the clean area of the laundry area on the cabinet. The Laundry Staff said she would throw the sling away with the broken strap. She said she did not bleach the Hoyer slings that came to her in routine laundry, she washed them with the colored clothes of the residents. She said that she was washing the Hoyer slings that came to her in isolation bags with bleach, she did not separate the slings from the bleachable items and then she air dries them. She said that she shows any worn, torn, or [NAME] slings the Housekeeping Supervisor and she decides if they need to be thrown away. She said worn, torn and faded slings could cause the Hoyer sling to tear or break causing a possible injury to the resident. During an interview on 11/06/24 10:04 AM the Housekeeping Supervisor said she had not considered the slings that were faded to be unsafe. She said the facility would have to come up with a plan for disinfecting the slings without using bleach. The housekeeping supervisor was not aware the slings were being bleached. She said all staff would need in-servicing on what conditions require the straps to be removed. She said using bleach during the wash cycle would deteriorate the slings. She said worn, torn and faded slings could cause the Hoyer sling to tear or break causing a possible injury to the resident. During an interview on 11/06/24 at 10:37 AM the Administrator said that bleached, worn torn or [NAME] Hoyer slings should be removed from service. She said the staff would be in-serviced and the facility would address not bleaching the slings during laundry service. She said the staff will be in serviced on when to take the slings out of service. She said worn, torn and faded slings could cause the Hoyer sling to tear or break causing a possible injury to the resident . Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 11/06/24 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use . Record review of manufacture guidelines Invacare Patient Sling Reference Guide accessed at www.invacare.com on 11/06/24 reflected .Inspect sling before each use for wear, tears, and loose stitching. Bleached, torn, cut, frayed or broken slings are unsafe and could result in injury. Discard immediately . Record review of an undated facility policy titled Hoyer Slings, indicated . IT IS THE POLICY OF THE FACILITY THAT EACH RESIDENT IN NEED OF HOYER TRANSFER SHALL HAVE TWO ASSIGNED SLINGS. PROCEDURE: I. Residents requiring Hoyer transfer will be provided two Hoyer slings in their proper size. 2. C.N.A or anyone performing a transfer shall inspect the sling prior to each use per the manufacture guidelines. 3. Central Supply shall inspect the slings monthly. 4. If the sling becomes torn, ripped, stretched, or altered per the manufacture guideline, the facility shall dispose and replace it immediately.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #184) and 2 of 4 staff (CNA F and CNA G) reviewed for infection control. CNA F and CNA G did not sanitize or wash their hands between glove changes when incontinent care was provided on 11/5/2024 to Resident #184. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an Admission Record for Resident #184 dated 11/5/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of UTI (infection in the urinary tract), Alzheimer's disease and urogenital candidiasis (yeast infection in or around the genitals). Record review of an Admission MDS Assessment for Resident #184 dated 9/7/2024 indicated he had moderate impairment in thinking with a BIMS score of 6. He required substantial/maximal assistance with personal hygiene. He did not have an indwelling catheter but was always incontinent of urine and frequently incontinent of bowel. Record review of active physician's orders for Resident #184 dated 11/5/2024 indicated an order for catheter care every shift that started on 10/23/2024. Record review of a care plan for Resident #184 dated 10/24/2024 indicated he had an infection of the urine with interventions to maintain standard precautions when providing resident care. He had bowel/bladder incontinence related to disease process dated 9/11/2024 with interventions for incontinent: check as required for incontinence, wash, rinse, and dry perineum. During an observation on 11/05/2024 at 11:04 AM, in the room of Resident #184, revealed CNA F and CNA G were present to perform catheter and incontinent care. Both washed their hands in the bathroom, donned (put on) gowns and gloves. Supplies were in a plastic bag and two pans of water were on the over bed table, one with soap and the other without. CNA F pulled down Resident #184's pants. His urinary catheter was anchored to his left thigh, and he was rolled onto his side and a towel was placed underneath his buttocks. His brief was opened and pulled down between his thighs. CNA F removed a washcloth from the soapy water and cleaned down this right and left inner thighs, and placed the towel in a plastic bag. A small bowel movement was noted in the brief. CNA F removed her gloves and placed them in the trash, she did not sanitize or wash her hands, and placed clean gloves on. CNA F removed wipes from the plastic bag x4 and cleaned his rectum from front to back and removed the brief and placed it in the trash. CNA F doffed (took off) her gown and gloves and said she was going to get the nurse because the dressing to Resident #184's sacrum (bone that holds the pelvis and spine together) was loose and needed to be replaced. Resident #184 was covered back up and CNA F exited the room. CNA F returned to the room and washed her hands, donned a gown and gloves, and removed a soapy towel from the basin and cleaned the shaft of the penis from the tip to the base and pulled his skin back and placed the towel in the plastic bag. CNA F removed her gloves and placed them in the trash and applied clean gloves to both hands without sanitizing them. CNA F removed another towel from the soapy water and cleaned the tip of the penis and placed the towel in a plastic bag. CNA F removed her gloves and placed them in the trash and applied clean gloves to both hands without washing or sanitizing them. CNA G removed a towel from the soapy water and cleaned down the catheter tubing and then removed her gloves and placed them in the trash which fell to the floor. CNA G took another a soapy towel and cleaned both inner thighs and placed the towel in a plastic bag. Resident #184 asked CNA G to dry him and she removed a dry towel from the plastic bag and patted him dry with the towel. CNA F removed her gloves and placed them in the trash and the gloves fell to the floor because it was overflowing and placed clean gloves on her hands without sanitizing them. CNA F and CNA G both removed the towel that was underneath Resident #184's buttocks and placed a clean brief and secured it. Both removed their gloves and gowns and placed them in the trash and then they washed their hands. During an interview on 11/5/2024 at 11:36 AM, CNA G said she had been employed at the facility for a year. She said during the care provided to Resident #184, she should have had extra gloves in the room, should have sanitized between glove changes, should have folded the towel when she cleaned, would have circled around the base of the penis to the body then cleaned the area. She said if a male resident was uncircumcised then she would have pulled the skin back to clean and then pulled the skin back over after. She said there was a risk of cross contamination and infections if they did not follow the proper procedures. She said the gloves should not be on the floor and should have been in the trash. She said she was not sure when the last time she had skills check off by staff. Record review of a Skills Checklist-Catheter Care, indwelling for CNA F dated 8/30/2024 indicated she was successful with catheter care and perineal care, conducted by ADON H. During an interview on 11/5/2024 at 12:54 PM, CNA F said she had been employed at the facility for 2 months and worked both shifts. She said during the care provided to Resident #184, she would have one pan for the washcloths, would have cleaned more thoroughly, should have sanitized between glove changes, and would have pulled skin back in place because he had excess skin on his penis. She said she should have washed from the base up, would have gotten another towel and cleaned the tubing in one single stroke. She said she should have cleaned the thighs and peri area before starting the Foley catheter care. She said there was risk for residents to get UTIs, yeast infections and sepsis (infection in the blood stream) if left untreated. She said she was unsure if she had skills check off with any staff. Record review of a Skills Checklist-Catheter Care, indwelling for CNA F dated 8/31/2024 indicated she was successful with catheter care and perineal care. During an interview on 11/6/2024 at 9:34 AM, ADON A said the Treatment Nurse was responsible for conducting skills check offs with staff. She said she did conduct in-services with staff at times. She said she was made aware of the care provided to Resident #184 yesterday 11/5/2024. She said hand hygiene should be performed before care, between glove changes and after care. She said gloves should be placed in the trash and not on the floor. She said during incontinent care, staff should use 1 wipe per side and they should have cleaned the bowel movement first and then performed Foley care. She said there was a risk for UTIs, sepsis, and skin breakdown if care was not done properly. During a joint interview on 11/6/2024 at 9:44 AM, ADON H and the Treatment Nurse both said skills check offs were conducted with staff on hire, annually, and prn. They said part of the skills check offs were hand hygiene and peri care with return demonstration. They said hand hygiene should be done before care, after care, with each glove change and gloves should be placed in the trash and not on the floor. They said they planned to recheck both staff off on skills and conduct an in-service with all staff. Both said if a male resident was not circumcised, staff should pull the skin back, clean and place the skin back after. Both said there was a risk for skin breakdowns, UTIs, and wounds if staff did not follow proper procedures when performing incontinent care and urinary catheter care. During an interview on 11/6/2024 at 2:00 PM, the DON said she was responsible for all staff training on infection control. She said training should be done on hire, annually and prn in between times. She said hand hygiene should be performed before care, when gloves were removed and after gloves were removed. She said gloves should never be placed on the floor. She said they conducted training all the time at the facility. She said incontinent care should start at the front of the body before going to the back. She said there was a risk of infections if they did not perform hand hygiene. She said they would plan to do more training with staff. During an interview on 11/6/2024 at 2:25 PM, the Administrator said Management Nurses were responsible for training staff at least annually and prn. She said hand hygiene should be performed before care, during and after care and between glove changes. She said gloves should never be placed on the floor. She said they planned to do an in-service with staff and more education. She said there was a risk for infections. Record review of a facility policy titled catheter policy/procedure revised 1/2024 indicated, .It is the policy of this facility that each resident with an indwelling urinary catheter will receive catheter care daily. To promote hygiene, comfort and decrease risk of infection for catheterized residents . Record review of a facility policy titled Hand Hygiene revised 12/2023 indicated, .It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene. Procedure: 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: j. After contact with blood or bodily fluids; m. After removing gloves .

Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 3 days reviewed (11/4/2024) nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 11/4/2024. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings: During an observation on 11/4/2024 at 9:15 AM, revealed there was no daily staffing posting in or around the front entrance or at the nurse's station. During an observation and interview on 11/5/2024 at 7:55 AM, revealed the daily staffing posting dated 11/4/2024 was located on hall A on a wall,, unable to see the posting if coming in the front entrance and not in a place where residents and visitors could see it. The Treatment Nurse said she was responsible for placing the posting on the wall but did not gather the information for staff numbers. She said the posting where it had always been posted and was not in any other location. The daily posting had all required information with census numbers and staffing hours for nurses and nurse aides. During an observation on 11/6/2024 at 8:12 AM, revealed the daily staff posting dated 11/5/2024 was located at the front entrance. During an interview on 11/6/2024 at 9:15 AM, the Treatment Nurse said she was responsible for assisting with staffing. She said she was responsible for completing the daily and monthly schedule and putting up the daily posting. She said she put out the posting in the morning after she arrived at work. She said she was told to put the posting on A hall on the wall by management. She said she was not aware that the posting needed to be in a visible place for all residents and visitors to see. She said they changed the location yesterday for the posting to be placed at the front of the facility. During an interview on 11/6/2024 at 2:25 PM, the Administrator said the Treatment Nurse was responsible for putting up the daily staffing census posting daily, and it had to be put up within 2 hours. She said the posting should be in plain sight.

Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 5 residents (Resident #5) reviewed for ADLs. The facility failed to ensure Resident #5's bed linens were clean when her bed linens were visibly dirty with a dark yellow stain with a brown ring around the outer edges on 10/28/2024. This failure could place residents at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: Record review of Admission Record for Resident #5 dated 10/29/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included diagnoses of Pneumonia (a respiratory infection) Muscle Wasting (loss of muscle mass and strength), Weakness, and Difficulty Walking. Record review of Resident #5's quarterly MDS Assessment, dated 8/02/24, indicated no cognitive impairment in thinking with a BIMS score of 15. Resident #5 required Supervision or touching assistance for all ADLs and she was occasionally incontinent of bladder. Record review of a Care Plan for Resident #5 dated 08/05/2024, reflected she had an ADL Self Care Performance Deficit related to weakness and poor balance and bowel/bladder incontinence related to disease process and weakness. An observation on 10/28/24 at 3:30 PM revealed Resident #5's room had a strong odor of ammonia. Her bed had a dark yellow, circular, stain, with a brown ring around the outside edges. The stain covered almost the full horizontal width of the bed and roughly 2 feet vertically. During an interview on 10/28/2024 at 3:55 PM, Resident #5 said she had been wet for hours this morning, staff did not check her bed they only brought her tray in. She said she had been in the facility for 5 years and it had been an ongoing problem with staff not doing what they were supposed to. She was thinking about leaving and moving to another facility because of the issues. She said this wasn't the first time. She said not receiving ADL assistance made her feel not good and she was dealing with pneumonia at this time. She said she used to be able to change her own linens, but she needed help now. She said the staff was always changing and she never knew who was working her hall. During an interview on 10/28/2024 at 4:12 PM, ADON B said she and ADON C were working on Resident #5's hall today and ADON B was taking care of Resident #5 today. She said the standard was to round on residents every 2 hours or as needed. She said Resident #5 was usually continent and took care of herself and changed her own linens. She said Resident #5 was known to throw wet briefs into her trash can and stated, my sinuses are messed up, I'm not negating that there may have been a urine smell in the room. She said risks to residents wearing wet briefs or lying on wet linens would be skin impairment. During an interview on 10/28/24 at 4:20 PM, ADON C said ADON B was assigned to Resident #5's hall today and she had only been assisting. She said she was helping with transfers, bed changes, or activities that required a second staff member. She said Resident #5 was usually continent and changed her own briefs. She said residents should be rounded on at least every two hours. She said when she entered Resident #5's room she saw the bed was wet with urine, and she could smell an odor of urine. She said if staff smelled a urine odor in a room they should be checking for soiled linens and briefs. She said the risks to a resident wearing wet briefs or lying on wet linens would be skin breakdown and wound development. During an interview on 10/29/24 at 8:29 AM with CNA D, she said she sometimes worked on Resident #5's hall and she made rounds every 2 hours, checked the briefs, and saw if they needed anything. She said Resident #5 was very independent, but she checked on her to see if she would go to the bathroom, checked her bed and clothes, and took out laundry. She said Resident #5 had frequent accidents. She said she went into her room and found her bed frequently soaked with urine. During an interview on 10/29/24 at 12:45 PM with the Administrator, she said the standard and the expectation was residents would be rounded on every 2 hours or as needed. She said the nursing services were responsible for training and CNAS and nurses both received the same in-services, but nurses had extra training they completed. She said the risks for a resident who was not rounded on every 2 hours would be skin break down or they could hurt themselves in some way that we did not identify. During an interview on 10/29/24 at 1:10 PM with the DON, she said as the DON she was responsible for ensuring all CNAs and Nurses received training. She said her expectation was the residents were rounded on at least every 2 hours. She said the facility used special briefs with an indicator that alerted when they were wet. She said if a CNA or nurse entered a room and there was an odor of ammonia, the expectation was that they investigate to find where the smell was coming from. She said it was her expectation that patients who had a history of being noncompliant with care were still offered help. She said the risk to a resident being left in wet briefs or lying on wet linens was skin impairment. During an interview on 10/29/24 with MA A, she said when she went into Resident #5's room to pass medications, the first thing she noticed was a large stain with a brown ring around it, about the size of a pillow on Resident #5's mattress and the room smelled like urine. She said it wasn't uncommon for Resident #5's room to smell like urine. She said that if she had time, she would assist patients herself with ADL care, but if she had other duties such as passing medications, she would alert the CNA or nurse that the resident needed attention. Record review of Orientation and Annual Skills Checklist for ADON B, dated 3/10/24, indicated successful completion. Record review of the facility's Policy ADL, Services to Carry Out reflected . Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain Personal Hygiene

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 3 residents (Resident #1 and Resident #4) reviewed for accidents. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 11/7/2023 when he climbed out of a window in the secured unit and broke a fence in the courtyard. The facility failed to keep Resident #4 in a safe environment to prevent an elopement on 11/20/2023. The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on 11/7/2023 and ended 11/20/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for serious injury and accidents. Findings included: 1.Record review of an Elopement/Wandering Evaluation by ADON D dated 7/14/2023 for Resident #1 indicated he admitted to the facility on [DATE]. He had dementia, ambulated with an assisted device, was disoriented, and had a history of 2 or more episodes of elopement in the last 6 months. He was indicated as a high risk for elopement with a score of 16. Score ranges: low risk 0-9 and high risk 10-55. Record review of an Admission Record dated 8/19/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, depression, and anxiety disorder. Record review of a care plan dated 9/19/2023 for Resident #1 indicated he had secure unit placement and was an elopement risk/wanderer related to dementia. History of dangerous walking, elopement attempts. Interventions included to document wandering behavior and attempted diversional interventions. Record review of an Elopement/Wandering Evaluation by ADON D dated 10/11/2023 for Resident #1 indicated he admitted to the facility on [DATE]. He had dementia and ambulated independently or with supervision. He had intermittent confusion, made statements about a desire to leave the facility and wandered aimless with the potential to go outside with active exit seeking behavior. He was indicated as a high risk for elopement with a score of 15. Score ranges: low risk 0-9 and high risk 10-55. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 9. He had potential indicators of psychosis with delusions (misconceptions or beliefs that are firmly held, contrary to reality). Record review of a nurse progress note for Resident #1 dated 11/7/2023 at 2:30 PM by ADON D indicated, Spoke with desk at Dr. office at this time, updated on incident which occurred on today regarding elopement attempts. Stated she would forward the message to Dr and his nurse with priority for response. Awaiting return call at this time. Record review of an Incident Report titled Skin Alteration for Resident #1 dated 11/7/2023 at 2:30 PM by ADON E indicated, Pt. noted not inside of room. Staff noted window unlocked and Pt. was not inside of unit. Staff went outside and noted Pt. behind storage building on outskirts of courtyard, during head-to-toe assessment/skin assessment. Pt noted with 0.5 cm x 0.5 cm S/T to right arm, scattered/multiple scratches to bilat upper and lower extremities. Resident description: Pt. states I just wanted to go outside so I unlocked my window and crawled out, I'm not hurt, it's just some little scratches. Record review of a witness statement dated 11/7/2023 by LVN C indicated, Resident #1 was in hallway upset, because he wanted to go home and requesting a phone. He stated that's ok, I'll find one. Resident then proceeded to his room and closed the door as he always does. I then preceded to contact his family member and update her on his request to go home. She stated, I'm gonna go ahead and get my husband and we'll be up there to let him know he'll be staying there permanently. I was in unit talking to staff about medications. Resident family and her husband arrived about 15-20 minutes later. She stopped to speak with me, then went into resident room. A few minutes later the daughter came out and said he's in the bathroom, I've been knocking and waiting but he won't come out. I immediately went in and knocked on the door, no response. I opened the door and resident was not inside. I went to the window and noticed the back gate was open. I then alerted admin and staff to search for resident. Record review of a Q 15-minute observation form for Resident #1 indicated q15 minute monitoring started at the facility on 11/7/2023 at 2:45 PM and ended on 11/8/2023 at 2:30 PM. Record review of an elopement/wandering evaluation post incident on 11/7/2023-11/10/2023 did not reveal any evaluations were conducted. 2. Record review of a facility face sheet dated 8/19/24 for Resident #4 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's and hypertension. Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated that she had a BIMS score of 3, which indicated that she had severe cognitive impairment. She had no wandering behaviors during assessment period. She used a wheelchair for mobility and was dependent with most ADLs. Record review of a comprehensive care plan dated 11/20/23 for Resident #4 indicated that she was an elopement risk/wanderer related to history of attempts to leave facility unattended and she wandered aimlessly. Focus included secure unit placement on 11/20/24. Record review of a facility form titled Elopement/Wandering Evaluation dated 9/6/23 for Resident #4 indicated that she was mobile in wheelchair, had intermittent confusion, no history of elopement, and was a low risk for elopement. Record review of a facility incident report dated 11/20/23 for Resident #4 indicated that she propelled self out of facility. During an observation on 8/19/24 at 9:18 am Resident #4 was observed sitting up in wheelchair in common area of secured unit. She was confused and did not answer questions. During an observation on 8/19/2024 at 9:34 AM, in the secured unit by the dining room exit had a keypad, exit leads out into a wooden fenced in area in a courtyard. There was a wooden fence that was about 8 feet tall that had double doors that was secured by a metal latch and pad locked. During an observation and interview on 8/19/2024 at 9:38 AM, CNA B said she had been employed at the facility for 9 years and work 6a-6p and always worked in the secured unit. She said about 65% of the residents in the unit wander and some like to go up and down the halls and will go in other rooms rummaging through other resident's things. She said there were a couple of them that tried to exit seek with holding down the exit door and would get out in the courtyard that was fenced in. She said she remembered when Resident #1 was in the secured unit and there was an incident when he used silverware and popped the screen off his window and the screw or nail came out. She showed the Surveyor the room where he resided and the window in the room had 2 screws on frame of the window above the top of the window on the left and right side that were screwed into the frame. She said on that day a family member had stopped by to visit him. She said Resident #1 kicked the gate open in the courtyard and it had a pad lock. She said that day she was not on the clock but was at the facility visiting a friend who worked that day. She said they found Resident #1 not long after it was discovered that he was not in his room. She said if there was not a fence dividing the property, then there could have been a chance for it to have taken longer to find him. She said no one heard him go out of his window or break the fence. She said he was not outside for a long time. She said they brought him back in and he was winded but looked fine. She said they did provide 1:1 supervision with him after the incident and he was informed that he could not leave. She said shortly after the incident he discharged and did not return. She said following the incident they had in-services on elopement. She said if they noticed a resident was missing, they were to report to the nurse and check everywhere. She said she just tells the nurse, and they take over from there. Attempted a phone interview with LVN C on 8/19/2024 at 11:00 AM, left a message for a return phone call. During an interview on 8/19/2024 at 11:06 AM, ADON D, said Resident #1 resided on the secured unit when he was at the facility. She said she called the physician about Resident #1 having an elopement at the facility. She said on 11/7/2023, Resident #1 unscrewed the window in his room, as there was a screw that kept the window from opening all the way. She said he took a butter knife and opened the window and got out into the courtyard in the secured unit. She said he did go out of the gate, but never left the premises. She said the physician called her back on the 11/8/2023 and gave an order for Rexulti 2 mg daily and then recommended behavioral hospital and started working on that and he discharged to a behavioral hospital sometime after the incident. She said he was on the secured unit for wandering purposes, he was on q15 minutes checks. The other ADON was the one responsible for handling incident/accidents for the resident. She said an aide noticed him and would not tell the surveyor anything else. Said she needed to get someone else because she could not answer those questions. During an interview on 8/19/2024 at 11:26 AM, ADON E said she was responsible for the incident/accidents, changes in condition and 24-hour reports. She said Resident #1 was admitted to the secured unit when he arrived at the facility. She said on 11/7/2023, Resident #1 was in the secured unit when he broke out of his window in his room into the courtyard and got out of the fence. She said when he was found he had scratches on his arms and a skin tear. She said they found him back by some trees at the back of the facility behind the secured unit. She said he was immediately assessed; his family member was at the facility to visit but was not sure if the family member was present at the time of the elopement. She said he was found not far away from the facility and did not think the incident was a reportable event because he was still on the grounds. She said Resident #1 left the facility without staff knowing and was not sure if he had done that before. She said it was not left up to her to make the decision if the incident was reportable or not. She said the abuse coordinator who was the Administrator, and the DON would make that decision. During an observation and interview on 8/19/2024 at 11:38 AM, ADON E conducted a walk through the secured unit on how Resident #1 was able to exit the unit. She walked with the Surveyor from the room where Resident #1 resided in the secured unit into the courtyard and showed how he broke through the wooden fence and was found in the wooded area by the facility approximately 30 feet from the wooden fence. She said he was found leaning up against a tree still on the property, not in the woods. There were 4 brown portable buildings noted and 2 trash cans by the building where she said he was found. She said when they found him, they took him and sat him on the bench that was outside at the end of A hall because he was winded, and his daughter was present at that time. She said the facility did have cameras at the facility but had recently upgraded their system and was not sure if they still had video footage of the incident with Resident #1. During an interview and observation on 8/19/24 at 11:40 am ADON E said that Resident #4 was found near the dumpsters at end of C-hall. She said she can't remember who brought her back in, that it was on the night shift. Dumpsters observed near several portable buildings and wooded area with chain link fence. During an interview on 8/19/2024 at 11:49 AM, the Maintenance Supervisor said Resident #1 resided in the secured unit in room [ROOM NUMBER]. He said the windows in the secured unit had lag bolts on both sides of the windows. He said he found the bolt and a butter knife in Resident #1's drawer in the room following the incident. He said Resident #1 was able to tell him that he used it to get out of the window on 11/7/2023. He said Resident #1 broke the back double gate in the courtyard of the secure unit and it previously had a smaller hook and clasp, and it broke. He said the door on the fence with a larger clasp and a bigger bolt with a pad lock. He said he also secured the door on the fence with stronger lag bolts and wood to secure it. He said he conducted an elopement drill with staff on day and night shifts following the incident and made sure all the lag bolts on the windows were secured and replaced and put in a different place on Resident #1's window. He said he made sure all the windows had devices in place in the secure unit. During an interview on 8/19/2024 at 12:11 PM, the DON said Resident #1's family member was at the facility at the time of the incident on 11/7/2023. She said the family member of Resident #1 told the aides that he was in the bathroom and would not come out. She said that was when they discovered he was not in the room and said she was not gone for no more than 5 minutes. She said the staff in the secured unit had just seen Resident #1 in his room. She said Resident #1 broke out of the window in his room and kicked the door down in the courtyard. She said following the incident, the Maintenance Supervisor placed a bigger latch on the courtyard door. She said since he was not gone anytime, she did not report it. She said she investigated the incident, talked to staff, and said the staff told her they had just seen him prior to the incident. She said she in-serviced the staff on elopement. During an interview on 8/19/24 at 12:15 pm DON said the staff heard the alarm go off when Resident #4 went out the end B-hall door. She said staff were all in rooms and when they heard the alarm go off, they looked out of the rooms into the hallways. She said they were doing a foley catheter on someone on F-hall and they didn't see anyone. She said they did not do a room check. She said resident was outside a long time and that it was reported to state agency as an elopement. During an interview on 8/19/24 at 12:25 pm Maintenance Sup said he was not here when Resident #4 eloped and did not remember exactly where she was found. He said he did elopement drills afterwards and checked the egress doors. During an interview on 8/19/24 at 1:42 pm DON said that the garbage man found Resident #4 while he was here to pick up the trash from the dumpsters. She said she watched the video showing Resident #4 eloping from the egress door on the end of B-hall. She said she could not remember exactly how long she had been outside but said possibly 15 to 20 minutes maybe. Said that staff did not do a head count after they heard the alarm going off, said they did look outside but it was dark, and they did not see anything. During a telephone interview on 8/19/24 at 2:18 pm Director of city disposal services was questioned on which driver would have picked up trash that night and he took surveyors name and telephone number. He said he would call back with further information if he found out anything. During a telephone interview on 8/19/24 at 2:18 pm Director of city disposal services returned phone call and said that he had spoken to his driver that picked up the trash at facility. He said the driver did not recall any incident of finding a resident outside and bringing her back. During a follow up interview on 8/19/2024 at 2:42 PM, the DON was questioned about how they determine when an incident should be reported to the state agency. She said it depended on the situation. She said she did a lot of the reporting to the state agency when she was on call, but they were mostly done by the Administrator. She said they followed their policies and incidents were situational. She said she could not give any specifics regarding incidents being situational. She said they did reach out to their Resource Leader who helped the facility with making decisions about reporting incidents. She said she did not consider a resident missing if they did not leave the premises and Resident #1 did not leave the premises. She said she in-serviced the staff and started a soft file on the incident but did not report it. During an interview on 8/19/2024 at 2:52 PM, the Administrator said she was the abuse coordinator for the facility. She said she was notified on the day Resident #1 eloped from the facility on 11/7/2023. She said he had gotten out of the gate of the secured unit, exited the window and went through the gate. She said he was found next to a tree outside of the facility. She said the incident was not reported because he did not leave the premises. She said on admission to the facility, Resident #1 was confused but at the time of the incident on 11/7/2023 his thinking had improved. She said regarding reporting if someone was missing or not, the time frame would have to be about 10 minutes or so of not being aware of them missing. She said she did not think the incident needed to be reported. She said she did not consider him a missing resident. She said she and the DON on occasions reach out to their Resource Leader and they would let them know if the incident was reportable or not. During an interview on 8/19/2024 at 3:14 PM, the Resource Leader said the facility did not contact her on a regular basis about any issues because she visited the facility about once a week. She said she spoke to the DON and another Resource Leader about the incident on 11/7/2023 with Resident #1 and they looked at the PL 19-17 for guidance. She said Resident #1 did not leave the premises and according to their elopement policy, if a resident does not leave the premises, then they are considered missing, so the incident was not reported to the state agency. During a telephone interview on 8/19/24 at 4:07 pm CNA AB said she was in a room with a resident when she said she heard the alarms going off. She said she notified the nurse and went outside to look for resident but did not find her. She said that they checked the rooms and by then, someone was ringing the doorbell with Resident #4. During a telephone interview on 8/19/24 at 4:20 pm CNA AC said she was in another room on F hall helping the nurse do a catheter on a resident. She said she never heard the alarms going off when Resident #4 opened the egress door. She said after she came out of the room, they heard the alarm going off, but they thought it was the fire alarm. She said they checked rooms, but did not notice that Resident #4 was missing, and they assumed she was in the bathroom. She said someone came to empty the trash and found her, then brought her back to the front. She said she was new at the time and did not know what the fire alarm sounded like. She said shortly after the incident they had an in-service on alarms to distinguish the difference. During a telephone interview on 8/20/24 at 8:18 am LVN A said that she, another nurse and 2 CNAs were in a resident room doing a catheter for a urine sample. She said she thought the other 2 aides in the facility were making rounds. She said she did not hear the door alarm going off at all while she was in the room, but when she came out of the room, the doorbell was ringing. She said after resident was brought back in, they assessed her, did vitals, and the other nurse did notifications of on-call nurse. The on-call nurse then notified the DON. She said she did not remember doing any in-services after the incident. She said after Resident #4 was back in facility and all notifications were made, they then did a head count to ensure there were no other missing residents. Record review of a facility policy titled Secured unit Admission Criteria dated 9/2023 indicated, .Admission to the Secured Unit is based on diagnostic, functional and behavioral criteria that determine that the resident can benefit from this special environment. Once a resident is accepted for admission to the unit, assessment of the resident's status and appropriateness for the unit is ongoing (at least quarterly and PRN for changes in condition) . Record review of a facility policy titled Elopement/Unsafe Wandering revised 12/2023 indicated, .If is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. Elopement occurs when a resident leaves the facility premises without the facility's knowledge, authorization (i.e., an order for discharge, appointment, or leave of absence) and/or any necessary supervision to do so. 6. Complete an Elopement/Wandering Evaluation of the resident post elopement incident with continued follow up documentation for a minimum of 72 hours following the incident . The facility took the following action to correct the non-compliance on 11/20/2023: Record review of emergency preparedness drill: missing person/elopement was conducted on 11/7/2023 at 10:15 AM by the Treatment Nurse. Record review of emergency preparedness drill: missing person/elopement was conducted on 11/7/2023 at 8:00 PM by the LVN AD. Record review of a Q 15-minute monitoring for Resident #1 was started on 11/7/2023 at 2:45 PM and ended on 11/8/2023 at 2:30 PM. Record review of an In-service training report dated 11/20/23 indicated that all staff were in-serviced on fire drills on 11/20/23. Record review of facility form titled Emergency Preparedness DRILL: Missing Person/Elopement dated 11/20/23 indicated that staff on all shifts received an elopement drill on 11/20/23. Record review of an in-service training report dated 11/20/23 indicated that all staff were in-serviced on Elopement drills, trauma, sensitivity, Alzheimer's Dementia, and elopement/unsafe wandering guidelines on 11/20/23. Record review of a physician's order dated 11/20/23 for Resident #4 read .May admit to secured unit . Record review of a facility form titled Weekly Preventative Maintenance Task Sheet - Door Security Systems dated 11/20/23 indicated that all egress doors had been checked and were functioning and that affected personnel in area had been trained on 11/20/23. Interviews on 8/21/2024 from 9:27 AM to 12:00 PM included: During an interview on 8/21/2024 at 9:27 am, the DM said she had a training drill on elopement early this morning in the facility and had in-services on elopement/missing residents this past week. She was able to verbalize the silver dots on the doors indicated that a resident was a high risk for elopement, could also look in the elopement binder and the Kardex. She said dietary did not have access to the Kardex. She said she took a test on wandering on their online training program and had one that was written when they did in-service over true/false questions. She said if you received a notification that a resident was missing, then you did a head count, checked closets, bathrooms, go outside and around building and if resident cannot be found, call the DON. She said you must check to see if they are out on pass, if not, call the emergency contact, physician, and law enforcement. During an interview on 8/21/2024 at 9:30 am, the [NAME] verbalized trainings on elopement/missing residents was held this past week. She said if a resident came up missing, if a light goes off, they have probably gone out of the door. She said they are to immediately stop what you they were doing, try to locate the resident and conduct a head count. She said she was trained on where to find the elopement binder, to look in the book to see if the resident was out on pass, and to call and see if they are out on pass. She said they would also conduct a head count. She said the silver stars on doors and the elopement book would let them know which residents were high risk for elopement. She said she took a test on the computer and did a paper test over elopement. During an interview on 8/21/2024 at 9:36 am, the DA said he received training on elopement/missing residents this past week. He said he was trained on the silver dots are for residents that are high risk. He said if a resident was missing then they would look for the lights on the hall, go outside to try to find the resident, and if unable to locate, then would notify the nurse. He said he took a test online and a true/false test on paper. During an interview on 8/21/2024 at 9:38 am, the Dishwasher said he had trainings this past week on elopement/missing residents. He said he had training on the computer regarding if someone came up missing, on the door alarms, and steps to take on when they are or not found. He said if a resident was missing, find out which hall the alarm was going off on and go out there and look for the resident, notify the nurse, and conduct a head count. He said he would look behind the buildings, by dumpsters, and in wooded areas to try and find residents. He said residents that were high risk in the facility had a silver dot on their doors, listed in the binder by nurses' desk, and was in the Kardex. He said he took a test on what to do when the alarm goes off and a test on paper. During an interview on 8/21/2024 at 9:45 AM, the BOM said she received training this past week on elopements on their online training program, had active drills for elopements, and was in-serviced as a group over elopements. She said if a resident was missing, they would call a code silver, start search, notify the nurse, the Administrator and DON. She said she was part of the calvary that was called in to help search and they would also call the police but would immediately start searching. She said she was taught in elopement training that if an alarm goes off, a light above the hall that the alarm was from, go outside and physically search for them while other employees look inside the facility. She said they would then conduct a head count, call the police, notify the DON, Administrator, and other department heads. She said residents that were high risk for elopement had silver dots outside their door, there was a book at nurses' station with their information in it and they could look at the Kardex in the computer charting system. She said she took a test online and a paper test with the in-service. During an interview on 9:48 am, Admissions said she was trained on how to identify elopement risks, and there were silver dots on the name plates of the residents that were high risk and could find the information in the Kardex in the charting system. She said there was a binder that also had the information. She said if an alarm went off, employees would split up and start searching, and do a head count. She said they had elopement drills, took a test on paper and online. During an interview on 8/21/2024 at 9:50 am, the ABOM said this past week she had trainings over elopement and wandering risks. She said they had an elopement drill and completed videos online on elopement, and took a test on elopement, and had in-service trainings. She said a resident that was high risk for elopement would have a silver dot outside of their room on their doors, they would also be in the elopement risk binder, and in the Kardex. She said if a resident was missing, would notify the Administrator, Don, MD on call, law enforcement the family. She said they would immediately search for the resident outside of the facility, do head count, and search facility wide. She said they would check the binder to see if family had taken them out on pass, if not, would keep searching and get everyone involved. She said she took a written test and online training with a test on elopement. During an interview on 8/21/2024 at 9:54 AM, the Receptionist said this past week she had trainings on elopement/missing residents. She said they had drills for when the lights flash to see if a resident had gotten out and to check all areas inside and out. She said she had training and testing on the computer and an in-service on elopement. She said the silver stars or dots on door nameplate, a binder with info, and the Kardex (she does not have access) would help to identify what residents were at risk for elopement. She said she took tests online and one on paper. During an interview on 9:56 am, the Transportation Driver said she had trainings over elopement this past week. She said there were alarms on each door, and it would identify which hall and go out that hall door and look. She said if you do not see anyone, notify the nurse and she would call a code silver. She said the nurse would then assign everyone somewhere to search and conduct a head count, identify who was missing and if not located, notify the DON, Administrator, and the police. She said residents who were high risk for elopements could be found in the Kardex, a binder, and there were silver dots on their doors. She said she had tests on paper and one online. During an interview on 8/21/2024 at 10:00 am, PTA said she had elopement training this week. She said the training included on knowing what to do, what the alarm sounded like, fastest way to identify a missing patient, identify which hall alarm was coming from, go outside and look, if you don't see anyone, notify nurse, code silver, check all rooms, closets, bathrooms, do head count. Look to see if they are on pass. She said there was an elopement binder at nurses' station that had residents who were high risk for elopement, could also find the information in the Kardex in the charting system and their rooms would have a silver dot by their names. She said she did a test on paper and online over elopement. During an interview on 8/21/2024 at 10:03 am, the OTA/ADOR said he was trained on elopement this week and how to identify a resident who was at risk along with the steps to take. He said the elopement binder, Kardex and a silver dot on the name plates indicate who are high risk for elopement. He said if a resident was missing, would identify door light, report to the charge nurse, check the immediate area outside, call code silver, and do a head count. He was tested on elopement online and paper. During an interview on 8/21/2024 at 10:05 am, PT said he was trained on identifying elopement risks for residents and procedures. He said if a resident was a high risk for elopement could find that information in the Kardex, in the care plan, the elopement binder at nurses' station, or a silver dot on the resident's door. He said if a resident was missing resident an alarm would go off, would go down to the end of the hallway and report to the charge nurse. He said he would go outside and search for the resident, conduct an internal search, and conduct a head count of the residents. He said then they would notify the DON, Administrator, RP, and the police. He said he was tested on procedures on paper and online. During an interview on 8/21/2024 at 10:07 am, OT said he had been trained and had in-services on elopements and identifying if someone had left the facility. He said they were told to look for the lights, sounds, and see where they were coming from. He said they would look for them, do a head count, and notify the DON and the Administrator. He said if a resident was high risk for elopement they would have a silver sticker on their doors, could find the information in the Kardex and in the elopement binder. He said he was tested on paper and online. During an interview on 8/21/2024 at 10:10 am, COTA said she had elopement trainings and some on the computer. She said they were taught on the procedure to take which included if an alarm sounded, look at the end of each hall to identify the hall where the resident was, look outside to see if you can see them, and if not notify the nurse for a code silver. She said the silver dots on the doors, the elopement binder and the Kardex would indicate

Based on observation, 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 2 of 7 residents (Resident #3 and Resident #7) reviewed for resident rights. 1.The facility failed to ensure CNA Z did not speak degradingly to Resident #3 during personal care on 2/19/24. 2.The facility failed to ensure CNA G did not tap the hand of Resident #7 in a degrading manner during personal care on 6/29/24. These failures placed residents at risk of decreased feelings of self-worth and decreased quality of life. This was determined to be past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey on 6/29/24. Findings include: 1.Record review of a facility face sheet dated 8/20/24 for Resident #3 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Arthritis (swelling and tenderness of one or more joints), dysphagia (difficulty swallowing that can be caused by various conditions affecting the throat or esophagus), dementia (a group of symptoms affecting memory, thinking and social abilities), and type 2 diabetes mellitus (a condition that affects how the body uses sugar as a fuel). Record review of a Quarterly MDS assessment dated [DATE] for Resident #3 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. She was dependent with toileting and personal hygiene. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 1/9/24 for Resident #3 indicated that she had an ADL self-care deficit related to impaired cognition and dementia, poor mobility, weakness, and incontinence. Interventions included to converse with resident while providing care, and to explain all procedures/tasks before starting. During an attempted telephone interview with CNA Z on 8/20/24 at 2:59 pm a message was received that number was no longer in service. During a telephone interview on 8/20/24 at 3:11 pm LVN AA said that on 2/19/24 just after the evening meal, Resident #3 had thrown up on herself in the dining room. She said she had asked CNA Z to assist her with cleaning the resident up. She said CNA Z did not act like she wanted to, since it was shift change. She said she took Resident #3 to her room and when they pulled down the resident's brief, they realized the resident had also had a bowel movement. She said CNA Z said .are you fucking kidding me? . LVN AA said she was a new nurse at that time and had only been in training at the facility for a few days and really did not know how to handle the situation. She said she sent CNA Z to get her needed supplies to clean the resident. She said CNA Z left room to retrieve supplies when resident began saying that she was getting weak in the knees. She said CNA Z returned to room and they got the resident in the bed. LVN AA said she told CNA Z to leave the room because she continued yelling and cursing at the resident, but she continued standing there yelling at Resident #3 and cursing at her. She said she finally got CNA Z to leave the room and she finished cleaning Resident #3 on her own. She said she had to stay in room for a while with Resident #3 to console her as she was upset. She said she immediately tried to report the incident to the nurse she was training with (LVN C) but LVN C told her .you will have to tell me tomorrow; I have to go .or something to that effect LVN AA said she was finally able to reach the Administrator the next morning and reported the incident. She said she was suspended for not immediately reporting incident to Administrator or DON and was given trainings on how to handle situations in the future. She said she now understood she should have handled the incident differently and immediately reported to administration. She said she no longer works at this facility. During a telephone interview on 8/20/24 at 3:30 pm LVN C said she had been training LVN AA on 2/19/24 and at the end of the shift Resident #3 had vomited in the dining room. She said LVN AA then took resident to her room. She said she heard LVN AA ask CNA Z for help. She said when LVN AA came out of room she did not tell her anything about what happened, and she was unaware of it until the next day. During an observation and interview on 8/20/24 at 3:40 pm Resident #3 was observed in bed wearing a hospital gown. She was alert to person and place. She was unable to appropriately answer questions. She said that her daddy was going to be 67 and he's going to be at the nursing home. 2.Record review of a facility face sheet dated 8/19/24 for Resident #7 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: metabolic encephalopathy (an alteration in consciousness caused by diffuse or global brain dysfunction from impaired cerebral metabolism), bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows), dementia (a group of symptoms affecting memory, thinking and social abilities), and post-traumatic stress disorder (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event). Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated that he had a BIMS score of 3, which indicated that he had severe cognitive impairment. He had no behaviors indicated on assessment. He required substantial/maximal assistance with toileting and personal hygiene. He was always incontinent of bladder and frequently incontinent of bowel. Record review of a comprehensive care plan dated 2/28/24 for Resident #7 indicated that he was at risk for impaired cognitive function/dementia or impaired thought processes related to Alzheimer's. Interventions included to provide with necessary cues - stop and return if agitated. During an observation and interview on 8/19/24 at 9:00 am Resident #7 was observed in his bed with head of bed elevated eating breakfast. He did not speak much and would only answer yes/no questions. He was asked if staff were all nice to him and he answered yes. He was asked if any staff had ever been mean to him and he answered no. He appeared well-groomed and no odors were noted. During a telephone interview on 8/19/24 at 10:24 am CNA G said on 6/29/24 she and another CNA were changing Resident #7 and he was fighting and becoming aggressive. She said Resident #7's family member alleged that she had tapped his hand like a toddler. CNA G said Resident #7 was slapping her and that she was trying to keep him from hitting her. She said she was suspended for a day or so and had to complete some training classes before she was allowed to return to work. She said she did not work with Resident #7 at any time after incident. During an interview on 8/19/24 at 10:35 am CNA H said on the day of the incident (6/29/24) Resident #7 was wet and she did not want to change him alone due to his behaviors. She said she got CNA G to assist her. She said he was refusing care. She said she was explaining things to him as they went and as she was taking his brief off, he was talking about hitting and kicking them. She said at one point he grabbed CNA G's arm with both of his hands and started squeezing her with both of his hands and he kept squeezing her arm. She said CNA G tried to get him to let go and she lightly tapped him on the hand. She said after they finished his care, they reported his behaviors to the charge nurse. She said she had been trained on dealing with aggressive behaviors and they are supposed to leave the resident in a safe position and return later to try again. During an interview on 8/20/24 at 9:00 am the DON said on 6/29/24 Resident #7's family member had come in and said she had seen on the camera when CNA G and CNA H were in room that CNA G had tapped his hand like a baby. She said she started an investigation and watched the video many times and both CNAs were suspended. She said she reported the incident to state, spoke to both employees, did in-services and trainings. She said CNA G was no longer allowed to work with Resident #7 after incident. She said there had been no prior incidents with CNA G and none after. She said CNA G had been a very good aide. She said she does train her staff to walk away and notify a nurse if a resident is combative or refusing care. During an observation on 8/20/24 at 11:15 am a video sent from Resident #7's family member was observed in which CNA H and GNA G were observed providing incontinent care to Resident #7. CNA G was explaining to Resident #7 they were trying to help him and change his brief. She told him multiple times not to hit her. CNA H was then observed on residents left hand side of bed and had his left hand/arm with her hands, while CNA G was observed on residents' right-hand side of bed and had his right hand/arm in her hands. CNA G again told Resident #7 not to hit her. Resident #7 was then observed raising left hand/arm. At this point, Resident #7 said I'll break your Goddamn arm; CNA G appeared to tap Resident #7 on the right hand; an audible sound could be heard which sounded like a slap, then video stopped. During an interview on 8/20/22 at 11:38 am Family Member of Resident #7 said that he had returned to facility on 6/27/24 after a stay at a behavioral facility. They said they notified the facility on 6/29/24 of the incident on video. They said Resident #7 did have some behavioral issues, but he still deserved to be treated appropriately. During an interview on 8/21/24 at 3:15 pm the DON said that she and the Administrator are both responsible for training staff on dignity and resident rights and ensuring residents are treated with dignity and respect. She said she terminated CNA Z as soon as she was made aware of the incident. She said she and the Administrator were unable to determine if CNA G had tapped Resident #7's hand or not. She was suspended, received in-services and trainings, and was allowed to return to work. She did not work long after the incident and no longer works at the facility. She said going forward, they would continue to do orientations, trainings and in-services on resident rights and dignity. She said residents could be at risk of feeling intimidated and threatened if staff treated them without dignity and respect. During an interview on 8/21/24 at 3:39 pm Administrator said they would be providing additional trainings on resident rights and dignity. She said residents could be at risk of being scared, intimidated, and not calling for help when needed if they were not treated with dignity and respect. Facility took the following actions to correct the noncompliance on 6/29/24: Record review of a termination form dated 2/20/24 for CNA Z indicated that her last day worked was 2/20/24 and termination date was 2/20/24. Form indicated that this was an involuntary termination due to Code of Conduct Violation, Gross Misconduct, and Poor Job Performance and was signed by DON, Administrator and HR on 2/20/24. Record review of a facility in-service form dated 2/20/24 titled Abuse/Neglect; Elder Justice Act; Trauma; Alzheimer's/Dementia indicated that all staff were in-serviced on these topics on 2/20/24. Record review of personnel files for CNA H and CNA G indicated that they both received an in-service on Abuse and Neglect which included Recognizing, Reporting and Preventing Abuse, Managing Challenging Behaviors in Dementia, Dementia Care and Behavioral Challenges, Physical Abuse, Abuse and Neglect, and Trauma Informed Care on 6/29/24. Record review of a facility in-service indicated all staff were in-serviced on Abuse and Neglect which included Recognizing, Reporting and Preventing Abuse, Managing Challenging Behaviors in Dementia, Dementia Care and Behavioral Challenges, Physical Abuse, Abuse and Neglect, and Trauma Informed Care on 6/29/24. Record review of a facility policy titled Resident Rights - Dignity and Respect revised 8/2021 read .It is the policy of this facility that all residents be treated with kindness, dignity and respect . and .The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings .

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment that did not result in bodily injury within 24 hours for 1 of 17 residents (Resident #1) reviewed for abuse and neglect. The Administrator failed to report an allegation of neglect on 11/7/2023 when Resident #1 eloped from the secured unit out of his window, into the courtyard and broke out of the wooden fence. This failure could place residents at risk for harm and injury. Findings included: Record review of an Admission Record dated 8/19/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, depression, and anxiety disorder. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 9. He had potential indicators of psychosis with delusions (misconceptions or beliefs that are firmly held, contrary to reality). Record review of a care plan dated 9/19/2023 for Resident #1 indicated he had secure unit placement and was an elopement risk/wanderer related to dementia. History of dangerous walking, elopement attempts. Interventions included to document wandering behavior and attempted diversional interventions. Record review of a nurse progress note for Resident #1 dated 11/7/2023 at 2:30 PM by ADON D indicated, Spoke with desk at Dr. office at this time, updated on incident which occurred on today regarding elopement attempts. Stated she would forward the message to Dr and his nurse with priority for response. Awaiting return call at this time. Record review of an Incident Report for Resident #1 dated 11/7/2023 at 2:30 PM by ADON E indicated, Pt. noted not inside of room. Staff noted window unlocked and Pt. was not inside of unit. Staff went outside and noted Pt. behind storage building on outskirts of courtyard, during head-to-toe assessment/skin assessment. Pt noted with 0.5 cm x 0.5 cm S/T to right arm, scattered/multiple scratches to bilat upper and lower extremities. Resident description: Pt. states I just wanted to go outside so I unlocked my window and crawled out, I'm not hurt, it's just some little scratches. During an interview on 8/19/2024 at 11:26 AM, ADON E said she was responsible for the incident/accidents, changes in condition and 24-hour reports. She said Resident #1 was admitted to the secured unit when he arrived at the facility. She said on 11/7/2023, Resident #1 was in the secured unit when he broke out of his window in his room into the courtyard and got out of the fence. She said when he was found he had scratches on his arms and a skin tear. She said they found him back by some trees at the back of the facility behind the secured unit. She said he was immediately assessed; his family member was at the facility to visit but was not sure if the family member was present at the time of the elopement. She said he was found not far away from the facility and did not think the incident was a reportable event because he was still on the grounds. She said Resident #1 left the facility without staff knowing and was not sure if he had done that before. She said it was not left up to her to make the decision if the incident was reportable or not. She said the abuse coordinator who was the Administrator, and the DON would make that decision. During an interview on 8/19/2024 at 12:11 PM, the DON said Resident #1's family member was at the facility at the time of the incident on 11/7/2023. She said the family member of Resident #1 told the aides that he was in the bathroom and would not come out. She said that was when they discovered he was not in the room and said she was not gone for no more than 5 minutes. She said the staff in the secured unit had just seen Resident #1 in his room. She said Resident #1 broke out of the window in his room and kicked the door down in the courtyard. She said following the incident, the Maintenance Supervisor placed a bigger latch on the courtyard door. She said since he was not gone anytime, she did not report it. She said she investigated the incident, talked to staff, and said the staff told her they had just seen him prior to the incident. She said she in-serviced the staff on elopement. During a follow up interview on 8/19/2024 at 2:42 PM, the DON was questioned about how they determine when an incident should be reported to the state agency. She said it depended on the situation. She said she did a lot of the reporting to the state agency when she was on call, but they were mostly done by the Administrator. She said they followed their policies and incidents were situational. She said she could not give any specifics regarding incidents being situational. She said they did reach out to their Resource Leader who helped the facility with making decisions about reporting incidents. She said she did not consider a resident missing if they did not leave the premises and Resident #1 did not leave the premises. During an interview on 8/19/2024 at 2:52 PM, the Administrator said she was the abuse coordinator for the facility. She said she was notified on the day Resident #1 eloped from the facility on 11/7/2023. She said he had gotten out of the gate of the secured unit, exited the window and went through the gate. She said he was found next to a tree outside of the facility. She said the incident was not reported because he did not leave the premises. She said on admission to the facility, Resident #1 was confused but at the time of the incident on 11/7/2023 his thinking had improved. She said regarding reporting if someone was missing or not, the time frame would have to be about 10 minutes or so of not being aware of them missing. She said she did not think the incident needed to be reported. She said she did not consider him a missing resident. She said she and the DON on occasions reach out to their Resource Leader and they would let them know if the incident was reportable or not. During an interview on 8/19/2024 at 3:14 PM, the Resource Leader said the facility did not contact her on a regular basis about any issues because she visited the facility about once a week. She said she spoke to the DON and another Resource Leader about the incident on 11/7/2023 with Resident #1 and they looked at the PL 19-17 for guidance. She said Resident #1 did not leave the premises and according to their elopement policy, if a resident does not leave the premises, then they are considered missing, so the incident was not reported to the state agency. Record review of a facility policy titled Elopement/Unsafe Wandering revised 12/2023 indicated, .If is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. Elopement occurs when a resident leaves the facility premises without the facility's knowledge, authorization (i.e., an order for discharge, appointment, or leave of absence) and/or any necessary supervision to do so.10. The facility will notify the appropriate State Agency in accordance with state requirements. 11. Notification to the appropriate State Agency will be made: a. Within twenty-four (24) hours of the serious accident/incident . Record review of a Long Term Care Regulatory Provider Letter titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) dated July 10, 2019 indicated, .2.1 Incident that a NF Must Report to HHSC and the Time Frames for Reporting: A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: a missing resident. An incident that does not result in serious bodily injury and involves: a missing resident-Immediately, but not later than 24 hours after the incident occurs or is suspected . Record review of a facility policy titled Resident Rights-Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised 11/28/2017 indicated, .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property, are reported immediately but: Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: The State Survey Agency .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 5 errors out of 31 opportunities, resulting in an 16.13% percent medication error involving 1 of 5 residents reviewed for medication pass. (Resident #20) MA H failed to administer Protonix 40 mg delayed release (treats acid reflux), Metoprolol 25 mg extended release (for high blood pressure), Depakote 250 mg delayed release (to treat bipolar), Potassium 8 meq extended release (supplement) and Venlafaxine 225 mg extended release (for increased restlessness and irritability) medications as ordered that indicated do not crush. This failure could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life. Findings included: Record review of an Admission Record dated 10/17/2023 for Resident #20 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (loss of memory, language and problem solving), COPD (a group of lung diseases that cause breathing problems), depression, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), bipolar type (extreme mood swings), and unspecified convulsions (uncontrollable contractions of muscles) and atherosclerotic heart disease (buildup of fats and cholesterol in the arteries). Record review of an active physician order summary report dated 10/17/2023 for Resident #20 indicated he had medication orders for: pantoprazole 40 mg delayed release give one tablet by mouth one time a day with a start date of 6/9/2023. divalproex 250 mg delayed release give one tablet by mouth one time a day with a start date of 5/30/2023. metoprolol 25 mg extended release give one tablet by mouth one time a day for hypertension, do not crush, with a start date of 5/30/2023. potassium chloride 8 meq extended release, give one capsule by mouth one time a day, do not crush, with a start date of 1/4/2023. venlafaxine 225 mg extended release given one tablet by mouth one time a day, with a start date of 11/22/2022. Record review of a Quarterly MDS assessment dated [DATE] for Resident #20 indicated he did not have any impairment in thinking with a BIMS score of 14. Record review of a Swallowing Precautions note revised 7/20/2023 for Resident #20 indicated his diet was regular texture with thin liquids, should receive a Mighty Shake on all meal trays. There was no indication that his medications were to be crushed. Record review of a care plan for Resident #20 dated 11/22/2022 indicated he had the potential for mood problem related to admission, disease process and medication side effects with interventions to administer medications as ordered, monitor/document for side effects and effectiveness. During an observation on 10/17/2023 at 7:49 AM, MA H administered medications to Resident #20. Prior to administering medications to Resident #20, she checked his blood pressure which was in parameters. She sanitized and placed gloves on her hands and opened the capsule of protonix 40 mg delayed release and emptied the contents into a medication cup along with medications that indicated do not crush on the blister pack which included: metoprolol 25 mg extended release (do not crush), Depakote 250 mg delayed release (do not crush or chew), potassium 8 meq extended release (do not crush) and venlafaxine 225 mg extended release. MA H placed levothyroxine 100 mcg 1 tablet, amlodipine 10 mg 1 tablet, Buspar 7.5 mg 1 tablet, docusate 100 mg 1 tablet, furosemide 20 mg 1 tablet, gabapentin 100 mg 1 tablet, sennasides 8.6 mg 1 tablet, vitamin d3 125 mcg 1 tablet, Zyrtec 10 mg 1 tablet, crushed the medications and mixed them with magic shake (a pudding texture that contains extra calories) and administered them to Resident #20. During an interview on 10/18/2023 at 8:30 AM, MA H said she had been employed at the facility for 10 months on the 6am-2pm shift and worked all over the facility and was not assigned to a specific hall. She said she had been a medication aide for [AGE] years. She said Resident # 20 had been receiving all of his medications crushed. She said all of his medications were caplets except for his protonix and it was a capsule. She said on yesterday 10/17/2023 she opened the capsule of protonix and poured it into the plastic medicine cup to be administered along with all of the other medications that were scheduled and she crushed all of them and mixed it with magic shake. She said Resident #20 had swallowing precautions and there was a sheet in the binder that was on the cart that indicated his medications needed to be crushed. She said therapy told her that his medications needed to be crushed. She said all staff had been crushing his medications when they administered to him. She said the hall that Resident #20 resided on was a new hall to her. She said she always made sure to double check the orders and the medication to be sure it was correct. She said she also used the binder that indicated if residents required their medications to be crushed or not. She said a resident could be at risk of getting an instant effect from the medications if they were delayed release or extended release. Record review of a Skills Checklist-Med Pass dated 1/4/2023 for MA H indicated she demonstrated competency and followed the six rights of medication administration. During an interview on 10/18/2023 at 2:50 PM, ADON N said she had been employed at the facility for over a year. She said pharmacy conducted check offs with nursing and medication aides when they visited the facility monthly. She said staff should be able to tell if a resident had medications that could be crushed or not because it would tell them on the MAR. She said she guessed it depended on the medications and what could happen if a medicine was crushed that should not have been. She said the pharmacy consultant visited the facility in September but did not provide a copy of the audit that was conducted at that time. During an interview on10/18/2023 at 3:05 PM, the DON said staff should be utilizing the ten medication rights. She said the DON, pharmacy consultant, and ADON's observed staff with medication pass often. She said with Resident #20 they completed a medication error report following the incident on 10/17/2023 after MA H crushed his medications that indicated to not crush. She said they contacted the physician and placed the resident on 72-hour checks and the physician did not want any labs ordered at this time. She said the pharmacy consultant would be at the facility later this week and would conduct a medication pass observation with MA H. She said staff should review the medications and the orders one by one before administering. She said MA H received verbal instruction on 10/16/2023. She said MA H had been assigned more online training on medication administration. She said the risk depended on the medications and what could happen if a medicine was crushed that should not have been. Record review of a facility policy titled Oral Medication Administration undated indicated, .To administer oral medications in a safe, accurate, and effective manner. Special Considerations: 1. Refer to crushing guidelines prior to crushing any medication for assurance that it can be pulverized. 3. For solid medications: b) Crush medications, if indicated by prescriber's order for this resident, only after checking the Medication Crushing Guidelines . Record review of a facility policy titled Medication Errors and Adverse Reactions with a revision dated of 1/2022 indicated, .It is the policy of this facility that medication errors and adverse drug reactions must be reported to the resident's attending physician. Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: The prescriber's order, Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological .

46436 Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 staff (CNA D, NA M and ADON N) and 3 of 8 residents (Resident #57, Resident #12, and Resident #17) reviewed for infection control. CNA D did not wash or sanitize her hands when changing gloves while performing incontinent care to Resident #57. ADON did not wash or sanitize her hands when changing gloves while performing incontinent care to Resident #12. NA M wiped Resident #12, a female resident from back to front while performing incontinent care. The facility failed to ensure the urinary catheter bag for Resident #17 did not touch the floor. These failures could place residents at risk of exposure to communicable diseases and infections. Findings Included: 1. Record review of facility face sheet dated 10/17/2023 indicated Resident #57 was an [AGE] year-old female readmitted to the facility on [DATE] for diagnosis of heart disease. Record review of quarterly MDS dated [DATE] indicated Resident #57 had a BIMS of 13 indicating intact cognition and required total dependence in toileting. Record review of comprehensive care plan dated 10/11/2023 indicated Resident #57 had bowel and bladder incontinence and to provide pericare after each incontinent episode. During an observation of incontinent care on 10/17/2023 at 12:25 pm NA B and CNA D washed their hands and applied gloves. CNA D opened and pulled down Resident #57's soiled brief and provided pericare using wipes. NA B turned Resident #57 to her right side and CNA D cleaned her buttocks using wipes and removed soiled brief. CNA D removed her soiled glove from her right hand and applied a new glove without hand hygiene. CNA D used her right gloved hand to apply a skin barrier cream to Resident #57. CNA D removed both gloves and sanitized her hands. NA B applied a new brief, removed her gloves, and sanitized her hands. During an interview on 10/17/2023 at 12:30 pm CNA D stated she should have removed both gloves when going from dirty to clean, sanitized her hands, and then reapplied gloves. She stated she changed only the right glove because she did not have enough gloves on hand. She stated she had been trained on incontinent care and maintaining infection control including hand washing and changing gloves. She stated by not following infection control measures could cause a resident to get sick. During an interview on 10/17/2023 at 12:40 pm the treatment nurse stated she was responsible for CNA competency and training. She stated CNA D had been properly trained on infection control and incontinent care. She stated she would begin retraining staff on infection control measures. She stated by not following proper infection control measures could cause a resident to get an infection. Record review of certificate of Achievement dated 10/10/2023 for NA B indicated she had completed the NATCEP (Nurse Aide Training and Competency Evaluation Program) and met all criteria for clinical competency skills checklist. Record review of CNA competency skills checklist dated 06/01/2023 indicated CNA D had met criteria for incontinent care and hand hygiene. 2. Record review of an Admission Record dated 10/17/2023 for Resident #12 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (loss of memory, language and problem solving), alcoholic cirrhosis of liver (liver disease that causes the liver to become stiff, swollen and unable to do its job), bipolar (extreme mood swings), and Alzheimer's disease (a progressive disease that leads to memory loss). Record review of a Quarterly MDS Assessment for Resident #12 dated 7/21/2023 indicated she had severe impairment in thinking with a BIMS score of 1. She required extensive assistance with ADL's with two person assist. She was always incontinent of bowel and bladder. Record review of a care plan for Resident #12 with a revision date of 3/31/2016 indicated she had bowel/bladder incontinence with impaired mobility that included interventions to check as required for incontinence. Wash, rinse, and dry perineum. During an observation on 10/16/2023 at 11:50 AM in the Room of Resident #12, ADON L and NA M were present to provide incontinent care. Resident #12 was sitting up on the side of the bed being assisted by NA M who had visible feces noted on the draw sheet and her brief. NA M sanitized her hands and applied gloves. ADON L applied gloves to her hands without washing or sanitizing them. Resident #12 was positioned in bed and her brief was pulled down between her legs. ADON L removed wipes from the container and wiped Resident #12's perineal area from front to back using multiple wipes and placed them in the trash. Resident #12 was rolled onto her right side by NA M. ADON L removed the soiled brief and placed it in the trash. ADON L placed her gloves in the trash and put on clean gloves without washing or sanitizing her hands. NA M was given wipes by ADON L and NA M wiped Resident #12's rectal area from back to front two times. NA M placed the wipes in the trash along with her gloves and sanitized her hands. NA M applied clean gloves to her hands. ADON L removed the draw sheet and linens from the bed and placed them in a plastic bag. ADON L placed a clean brief underneath Resident #12's buttocks and resident was repositioned and the brief secured. ADON L removed her gloves and placed them in the trash and washed her hands. ADON L placed clean gloves on her hands and assisted NA M with transferring Resident #12 from her bed to the wheelchair. Both removed gloves and placed them in the trash. During an interview on 10/16/2023 at 12:05 PM, NA M said she had been employed at the facility since February 2023. She said she was a nurse aide in training and had completed all of the required hours but was waiting to schedule to take her certification test. She said during the incontinent care provided to Resident #12 she should have wiped her from front to back and not from back to front. She said she received training and had been checked off multiple times by staff in the facility. She said residents could be at risk for UTI's or yeast infection if staff did not wipe properly. Record review of a Skills Checklist-Incontinence Care dated 3/3/2023 for NA M indicated she demonstrated competency with incontinent care. During an interview on 10/16/2023 at 12:15 PM, ADON L said she had been employed at the facility for 2 years. She said during the incontinent care provided to Resident #12 she should have sanitized her hands more with every glove change and she did not. She said she helped to oversee the nurse aides in training along with the DON and Administrative nurses. She said residents could be at risk for UTI's or could get septic if staff did not wash or sanitize their hand with gloves changes and if staff did not wipe female residents from front to back with incontinent care. Record review of a Skills Checklist-Incontinence Care dated 2/16/2023 for ADON [NAME] indicated she demonstrated competency with incontinent care. 3. Record review of an Admission Record dated 10/17/2023 for Resident #17 indicated she was [AGE] years old with diagnoses of major depressive disorder (persistent feeling of sadness and loss of interest) , obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract), COPD (a group of lung disease that affect breathing) and acute diastolic congestive heart failure (heart's inability to pump effectively). Record review of a physician order summary report dated 10/17/2023 for Resident #17 indicated an order with a start date of 5/13/2021 to secure catheter with a leg strap/leg band to minimize catheter related injury and accidental removal or obstruction or urine flow. Record review of a Quarterly MDS assessment dated [DATE] for Resident #17 indicated she did not have any impairment in thinking with a BIMS score of 15. She required extensive assistance with ADL's with one-person physical assist. She had an indwelling catheter and an ostomy. Record review of a care plan with a revision date of 8/24/2023 indicated she had an indwelling foley catheter related to obstructive reflux uropathy/sacral wound with interventions that included to secure catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal. During an observation and interview on 10/16/23 at 9:53 AM, Resident #17 was lying in bed. She said she had been at the facility for 4 years. She said she has had the foley catheter for a long time. Her foley catheter drainage bag was noted lying on the floor with a privacy bag covering it. During an observation and interview on 10/16/23 at 3:19 PM, Resident #17's foley catheter drainage was lying on the floor with a privacy bag covering it. Resident #17 said that the staff do not change the catheter as often as they did before because it was too hard to put back in last time. She said she was aware of the foley drainage bag being on the floor because she told the staff to put it there so it could drain. She said she did not want the bag sitting on the bed because it would back up and not drain properly. During an observation on 10/17/2023 at 3:14 PM, Resident #17's foley catheter drainage bag was on the floor. During an interview on 10/18/23 at 2:50 PM, ADON N said she had been employed at the facility for over a year. She along with the ADON and DON they were responsible for conducting some of the check offs with the nurses and aides. She said they also conducted random checks with staff on hand washing and hand hygiene. She said staff should be washing and sanitizing their hands with glove changes. She said when incontinent care was provided to female residents, staff should be wiping them from front to back. She said foley catheters should be positioned below the bladder and not on the floor. She said all had a risk for infections. During an interview on 10/18/2023 at 3:05 PM, the DON said she had several people that checked off staff in the facility on infection control with hand washing/hygiene that included the ADON, DON, MDS and the treatment nurse. She said staff were supposed to wash or sanitize their hands between glove changes. She said foley catheters should not be on the floor. She said residents could be at risk of infection with all. Record review of a facility policy titled Incontinence Care undated indicated .It is the policy of this facility to provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence. Staff providing incontinence care will do so while maintaining the dignity of the residents and providing care in a respectful manner. 1. Staff will wash their hands and don a clean pair of gloves. 4. Wash peri-area from front to back strokes, rinse, pat dry. 6. Remove gloves and wash hands . Record review of facility policy and procedure titled Hand Hygiene dated 10/2022 indicated, .2. use an alcohol-based hand rub, soap, and water for the following situations: m. after removing gloves . Record review of a facility policy titled Catheter Drainage Bag with a revision date of 1/2022 indicated, .It is the policy of the facility to maintain continuously closed urinary drainage system whenever possible and provide a receptacle for urine and to accurately measure output of urine. 12. Position the drainage bag below the level of the resident's bladder.

Based on observations, interviews, and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 4 of 24 residents (Residents #19, #37, #51, and #65) reviewed for call lights. The facility failed to ensure Residents #19, #37, #51, and #65's emergency call light located in the bathroom would reach the floor. The call light cord for Residents #19, #37, #51, and #65 was wrapped around the grab bar. This could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs. Findings: Record review of facility face sheet dated 10/17/2023 indicated Resident #19 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of heart failure. Record review of quarterly MDS dated [DATE] indicated Resident #19 had a BIMS of 03 indicating severely impaired cognition and was dependent in toileting. Record review of comprehensive care plan dated 10/11/2023 indicated Resident #19 was at risk for falls related to impulsiveness and cognition and to be sure the call light was within reach. Record review of facility face sheet dated 10/17/2023 indicated Resident #37 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of altered mental state. Record review of quarterly MDS dated [DATE] indicated Resident #37 had a BIMS of 09 indicating moderately impaired cognition and required maximum assist with toilet use. Record review of comprehensive care plan dated 09/22/2023 indicated Resident #37 was at risk for falls and required safe environment by ensuring the call light was working and reachable and had ADL self-care deficit and to provide extensive assistance to use toilet. Record review of facility face sheet dated 10/17/2023 indicated Resident #51 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's (impaired memory). Record review of quarterly MDS dated [DATE] indicated Resident #51 had a BIMS of 02 indicating severely impaired cognition and required extensive assistance with toileting. Record review of comprehensive care plan dated 9/28/2023 indicated Resident #51 had a risk for falls and needed a safe environment by making sure call light was working and reachable and had ADL self-care deficit and required supervision and assistance with toileting. Record review of facility face sheet dated 10/17/2023 indicated Resident #65 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's (impaired memory). Record review of quarterly MDS dated [DATE] indicated Resident #65 had a BIMS of 03 indicating severely impaired cognition and required extensive assistance with toileting. Record review of comprehensive care plan dated 08/25/2023 indicated Resident #65 had a risk for falls and needed a safe environment with a working and reachable call light and had ADL self-care deficit and to provide supervision and assistance with toileting. During an observation on 10/16/23 at 9:50 am Resident #54 was present in her room and the call light located in the bathroom was wrapped around the grab bar. The call light was pulled from the bottom of the cord and did not activate. During an interview on 10/16/2023 at 9:52 am Resident #54 stated she used the bathroom at times but had not had to use the call light that she could recall. During an observation on 10/16/23 at 10:08 am Resident #51 and Resident #65 resided in the room together and the call light located in the bathroom was wrapped around the grab bar. The call light was pulled from the bottom of the cord and did not activate. Neither resident was in the room during the observation. During an observation on 10/16/23 at 10:15 am Resident #19 was present and sitting up in her wheelchair propelling with her feet. The call light located in the bathroom was wrapped around the grab bar. The call light was pulled from the bottom of the cord and did not activate. During an interview on 10/16/2023 at 10:16 am Resident #19 stated she used toilet in the bathroom but could not recall if she had to ever use the call light. During an interview on 10/16/23 at 12:20 pm family member of Resident #51 stated that both her family member and the roommate both used their bathroom at times. During an observation on 10/16/2023 at 3:50 pm the bathroom call light for Resident's #19, #37, #51 and #65 remained wrapped around grab bar and call lights pulled again and did not activate. During an interview on 10/16/23 at 4:18 pm NA A stated call lights should be in reach for all residents and the cord should not be wrapped around the grab bar because if a resident fell , they could not reach it or it would not go off. She stated if the resident were to fall and be hurt, they would not be able to tell us. She stated that Resident's #19, #37, #51 and #65 all used their bathrooms with assistance and would need to have their call light accessible. During an interview on 10/17/23 at 8:12 am NA B stated the nurse aides were responsible for making sure all call lights were accessible by the resident including the call lights in the bathroom. She stated the call light should not be wrapped around the grab bar because the string would not pull to activate the alarm. She stated if the alarm could not be activated the resident would not get care if they needed it. During an interview on 10/17/23 at 8:20 am LVN C stated she had been a nurse at the facility for 9 months. She stated all staff were responsible for making sure call lights were always accessible. She stated call lights should be checked with each round and the call light cord should not be wrapped around the grab bar. She stated the light would not activate if it was wrapped and the resident would not be able to call for help or care could be delayed. During an interview on 10/17/2023 at 3:35 pm the maintenance supervisor stated he was also an LVN and helped with the nurse aide training program and checkoffs. He stated part of the training included proper placement of call lights in the room and bathroom. He stated the call light in the bathroom should be freely hanging on not wrapped around the grab bar. He stated if the cord was wrapped it could affect the light being activated and cause a delay in resident care. During an interview on 10/18/23 at 4:35 pm the DON stated everyone was responsible to check call lights and staff would be retrained on call lights including ensuring the call light cord in the bathroom was not wrapped around the grab bar. She stated the call light should be in reach so the resident could call for help. During an interview on 10/18/23 at 4:35 pm the administrator stated all staff were responsible for making sure call lights were accessible and the call lights were to be checked every morning on rounds. She stated the maintenance supervisor checked call lights monthly to ensure they were working properly. She stated that a delay in care could occur if a resident could not reach their call light and expected all staff to check the call lights and especially the bathroom lights to ensure they were accessible and not wrapped around the grab bar. Record review of facility policy and procedure titled Call Light/Bell dated 5/2007 indicated, .place the call device within resident's reach .

Based on observation, interview, and record review, the facility did not ensure adequate supervision was provided to prevent falls for 1 of 1 resident reviewed for accidents. (Resident #1) The facility did not provide two-person assistance to Resident #1 when the resident was being repositioned during incontinent care as required by the resident's care plan and MDS assessment. This resulted in Resident #1 falling from bed, sustaining multiple ankle fractures to her left and right ankles, and multiple fractures to her left leg. Resident #1 was sent to a trauma center and her left leg was amputated due to the extent of her injuries. Resident #1 discharged from the trauma center on hospice services with poor prognosis. An Immediate Jeopardy (IJ) situation was identified 11/6/20. While the IJ was removed on 11/9/20 at 11:00 a.m., the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for injury or death. Findings included: Physician orders [REDACTED].#1 was a [AGE] year-old female who admitted to the facility on [DATE]. Her most current readmitted was 6/29/2020. Resident #1's [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #1s cognition was intact. She required extensive assistance of two staff for bed mobility and toileting. She was always incontinent of bowel and bladder. A Kardex (a medical information system used by CNA's which shows a quick summary of individual resident needs) report dated 10/7/20 through 10/29/20 indicated Resident #1 required extensive assistance of two staff for bed mobility. A weight record dated 10/9/2020 indicated Resident #1 weighed 365.8 pounds A care plan revised 7/2/2020 indicated Resident #1 was at risk for falls related to limited mobility, poor balance, and weakness. Interventions included avoid rearranging furniture, keep the resident's bed in the lowest position, be sure the call light was within reach, and encourage the resident to use it for assistance as needed. A care plan dated 7/2/2020 indicated Resident #1 was totally dependent on two staff for transfers with the use of a Hoyer lift. A care plan dated 7/2/2020 indicated Resident #1 was at risk for ADL self-care performance deficit related to weakness, poor balance, and poor endurance related to shortness of breath and obesity. Interventions included: Bed mobility: required extensive assistance one to two staff participation to reposition and turn in bed. A care plan dated 10/6/2020 indicated Resident #1 required extensive assistance of two staff for bed mobility. The care plan did not indicate Resident #1 refused any type of care. A late entry nursing note dated 10/26/20 at 5:52 p.m. indicated Resident #1 was lying in bed during incontinent care when she slid to the floor. The note indicated Resident #1's back was supported by the wall and the residents left leg was beneath the resident. An open area was noted to the resident's left inner thigh with a large amount of blood on the floor. Resident #1 was alert and talked with staff. She had some pain at that time. Resident #1 was assessed, pressure was applied to the open area with towels, and 911 was called. A nursing note dated 10/26/20 at 5:06 p.m. indicated Resident #1's husband was notified the resident had a fall and was being transferred to the hospital. An incident report dated 10/26/2020 indicated Resident #1 was in bed when CNA F provided incontinent care to the resident. It was noted CNA F positioned her pad under the resident while she turned the resident to her left side. It was noted, while the CNA was trying to make sure the pad was in the right spot, Resident #1 started to slide off the side of the bed. The incident report indicated the resident landed on the floor before CNA F could stop the resident from sliding off the bedside. It was noted the CNA yelled out for help. The resident was assessed, EMS was called, and four EMS staff placed the resident on an emergency blanket for transfers and was taken to the hospital. The incident report indicated the resident was alert and oriented and no predisposing physiological or situational factors were identified. A nursing note dated 10/26/20 at 10:12 p.m. indicated Resident #1 was admitted to the trauma center. A care plan dated 10/26/2020 (date of the incident) indicated Resident #1 had an actual witnessed fall with major injury related to poor balance, inability to identify bed boundaries, and poor capability of maintaining self-balance. The care plan indicated Resident #1 sustained fracture of ankle and a left femur fracture. The care plan indicated the resident was sent to the hospital. A care plan revised 10/26/2020 (date of the incident) indicated Resident #1 refused to have 2 caregivers to provide incontinent care. Resident #1's care plan did not include any indication of the resident refusing care prior to the update on 10/26/20 During a telephone interview on 11/5/2020 at 8:10 p.m., Resident #1, who was still in the trauma center, said there was only one CNA (she could not remember her name) who changed her the night of her fall. She said the CNA rolled her over and the resident fell off the bed between the bed and the wall. Resident #1 said she never objected to having 2 people to change her, but there was usually only one available. She said the aide who changed her the night of the fall got in trouble, but it was not her fault. She said this was not the first time this happened. She said there were 2-3 other times when she almost fell out of bed when only one aide was changing her. She said she tried to warn the wound care nurse of this many times. She said the DON knew about all of this, and nothing was ever done. She said she had bed rails at the top of her bed, but not the bottom of her bed. She said had asked for bed rails on the bottom many times, and if she had them, she would not have fallen. She said her bed was also too small, and she had asked about getting a larger bed, but nothing was ever done. During an interview on 11/6/2020 at 2:03 p.m., CNA F said she provided incontinent care to Resident #1 on 10/26/20. She said she had the bed in the highest position when providing incontinent care for Resident #1, so the CNA would not hurt her back. The CNA said she was tucking the incontinent pad beneath Resident #1 as she turned the resident to her left side, away from her. She said she did not know if she pushed too hard. She said the resident slid off the bed and landed on her right side. She said the resident's shoulder did not hit the ground and both the resident's legs were out in front of her. She said it looked like the resident's right foot was bent bad. She said after Resident #1 fell , she asked CNA F to move the bed. CNA F said she moved the bed and went to go get help. CNA F said she had never heard Resident #1 say she only wanted 1 person in the room to care for her. She said the resident was on a bariatric bed, but she felt it was too small for the resident to roll over on while being cleaned. During an interview on 11/6/2020 at 11:35 a.m., RN D said the incident involving Resident #1 falling from the bed during incontinent care on 10/26/20 occurred sometime between 4:15 and 4:30 p.m. She said she heard someone say Resident #1 was on the floor. She said when she entered the room, she could not see the resident at first. She said she walked over to the resident's bed and found the resident on the floor between the bed and the wall. She said the resident was sitting with her back against the wall. RN D said CNA F was in the room. RN D said Resident #1 was alert the whole time. During an interview on 11/6/2020 at 11:25 a.m., LVN A said she heard someone say Resident #1 had rolled out of bed and went down to the room. Said she could not remember which CNA was in the room. She said she did not go into the room as she had a fractured ankle and was using a wheelchair. Said she did call the resident's husband and notified him of the fall as well as the transfer to the hospital. She said it was hard to assess the resident's injuries at that time. She said she could see a lot of blood, which appeared to be from her abdomen, but it was actually from her right leg underneath her. She said Resident #1 had blood on her gown. Said Resident #1 was alert and oriented x 4, usually required 1-2 person assist. During a telephone interview on 11/6/2020 at 11:50 a.m., LVN B said she was on break when the incident involving Resident #1 happened on 10/26/20. LVN B said when she got back, the nurses were already in the room. LVN B said when she provided incontinent care to Resident #1, she had a CNA in the room with her, but some CNAs do it by themselves. LVN B said Resident #1 was on a bariatric bed with an air mattress. She said the resident had side rails at the top of the bed. She said she did not see the extent of the resident's injuries due to a large amount of blood and towels covering the resident's leg. She said the Administrator and DON were also in the room. During a telephone interview on 11/6/2020 at 12:01 p.m., LVN E said she had just returned from break on 10/26/20 when she learned of the incident involving Resident #1. She said she was called into Resident #1's room and the resident was lying on the floor on the left side of the bed with her back against the wall. She said the incontinent pad was lying on the bed. LVN E said the resident's left leg was underneath her and there was a lot of blood. She was not aware of any previous falls for Resident #1. She said the resident needed 2 people to assist her with incontinent care but preferred 1 due to a dignity issue. She said some staff did 2 persons assist with Resident #1, and some did 1 person assist. She said Resident #1 would direct staff how to care for her. LVN E said Resident #1 was on a bariatric bed with an air mattress. During an interview on 11/6/2020 at 2:51 p.m. the DON said she was in Resident #1's room after the incident happened on 10/26/20. She said Resident #1's left leg was underneath her. The DON said she thought the resident was bleeding from the abdomen, but then discovered it was from the resident's leg. She said Resident #1 was alert and oriented and told the staff she slipped off her bed. During an interview on 11/6/2020 at 12:01 p.m., the administrator said a CNA came into her office on 10/26/20 and said Resident #1 rolled off the bed. The administrator said when she went in the room, she could not see the residents' legs, because they were underneath her. She said blood was coming out of the resident and she could not figure out where it was coming from. The administrator said Resident #1 said she slipped off the side of the bed. The administrator said she never saw the resident's wound. The administrator said when EMS arrived, they had to pull her forward to get her off her legs. The administrator said Resident #1 had some syncopal episodes (episodes of [MEDICAL CONDITION]) and was sent to the hospital for this. The administrator was not sure if this is what happened or not. The administrator said Resident #1 was able to pull and hold herself over. She said Resident #1 was alert and oriented and told them she rolled out of bed. The administrator said it was care planned for 1 person assist. She said the facility was not aware of the extent of injuries until they heard from the hospital 2 days later. An Emergency Physician Documentation Record dated 10/26/20 indicated Resident #1 was admitted to the hospital at 5:21 p.m. due to a fall injury. The resident had a displaced oblique [MEDICAL CONDITION] femur. The resident was given 1 gram of [MEDICATION NAME] (an antibiotic), 2 grams of [MEDICATION NAME] (an antibiotic), and 1 unit of packed red blood cells. X-ray reports indicated Resident #1 sustained a distal left tibia and left fibula fracture with soft tissue swelling and soft tissue gas. The resident sustained [REDACTED]. The resident sustained [REDACTED]. Physician documentation indicated Resident #1 had a 1-foot laceration to her left calf and a 4-inch laceration to her left ankle. The physician noted This was the worst open fracture seen in my entire career of the lower extremity on the left side. The physician noted he was told Resident #1 had feces on her, making this a very serious open wound infection. The note indicated the physician spoke with an orthopedic doctor who said Resident #1 needed a higher level of care. Resident #1 was then transported to a trauma center in critical condition. A discharge summary from the trauma center dated 11/11/20 indicated upon Resident #1's arrival to the trauma center, the resident was found to have bilateral lower extremity fractures with a significant soft tissue/open fracture to the left lower extremity. Resident #1 was prepared for an above knee amputation (AKA). She became unstable in the operating room, and surgery was aborted. Resident #1 was on multiple pressors (drugs used to treat hypertension resulting from cardiogenic shock which sometimes occurs during surgical anesthesia). Resident #1 required aggressive resuscitation and her renal function improved, and she was stable enough to return to the operating room to complete the AKA. Resident #1 was discharged post-operation on hospice services and a poor long-term prognosis. During a telephone interview on 11/4/20 at 7:22 p.m., a complainant said Resident #1 went to the hospital after falling out of bed when one CNA changed the resident in her room. The complainant said the resident had requested numerous times for the staff to use two people when changing her. The complainant said after Resident #1's fall, the resident was sent to the hospital and then to a trauma center. The complainant said the resident broke her left leg in 2 places above and below the knee and broke her right ankle. The complainant said Resident #1 lost over 5 pints of blood and her left leg had to be amputated. The administrator was notified on 11/6/20 at 5:30 p.m. an immediate jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator. The facility's plan of removal was accepted on 11/7/2020 at 8:10 p.m. and indicated the following: Immediate Action Taken: 1. The Medical Director was notified of IJ immediately. 2. There are two other bariatric residents. One is independent with ADLs and one is 2 person assist with bed mobility. Care plans and MDS' have been reviewed/updated for all facility residents. Nursing staff on duty in-serviced immediately on both resident's bed mobility status and assistance needed, by DON and or ADON. Nursing staff in-serviced on all resident bed mobility and assistance needed by DON and or ADON. To be completed by 11-7-2020. All other nursing staff to be in-serviced by DON and or ADON prior to start of their shift. No nursing employee to have direct resident contact until education with return demonstration completed. 3. The DON is overseeing the review/update of MDS' and Care Plans of all facility residents identified as needing assistance with bed mobility that have been identified by MDS and therapy screens. To be completed 11-07-2020. 4. Physical/Occupational Therapy have been assigned to screen all residents for assistance with bed mobility. To be completed 11-7-2020. 5. Education with nursing staff on duty to notify DON/Administrator of unusual occurrences related to bed mobility, i.e. assisted falls completed by DON and or ADON. Education initiated on 11/6/20. To be completed by 11-07-2020. All nursing employees to be in-serviced prior to start of their shift. No nursing employee to have direct contact until education with return demonstrated completed. 6. Education with return demonstration with nursing staff on providing assistance per MDS/Plan of Care with Bed Mobility completed by DON and or ADON. Return demonstrations initiated on 11/6/20. To be completed by 11-07-2020. All nursing employees to be in-serviced prior to start of their shift. No nursing employee to have direct resident contact until education with return demonstration completed. 7. QAPI Committee to review IJ Template/Plan of Removal weekly to ensure ongoing compliance. On 11/9/2020, the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Chart reviews were done on the following Residents: #2, #3, #4, #5, #6, #7, #8, and #9 and #10. All therapy screens were completed on all residents for their level of required assistance, including bed mobility. The level of assistance needed with bed mobility was updates on the MDS assessments and care plans. In-service sign in sheets dated 11/6/20 through 11/7/20 indicated training provided to staff included: 1. Bed mobility/status assistance with return demonstration 2. Fall prevention in bed, bed mobility, and all assisted falls to be reported to DON and Executive Director as well as all unusual occurrences. 3. ADL performance for bariatric residents Sign in sheets were all reviewed with no findings. On 11/9/2020 10:32 a.m. and 11:30 a.m., 7 CNAs, 3 CMAs, 5 LVNs, 1 ADON, and the admissions director were interviewed. All staff were able to answer the following questions: the main purpose of the training they received, how to check the bed mobility status of residents, what to do if the kardex required 2 persons assist and they are in the room alone, and how to pull a total assist resident up in bed. On 11/9/20 at 11:00 a.m. the administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment was free from accidents hazards for 1 of 2 residents reviewed for accidents. (Resident #1) Resident #1 was transferred by a Hoyer lift that was not maintained according to the manufacturer's recommendations and sustained a head injury requiring 14 sutures. This failure may have contributed to Resident #1's head injury. This failure could place 5 residents requiring Hoyer lift transfers at risk for injury. Findings included: A physician order [REDACTED].#1 was a [AGE] year old female, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1 had an order for [REDACTED]. A Weight Summary report dated 6/18/15 indicated Resident #1 weighed 453 pounds. An MDS dated [DATE] indicated Resident #1's cognitive status was undetermined. Her bed mobility and transfer assistance was extensive with the assistance of two people. A care plan dated 6/12/15 indicated Resident #1 had problems with ADL care performance due to poor balance, weakness, and obesity. The plan indicated Resident #1 required Hoyer lift transfer. A Provider Investigation Report dated 6/26/15 indicated on 6/25/15 Resident #1 was transferred from her bed to the wheelchair by Hoyer lift. The lift tilted causing the lift bar to strike Resident #1 in the forehead. Two CNAs and an occupational therapist assistant assisted with the transfer. The report indicated Resident #1 was observed with 2 small skin tears (right wrist 0.1x 0.3x 0.1 and left forearm 0.2x 0.6 x 0.1) and a laceration to her forehead (5/3x0.2x0.3). Pressure and ice were applied to the laceration and 911 was called. Resident #1 returned from the hospital with 14 sutures in the forehead. The CNAs, and charge nurses were in-serviced on the use of the lift and transfers. The lift was immediately taken out of use and was inspected according to manufacturer recommendations for use. An incident report dated 6/26/15 indicated Resident #1's CT scan of the head indicated superior right forehead contusion and adjacent anterior right scalp laceration. The indicated there was no underlying displaced fracture. The resident returned to the facility with 14 sutures to the scalp with an order to remove them in 7-10 days and Keflex 500 mg (antibiotic) every 6 hours for three days. During an interview and observation on 7/6/15 at 2:05 p.m., Resident #1 was in a bariatric bed. She was noted with a large fading bruise on the right side of her forehead with tape across an area about an inch and a half long. She had multiple bruises fading and bright red on both arms. Resident #1 said she remembered the incident and it was very traumatic for her. She said she saw the bar of the Hoyer lift coming towards her head but could do nothing to stop it. She said she tried to block the blow by throwing her hands up but was unsuccessful. She said after it hit her, her head hurt but there was so much blood all she could think was she was going to bleed to death because she was on blood thinners. Resident #1 said she was afraid to get out of bed with the lift and had not seen the lift they transferred her with on 6/25/15 but was still afraid. During an interview on 7/6/15 at 1:50 p.m., CNA A said on 6/25/15 three staff assisted with transfer of Resident #1. She said she held onto Resident #1's feet and worked the lift controls. She said they transferred the resident from the bed to the chair and the lift tilted. She said it pinned her on top of the resident and she was afraid she was going to fall on the resident. CNA A said the bar on the lift hit the resident in the forehead. During an interview on 7/6/15 at 2:35 p.m., CNA B said on 6/25/15 he, CNA A and the therapist transferred Resident #1 out of bed and into her chair. He said they locked the wheels of the lift, got her out of bed, unlocked the wheels and were transferring her to the chair. He said when they had her over the chair the lift tilted to the left. He said the lift pinned CNA A against the wall and the lift bar hit Resident #1 in the head. He said he and the therapist held on to Resident #1 and removed the lift from CNA A. He said the only thing he remembered was the lift rolled a little. CNA B said he always locked the wheels of the lift, he was taught to do it that way. During an interview on 7/6/15 at 2:47 p.m., the therapy director said she was in the room on the day of the incident with Resident #1. She said she was at the back of the lift with CNA B and helped to guide the resident. She said she thought the lift was locked when they picked the resident up from the bed but could not be sure. She said they had the resident over the chair and had just pulled her up and the lift tilted. She said she did not know why the lift tilted. During an observation of a transfer on 7/6/15 at 2:55 p.m. CNA B, CNA C and CNA D transferred Resident #2. When they moved the resident form the chair to the bed, CNA B reminded CNA C to lock the wheels of the lift. When the resident was up in the air and ready to be moved to the bed they unlocked the wheels. During an interview on 7/6/15 at 3:55 p.m., the ADON said she was involved in the training of the staff on the Hoyer lift transfers. She said she did not know if the lift was supposed to be locked or not during transfers. During an interview on 7/6/15 at 2:00 p.m., the administrator said the maintenance supervisor did not have any logs for checking the Hoyer lifts. She said after the incident they had obtained a bariatric lift to be used on Resident #1. During an interview on 7/6/15 at 4:30 p.m., the maintenance supervisor said he did not have a log for checking the lifts; he would occasionally look at them. He said he could not remember the last time he had checked the Invacare 600 pound lift used to transfer Resident #1. The maintenance supervisor said after the incident on 6/25/15 he did not check the lift to make sure it was working properly. The Policy and Procedures for Mechanical Lift Transfers dated 5/2007 indicated always be aware of and follow the manufacturer's recommendations for the particular lift being used. An instruction manual for the Invacare 600 pound lift printed from the internet on 6/25/15 indicated the lift had 26 features that should be checked monthly according to the Maintenance Safety Inspection Checklist. A section titled Safety indicated Warning maintenance must be performed only by qualified personnel. A section titled Transfer the patient indicated Invacare does not recommend locking of the rear casters (wheels) of the patient lift when lifting and individual. Doing so could cause the lift to trip and endanger the patient and assistants. Invacare does recommend the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed, or any stationary object. During an interview on 7/6/15 at 4:45 p.m., the administrator said after the incident the DON had checked the lift and the controls worked properly. The administrator said she was not aware the manufacturer's recommendations for the lift said not to lock the wheels. She said she could not hold her staff responsible when she did not know. The ADON provided a list on 7/6/15 of 5 residents who required Hoyer lift transfers.

Based on observation, interview, and record review, the facility failed to have detailed written plans and procedures to meet all potential emergencies for 2 of 4 bariatric residents reviewed for evacuation procedures. (Resident #s 69 and 39) Resident # 69 and 39 were bedfast and utilized a bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese residents). The facility failed to train staff on a disaster plan to include evacuation procedures for these residents that could not self evacuate in the event of an emergency evacuation. This failure created an Immediate Jeopardy situation identified on 09/30/13. While the Immediate Jeopardy was removed on 10/01/13, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice had the potential to delay or prevent the safe, rapid, and efficient evacuation from the facility for four residents identified as utilizing the bariatric beds, in the event of an emergency. Findings included: 1. Physician orders [REDACTED]. A quarterly MDS dated [DATE] indicated Resident #69 weighed 374 pounds. He required extensive assistance for transfer and all ADLs. He was unable to walk. His MDS indicated he was alert and oriented. During an observation and interview 09/30/13 at 10:50 a.m., Resident #69 was lying in a bariatric bed. He said his September weight was 374 pounds. He said he had not been out of bed since 9/15/13 when staff dropped him from the Hoyer lift as they were transferring him from his bed to a wheelchair. He said he was fearful to have that happen again. During an observation on 09/30/13 at 11:05 a.m. Resident #69's bed frame width measured 48.5 inches and the doorway width measured 42.5 inches. 2. Physician orders [REDACTED]. A quarterly MDS dated [DATE] indicated Resident #39 weighed 353 pounds. She was dependent on staff for all ADLs. She was unable to transfer or ambulate. Her MDS indicated she was alert and oriented. During an observation and interview on 09/30/2013 at 12:37 p.m., Resident #39 was in her room lying in a bariatric bed. She said she had not walked in [AGE] years. She said she weighed 353 pounds. She said she was given bed baths because she was extremely anemic and cold-natured. The last time she was up to a wheel chair was about 3 weeks ago. She said staff used the lift to get her up. During an observation on 09/30/13 at 12:45 p.m., Resident #39's bed frame width measured 43.5 inches and the doorway width measured 42.5 inches. During an interview on 09/30/13 at 12:30 p.m., CNA A said if Resident # 69 needed evacuation from his room, she would take him in his bed through the doorway. She said he would be too heavy to lift by herself. She said she had not been trained or in-serviced on evacuating a morbidly obese resident during an emergency. During an interview on 09/30/13 at 12:37 p.m., MA B said if Resident #s 69 and 39 needed to be evacuated from their rooms, she would take both in their beds through the doorways. She said she had not been trained or in-serviced on evacuating a morbidly obese resident during an emergency. During an interview on 09/30/13 at 2:20 p.m., the administrator said he was in charge of the disaster plan and any revisions applicable to the plan. He said he was aware the bariatric residents were unable to be evacuated. He said they had been aware for a year and had discussed it in March. He said to his knowledge; the staff had not been trained or in-serviced on evacuation of the bariatric residents. During an interview on 09/30/13 at 2:50 p.m., the administrator said there was no disaster plan for bariatric residents and evacuation procedures. He said he and the DON had talked about it. He said there had not been any in-services for the staff. He said there were three bariatric residents. During an interview on 09/30/13 at 3:45 p.m., CNA C said she would put Resident #69 out the window. The nurse aide said she would be unable to lift 353 pounds of dead weight. She said she had not been trained or in-serviced on evacuating a morbidly obese resident during an emergency. During an interview on 09/30/13 at 4:15 p.m., CNA D said he had never been in- serviced on evacuation of the "heavy" residents. He said he had never participated in a drill or had any training for getting the "large residents" out of the facility. He said a plan and training was needed in case they had to get them out of the building. The disaster plan dated 07/17/13 did not address emergency evacuation procedures or a plan for totally dependent bariatric residents. The administrator and DON were notified on 09/30/13 at 5:00 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 09/30/13 at 8:00 p.m. and included: "Transfer of bed-bound patients in a bariatric bed which cannot be removed from the room in the event of an emergency evacuation. Charge nurse will be responsible for directing staff to evacuate such identified patients according to the emergency preparedness plan. One bariatric hoyer sling or transfer sheet will be located in each identified patient's room. All nursing staff will be trained on bariatric evacuation procedures. Such training will include the following steps: 1. Lower the bed as close to the floor as possible 2. Fold the sling or transfer sheet in half-length wise, and place it in the bed beside the patient. 3. Roll patient to one side, placing sling/sheet half-way under patient 4. Roll patient to the other side, unfolding the sling/sheet under patient (patient centered on sling/sheet) 5. With four people, lift patient on the end of the bed using the handles on the sling/sheet 6. Carry patient in sling/sheet to safe area The above training will begin immediately and will continue until all nursing staff have been in-serviced. The Administrator/Designee will ensure that the above training is completed as planned. All new admissions will be screened prior to admission by DON/Designee to determine their evacuation needs. All bariatric patients needing the above procedures will have their care plans updated by 10/01/13. DON/Designee will monitor any change in residents' transfer status at weekly Standard of Care meeting. All circumstances requiring evacuation as per the Fire and Disaster Manual will trigger the above." The surveyors confirmed the Plan of Removal (POR) had been implemented sufficiently to remove the IJ by: Nine CNAs were interviewed and said they understood and were able to verbalize to surveyors how to transfer a totally dependent bariatric residents during an emergency. Staff members were instructed using demonstration on how to carry out this procedure. All were aware of the meaning of terms used in the disaster plan for evacuation. Five nurses, 1 MA, and 1 Medical Recods clerk were interviewed and said they were in-serviced on the disaster plan and how to evacuate totally dependent residents. They were aware of the modes of transfer listed in the disaster plan. All staff had been in serviced and shown a demonstration on transfers of dependent residents. The new policy dated 10/01/13 for Emergency Removal of Residents was reviewed and contained the requirements for evacuation. Care plans on bariatric residents were updated. The facility in-serviced staff on emergency procedures, terms used for transfer in the disaster manual and performed a demonstration on how to transfer totally dependent obese residents whose specialized beds will not fit through the bedroom door. On 10/01/13 at 11:22 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm because of the facility's need to monitor and evaluate whether the systems put in place were effective. A list provided by the facility on 10/01/13 indicated there were 4 bariatric residents who were totally dependent on staff for transfers.

Based on observation, interview, and record review, the facility failed to train employees in emergency procedures for 2 of 4 bariatric residents reviewed for evacuation procedures. (Resident # 69 and 39) Resident # 69 and 39 were bedfast and utilized a bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese residents). The facility failed to train staff on a disaster plan to include evacuation procedures for these residents that could not self evacuate in the event of an emergency evacuation. This failure created an Immediate Jeopardy situation identified on 09/30/13. While the Immediate Jeopardy was removed on 10/01/13, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice had the potential to delay or prevent the safe, rapid, and efficient evacuation from the facility for four residents identified as utilizing the bariatric beds, in the event of an emergency. Findings included: 1. Physician orders [REDACTED]. A quarterly MDS dated [DATE] indicated Resident #69 weighed 374 pounds. He required extensive assistance for transfer and all ADLs. He was unable to walk. His MDS indicated he was alert and oriented. During an observation and interview 09/30/13 at 10:50 a.m., Resident #69 was lying in a bariatric bed. He said his September weight was 374 pounds. He said he had not been out of bed since 09/15/13 when staff dropped him from the Hoyer lift as they were transferring him from his bed to a wheelchair. He said he was fearful to have that happen again. During an observation on 09/30/13 at 11:05 a.m. Resident #69's bed frame width measured 48.5 inches and the doorway width measured 42.5 inches. 2. Physician orders [REDACTED]. A quarterly MDS dated [DATE] indicated Resident #39 weighed 353 pounds. She was dependent on staff for all ADLs. She was unable to transfer or ambulate. Her MDS indicated she was alert and oriented. During an observation and interview on 09/30/2013 at 12:37 p.m., Resident #39 was in her room lying in a bariatric bed. She said she had not walked in [AGE] years. She said she weighed 353 pounds. She said she was given bed baths because she was extremely anemic and cold-natured. The last time she was up to a wheel chair was about 3 weeks ago. She said staff used the lift to get her up. During an observation on 09/30/13 at 12:45 p.m., Resident #39's bed frame width measured 43.5 inches and the doorway width measured 42.5 inches. During an interview on 09/30/13 at 12:30 p.m., CNA A said if Resident # 69 needed evacuation from his room, she would take him in his bed through the doorway. She said he would be too heavy to lift by herself. She said she had not been trained or in-serviced on evacuating a morbidly obese resident during an emergency. During an interview on 09/30/13 at 12:37 p.m., MA B said if Resident #s 69 and 39 needed to be evacuated from their rooms, she would take both in their beds through the doorways. She said she had not been trained or in-serviced on evacuating a morbidly obese resident during an emergency. During an interview on 09/30/13 at 2:20 p.m., the administrator said he was in charge of the disaster plan and any revisions applicable to the plan. He said he was aware the bariatric residents were unable to be evacuated. He said they had been aware for a year and had discussed it in March. He said to his knowledge; the staff had not been trained or in-serviced on evacuation of the bariatric residents. During an interview on 09/30/13 at 2:50 p.m., the administrator said there was no disaster plan for bariatric residents and evacuation procedures. He said he and the DON had talked about it. He said there had not been any in-services for the staff. He said there were three bariatric residents. During an interview on 09/30/13 at 3:45 p.m., CNA C said she would put Resident #69 out the window. The nurse aide said she would be unable to lift 353 pounds of dead weight. She said she had not been trained or in-serviced on evacuating a morbidly obese resident during an emergency. During an interview on 09/30/13 at 4:15 p.m., CNA D said he had never been in- serviced on evacuation of the "heavy" residents. He said he had never participated in a drill or had any training for getting the "large residents" out of the facility. He said a plan and training was needed in case they had to get them out of the building. The disaster plan dated 07/17/13 did not address emergency evacuation procedures or a plan for totally dependent bariatric residents. The administrator and DON were notified on 09/30/13 at 5:00 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 09/30/13 at 8:00 p.m. and included: "Transfer of bed-bound patients in a bariatric bed which cannot be removed from the room in the event of an emergency evacuation. Charge nurse will be responsible for directing staff to evacuate such identified patients according to the emergency preparedness plan. One bariatric hoyer sling or transfer sheet will be located in each identified patient's room. All nursing staff will be trained on bariatric evacuation procedures. Such training will include the following steps: 1. Lower the bed as close to the floor as possible 2. Fold the sling or transfer sheet in half-length wise, and place it in the bed beside the patient. 3. Roll patient to one side, placing sling/sheet half-way under patient 4. Roll patient to the other side, unfolding the sling/sheet under patient (patient centered on sling/sheet) 5. With four people, lift patient on the end of the bed using the handles on the sling/sheet 6. Carry patient in sling/sheet to safe area The above training will begin immediately and will continue until all nursing staff have been in-serviced. The Administrator/Designee will ensure that the above training is completed as planned. All new admissions will be screened prior to admission by DON/Designee to determine their evacuation needs. All bariatric patients needing the above procedures will have their care plans updated by 10/01/13. DON/Designee will monitor any change in residents' transfer status at weekly Standard of Care meeting. All circumstances requiring evacuation as per the Fire and Disaster Manual will trigger the above." The surveyors confirmed the Plan of Removal (POR) had been implemented sufficiently to remove the IJ by: Nine CNAs were interviewed and said they understood and were able to verbalize to surveyors how to transfer a totally dependent bariatric residents during an emergency. Staff members were instructed using demonstration on how to carry out this procedure. All were aware of the meaning of terms used in the disaster plan for evacuation. Five nurses, 1 MA, and 1 Medical Recods clerk were interviewed and said they were in-serviced on the disaster plan and how to evacuate totally dependent residents. They were aware of the modes of transfer listed in the disaster plan. All staff had been in serviced and shown a demonstration on transfers of dependent residents. The new policy dated 10/01/13 for Emergency Removal of Residents was reviewed and contained the requirements for evacuation. Care plans on bariatric residents were updated. The facility in-serviced staff on emergency procedures, terms used for transfer in the disaster manual and performed a demonstration on how to transfer totally dependent obese residents whose specialized beds will not fit through the bedroom door. On 10/01/13 at 11:22 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm because of the facility's need to monitor and evaluate whether the systems put in place were effective. A list provided by the facility on 10/01/13 indicated there were 4 bariatric residents who were totally dependent on staff for transfers.