Every finding on record at St James Wellness Rehab Villas

Based on interview and record review, the facility failed to ensure that a resident was free from a significant medication error. This applies to 1 of 3 residents (R4) reviewed for medication errors. The findings include: On 07/29/26 at 12:15 PM, R4 was in bed. R4 was wearing a boot to his right leg. R4 was alert but confused. R4 stated he did not know if he was receiving any injections from the nurses. R4 stated to speak with his wife regarding his medical condition. On 07/30/26 at 9:08 AM, V14 (R4's wife) stated R4 had been taking Lovenox since October of 2025 due to DVT's (Deep Vein Thrombosis) and PE (Pulmonary Embolism). V14 stated R4 was admitted to the hospital on [DATE] and she informed them that R4 was taking Lovenox. V14 stated R4 was discharged from the hospital to another nursing facility on 06/30/26. V14 stated when R4 was discharged from the hospital, he had orders for Lovenox 80 mg. V14 stated while R4 was still a resident at the other facility, she found out the Lovenox was going to be discontinued 10 days after the admission date. V14 stated she called the nurse at the other facility. V14 stated on 07/06/26, the nurse told her that the medication would be continuous with no stop date. V14 stated she was not happy with the care provided to R4 at the other facility, so she wanted him transferred to the current facility. V14 stated prior to R4 admitting to the current facility, R4's primary care provider sent a script to the facility for Lovenox. V14 stated on 07/23/26, while on a follow up appointment for R4, she discovered R4 had not been receiving Lovenox as ordered by the hospital and R4's primary care physician. V14 stated since R4 had not received Lovenox and R4's history of DVT's and PE's, she wanted him sent to the emergency room to be assessed. V14 stated R4 went to the hospital on [DATE] and returned to the facility on [DATE]. V14 stated while at the hospital, R4 received a dose of Lovenox, and was sent back to the facility with a script for Lovenox for 30 days. On 07/29/26 at 11:45 AM, V10 (LPN/Licensed Practical Nurse) stated on 07/25/26, she was the nurse taking care of R4. V10 stated she received a call from V14 regarding orders for Lovenox. V10 stated she informed V14 there were no orders listed for R4 to receive Lovenox. V10 stated she informed V14 that she needed to call the NP (Nurse Practitioner) to find out what happened with the order for Lovenox but V14 wanted R4 sent to the hospital for evaluation. V10 stated R4 should not have missed doses of Lovenox since he has a history of DVT. On 07/29/26 at 3:01 PM, V13 (NP) stated she first assessed R4 on 07/10/26. V13 stated R4's After Visit Summary from the hospital admission was not uploaded into R4's EMR (Electronic Medical Record). V13 stated she did not ask the facility for the hard copy of the After Visit Summary. V13 stated on 07/11/26, she went to the previous facility where R4 was a resident at before his admission to the hospital. V13 stated she retrieved R4's medical record from the facility and discontinued the Lovenox after reading the records. V13 stated she did not see the After Visit Summary, speak with V14, R4's hematologist/oncologist, or the primary care physician before discontinuing Lovenox. On 07/30/26 at 11:13 AM, V13 stated after reviewing the After Visit Summary, R4 had orders for Lovenox which did not have a stop date. V13 stated she made a mistake when discontinuing the Lovenox on 07/11/26. V13 stated if she had the information, she had today, she would not have discontinued the Lovenox. V13 stated with the history of R4's DVT's and PE, he is at risk for developing another DVT or PE since he had not received Lovenox since 07/10/26. On 07/30/26 at 12:53 PM, V2 (DON/Director of Nursing) stated he was not aware of the Lovenox being discontinued until the nurse called him. V2 stated he knew R4 had a history of DVT and PEs. V2 stated R4 could develop another blood clot, which could be fatal if he does not receive the medications as the doctors ordered. R4 was admitted to the facility on [DATE] with multiple diagnoses which included dementia, Alzheimer's Disease, hypertension, pulmonary embolism, peripheral vascular disease, acute embolism and thrombosis of unspecified deep veins lower extremity, chronic embolism and thrombosis of iliac vein. R4's MDS (Minimum Data Set) dated 07/15/26 showed R4 had moderate cognitive impairment. R4's MAR (Medication Administration Record) and current Order Summary Report for July 2026 showed discontinued orders for Lovenox 80 mg/ 0.8 ml (mililiter) SQ (subcutaneous) every 12 hours for PE, start date 07/11/26 and end date 07/12/26. Lovenox 80 mg/ 0.3 ml SQ every 12 hours, start date 07/10/26 and end date 07/09/26. Lovenox 100 mg/1ml SQ every 12 hours, start date 07/10/26 and end date 07/10/26. Lovenox 120mg/0.8ml, start date 07/26/26 and end date 08/25/26. The records showed R4 did not receive Lovenox 07/13/26 until 07/25/26 when he was sent to the emergency room for evaluation. R4's Progress Notes dated 07/09/26 at 8:00 PM, showed Received resident via ambulance x (times) two attendants from (Hospital). Diagnosis of status post right knee injury, noted 16 steri-strips, noted x two medium-size blisters above right knee. Left shin noted redness with healed blisters to left ankle OTA (Open to Air). All medications verified by second nurse on unit. Progress Notes dated 07/09/26 at 9:02 AM, showed V13 made aware at this time of admission, ordered labs in AM, CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Profile) order noted, will continue with hospital discharge medication profile. Progress Notes dated 07/10/26 at 1:56 PM, NP Initial Eval- HPI (History & Physical) status post revision of repair of right quadriceps tendon on 06/2026 with recommended weight bearing as tolerated with use of a right knee immobilizer. His course was complicated by history of recurrent DVT and pulmonary embolism requiring therapeutic anticoagulation. Vascular surgery evaluated for chronic venous insufficiency with bilateral iliac venous stents and noted adequate arterial perfusion with chronic non-occlusive thrombus within the right venous stent. Hospital records reviewed. Plan of care discussed with nursing with continuation of current treatment and rehabilitation plan. Past Medical History: Chronic embolism and thrombosis of other specified veins. Progress Notes dated 07/25/26 at 10:25 PM, resident wife contacted the facility expressing concern that the resident was not receiving a specific medication blood thinner. Writer addressed her concerns and to the best their ability; however, residents wife remained concerned and requested that the resident be sent to the hospital for further evaluation, per family request, EMS (Emergency Medical Services) 911 called and arrived at facility at 10:15 PM. Writer notified NP's and DON of the family's concerns and the resident transfer request. Awaiting return response. Progress Notes 07/26/26 at 1:10 AM, Resident returned to facility via standard ambulance services with new orders. No new diagnosis. Resident is in a stable condition. Progress Notes 07/26/26 at 2:50 AM, Enoxaparin Sodium Injection Solution Prefilled Syringe 120 mg/0.8 ml, inject 0.7 milliliter subcutaneously every 12 hours for prophylaxis until 08/25/26. (Hospital) After Visit Summary dated 07/07/2026-07/09/2026 showed, Instructions: Your medications have changed. Change how you take enoxaparin. Enoxaparin 100 mg/ml syringe. Commonly known as Lovenox. Inject 1 ml into skin every 12 hours. Last time this was given: 100 mg on 07/09/26 at 6:10 PM. What changed: medication strength, how much to take.The facility's Mediation and Treatment Order Policy, effective date February 2014, showed, 5) All telephone and/or verbal orders must be read back to the physician by the licensed personnel taking the order to ensure the information is clearly understood and correctly transcribed.

Based on observation interview and record review the facility failed to provide access to the call light device for care dependent residents.This applies to 2 of 2 residents, R8 and R63 reviewed for call light accessibility in the sample of 21.Findings include:1.On 02/24/2026 at 11:14 AM, R8 was sitting in his wheelchair on the right side of his bed. R8's call light was on the left side of his bed placed on his nightstand. R8 stated he uses his call light to call for staff assistance, but he could not locate it. R8's medical diagnoses include cerebral infarction, history of falling, epilepsy, abnormalities of gait and mobility, and spastic hemiplegia affecting right dominant side.R8's current care plan includes: The resident has impaired visual function. Place items within easy reach and orient to placement. R8 is high risk for fall related to history of falling, abnormal posture, lack of coordination, disorders of the muscle, hemiplegia, hemiparesis following a CVA (Cerebral Vascular Accident) affecting his right dominant side, unaware of safety needs. Interventions include Be sure R8's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.2.On 02/24/2026 at 11:39 AM, R63 was sitting in a side chair leaning over the overbed table in front of her attempting to get the attention of passersby. R63 stated she needed assistance with her dirty pants. R63 stated she would use the call light to call for assistance, but she could not get to it. R63's was positioned on the right side of her bed, and the call light was tied to the left side rail out of her reach.On 02/25/2026 at 1:11 PM, R63 was sitting in a side chair on the right side of her bed. The over bed table was in front of her. The call light was hanging on the left side of her bed out of her reachR63's medical diagnoses include Parkinsons disease, nonneural disorder, and ataxia.R63's current care plan includes: The resident is a high risk for falls related to Parkinson's disease, history of falls, vertigo and gait balance problems. Interventions include call don't fall sign, anticipate and meet the resident's needs.On 02/25/2026 at 5:22 PM, V2 DON (Director of Nursing) stated call lights should be placed in reach of residents so they can call for assistance when needed. The staff have been trained to make sure the call light is always in reach.The facility policy Answering the Call Light dated August 2008 states the purpose of this procedure is to respond to the residents' requests and needs. When the resident is in bed or confined to a chair, be sure the call light is within easy each of the resident.

Based on observation, interview and record review, the facility failed to provide timely incontinence care to a care dependent resident, and failed to ensure a resident was positioned to eat.This applies to 2 of 4 residents (R36, R24) reviewed for activities of daily living in the sample of 21.Findings include:1.On 02/24/2026 at 12:06 PM, R36's call light was on. R36 stated his call light was on earlier and staff came in and turned it off. R36 stated that it was the second time he put his light on for incontinence care. R36 stated he did not recall when he was last provided with incontinence care. V6 CNA (Certified Nursing Assistant) entered R36's room stating she was finishing a complete bed change next door and would return. R36 stated he was still wet.On 02/24/2026 at 12:11 PM, V6 CNA returned to provide incontinence care. V6 stated she arrived at 06:30 AM but that was the first time she was providing incontinence care to R36. V6 picked up R36's bed control which had a dried greenish brown substance on it that V6 identified as feces. Pulled back R36's bed linen and unfastened his incontinence brief. Feces had run down R36's thighs and up to his lower abdomen. R36's undergarment was soaked with urine and feces. When V6 turned R36 to his right side, he was covered in feces. His bed linen was soaked with urine and stool. As V6 cleaned R36 his buttocks were reddened, and his scrotum was excoriated. V6 removed the soiled bed linen. Urine and feces had soaked through to the mattress. V6 stated she should be checking residents every two hours, but she had fifteen residents on her assignment and was delayed tending to R36.On 02/25/2026 at 1:29 PM, R36 stated he was waiting for staff to come and provide incontinence care. R36 stated he had his call light on before and they said they would clean him up after he finished eating. V7 LPN / IP (Licensed Practical Nurse / Infection Preventionist) responded to R36's call light and provided incontinence care. R36's undergarment was completely saturated with urine. R36's buttocks were pink. The bed linens had a brown smear and were soaked with urine.On 02/25/2026 at 1:42 PM, V8 CNA (Certified Nursing Assistant) assigned to R36 stated she provided incontinence care to R36 at 09:00 AM. V8 stated residents should be checked every two hours for incontinence. V8 stated she got busy with other tasks and had not returned to R36.On 02/25/2026 at 5:22 PM, V2 DON (Director of Nursing) stated staff should check residents for incontinence care at least every two hours and as needed. Staff should provide incontinence care when the resident asks for it. If they cannot provide care at that time, they should not turn the call light off until the task is completed. Residents should not wait four to six hours for incontinence care. Residents should not be soaked through the undergarment to their mattress. Residents should not have to eat a meal wearing soiled undergarments.The facility policy Activities of Daily Living dated 2/2023 states in accordance with the comprehensive assessment, together with respect for the individual resident needs and choices our facility provides care and services for: hygiene, bathing, dressing, grooming 2.On 02/24/2026 at 12:42 PM, R24 was sitting in a reclining chair in the dining room at the table. R24's chair was in a reclined, lying, position and not upright. R24 was eating cake and drinking water without assistance from the staff in the lying position. V9 (CNA/Certified Nursing Assistant) encouraged R24 to eat but did not sit R24 in an upright position. On 02/25/2026 at 12:35 PM, R24 was again in the dining room in the lying position at the table. R24 attempted to eat lunch without staff assistance in the lying position.On 02/25/26 at 2:56 PM, V10 (LPN/Licensed Practical Nurse/Restorative Nurse) stated when R24 is eating or drinking, the reclining chair should not be in a laid-back position. V10 stated the reclining chair should be in an upright position. V10 stated a resident could choke while eating if in a reclined position. On 02/26/2026 at 11:48 AM, V11 (LPN) stated R24's reclining chair was broken. V11 stated the chair had been broken for a few days. V11 stated R24 should be sitting in an upright position while eating to prevent choking. On 02/26/2026 at 1:05 PM, V2 (Director of Nursing) stated residents should be in an upright, comfortable position while eating. V2 stated lying flat while eating is a risk for aspiration. V2 stated it is expected that all the residents are in an upright position while eating. R24 was admitted to the facility on [DATE] with multiple diagnoses which included Alzheimer's Disease, difficulty in walking, weakness, and major depressive disorder. R24's MDS (Minimum Data Set) showed R24 was dependent with changing positions from sitting to lying.

Based on observation, interview, and record review, the facility failed to provide foot care to meet the needs of all residents.This applies to 1 resident (R54) reviewed for podiatry services in a sample of 21 residents.The findings include:On 2/24/26 at 10:27 AM and 2/26/26 at 12:10 PM, R54 was observed lying in bed with overgrown, thick, yellow, and uneven toenails. The second toenail on both feet was observed to be especially long and curled over the tip of the toe. The skin on R54's legs was dry and flaky, with visible skin flakes noted on the sheet under her legs. On 2/24/26 R54 said her toenails bother her and can be painful. R54 said it had been a while since she last saw the facility podiatrist.R54's Face sheet shows she was admitted to the facility in 2018 and has the following diagnoses: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, lack of coordination, contracture of right upper arm muscle, muscle wasting and atrophy, difficulty walking, cognitive communication deficit, reduced mobility, Diabetes Mellitus, heart failure, and need for assistance with personal care. R54's POS (Physician Order Sheet) shows order dated 10/28/24 may be seen by Podiatrist. R54's MDS (Minimum Data Set) dated 1/27/26 shows she is completely dependent on facility staff for personal hygiene.On 2/25/26 at 4:14 PM, V4 (Social Service Director) said the facility podiatrist usually sees residents every 8 weeks. V4 said at a minimum, every resident should be seen every 3 months for foot care and podiatry services. On 2/25/26 at 4:37 PM, V4 provided the podiatry visit lists showing which resident had been seen since October 2025, and the current list of residents that are to be seen for the next podiatry visit. R54 is not seen on any of the lists provided (for almost five months).R54's progress note written by V3 (Podiatrist Physician) shows she was last seen on 9/16/25. This note states R54's diagnosis: long, painful, onychocryptosis (ingrown toenails) 1-5 both feet. Treatment completed including debridement of nails 1-5 on both feet. V3's Podiatry Evaluation uploaded into the EMR (electronic medical record) dated 9/16/25 reviewed, no follow up recommendation seen and no other podiatry visits or notes seen since 9/16/25.On 2/26/26 at 12:52 PM, V2 (DON/Director of Nursing) said residents are to be seen every 68 days per the facility podiatry policy. V2 said podiatry/foot care is important for residents to monitor for ingrown toenails, fungus, infection, and is important for overall hygiene. V2 said podiatry care is especially important for residents with Diabetes because they are at greater risk for infection due to poor circulation. V2 said if toenails get too long, thick, uneven, or overgrown there is potential for the nails to break off and create wounds and/or infection. V2 said diabetic residents need their feet monitored more closely to avoid any complications.The facility's undated policy titled, Podiatry Services states .We need podiatry group to do the following: 1) Come to the facility at appropriate intervals to assure that every resident is seen every 68 days.6) Do appropriate charting for each visit.Plan for the Facilities: 1) Podiatrist can do the following services for your patients: a. Visit each resident every 68 days (approx. 10 weeks) b. Foot assessment and care, including nail trimming.d. Circulatory and neuro assessments.2) Existing Patients: a. Every existing patient needs can be seen by a podiatrist at least every 10 weeks (68 days) b. If a podiatrist misses a visit with the patient, patient needs to be added to the list for the next visit.

Based on observation, interview, and record review, the facility failed to provide dressing changes to a resident's PICC (Peripherally Inserted Central Catheter) line. This applies to 1 resident (R103) reviewed for venous access maintenance.Findings include:On 02/24/2026 at 11:55 AM, R103's single lumen PICC line was observed with V5 LPN (Licensed Practical Nurse). The transparent film dressing with border was completely lifted at the lower edge of the dressing past the border. The dressing was dated 2/10/26 (two weeks earlier). V5 LPN stated she was not the staff who maintained the PICC line.R103's physician orders include may insert midline PICC for antibiotic therapy dated 02/10/2026. R103's MAR (Medication Administration Record) showed to change the PICC line dressing every seven days. The MAR documents a PICC line dressing change was done on 02/16/2026. The MAR instructions stated line dressing changes, the measurement of arm circumference, and the length of exposed PICC line, should be completed after every PICC line dressing change, to be done on admission and every seven days.On 02/26/2026 at 11:41 PM, V2 DON (Director of Nursing) stated the PICC line dressing should be changed every seven days, and the nurse should ensure the dressing is intact and there are no signs of infection. V2 stated the PICC line could become a source of infection if not maintained properly.The facility policy Catheter Insertion and Care dated 9/1/2016 will be changed at specific intervals or when needed to event catheter -related infections that are associated with contaminated, loosened, soiled or wet dressings.

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) with residents with wounds and indwelling urinary catheters. This applies to 2 of 2 residents (R4 and R10) reviewed for infection control in the sample size of 21.The findings include:1. On 02/24/26 at 12:08 PM, R10 did not have an Enhanced Barrier Protection sign outside of the room indicating a need for EBP. On 02/25/26 at 1:00 PM, R10 continued to not have a sign or notification of the need for EBP outside of the room. On 02/25/26 at 2:45 PM, V7 (LPN/Infection Preventionist) was observed in the room with R10. V7 was attempting to reposition R10 and checking for wounds without wearing a gown. On 02/25/2026 at 2:45 PM, V7 stated R10 should have had a sign outside of the room stating EBP due to an indwelling catheter and wounds. V7 stated she forgot to put the EBP sign and an isolation bin outside of R10's room. V7 stated the staff could get an infection from R10 or transmit germs to R10 if proper PPE (Personal Protective Equipment) is not put on. On 02/26/2026 at 1:05 PM, V2 (Director of Nursing) stated residents with indwelling urinary catheters and wounds should have EBP in place. V2 stated there could be a potential for infection for the resident and the staff if EBP is not being followed. V2 stated it is expected of staff to wear PPE when providing care to residents on EBP. R10 was admitted to the facility on [DATE] with multiple diagnoses which included stage four pressure ulcer of sacral region, osteoporosis, osteomyelitis, and proteus mirabilis per the Transfer and Discharge Report. R10's Order Summary Report for February 2026 showed Enhanced barrier precautions related to indwelling catheter and wounds. Indwelling catheter: 16 FR (French), 10 cc (cubic centimeter) balloon size for a stage 4 sacral wound.2. On 02/25/2026 at 9:02 AM, V9 (CNA/Certified Nursing Assistant) was in R4's room with the door open and privacy curtains not drawn. V9 was observed repositioning R4 in bed. V9 was not wearing a gown while providing care to R4. R4 had an Enhanced Barrier Precautions sign posted on the wall, outside of the room, stating to wear a gown and gloves while providing care to R4.On 02/25/2026 at 9:10 AM, V9 stated EBP is for residents with infections. V9 stated she should have worn a gown while repositioning R4. V9 stated if EBP is not followed, germs can be transferred from the resident to others. R4 was admitted to the facility on [DATE] with multiple diagnoses which included an unstageable pressure ulcer of left ankle, diabetes, acute and chronic respiratory failure, hemiplegia and hemiparesis, and chronic obstructive pulmonary disease per the admission Record. R4's Order Summary Report for February 2026 showed Enhanced Barrier Precaution: related to left ankle wound. R4's Enhanced Barrier Precautions care plan showed Interventions: Gown and glove use when performing high-contact resident contact activity. Use principles of infection control and enhanced barrier precautions.The facility's Enhanced Barrier Precautions Policy, Effective Date 01/20/24, showed Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a MDRO (Multidrug Resistant Organism) as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). Explanation and Compliance Guidelines: Clear signage will be posted on the door or wall outside of the resident room indicting the type of precautions, required personal protective equipment (PPE), and the high contact resident care activities that require the use of gown and gloves.

Based on observation, interview, and record review, the facility failed to repair their leaking ice machine in the nourishment room. This applies to 7 of 7 residents (R13, R14, R15, R16, R17, R18, R19) who are ambulatory and with impaired cognition. The findings include: The facility has nourishment room in each floor. On March 18, 2025, at 12:00 PM, the door of the second-floor nourishment room was wide open, the doorknob was not equipped with a lock. The ice maker machine that was inside the nourishment room was leaking water on the floor. A puddle of water was observed. On March 18, 2025, at 12:12 PM, V17 and V18 (Both Certified Nursing Assistant/CNA) said the ice machine has currently been leaking for a week, and they reported it. On March 19, 2025, at 7:06 AM, the nourishment room was unlocked. There were folded bedsheets on the floor absorbing the water leaking from the base of the ice machine. As surveyor stepped on the sheets, water squeezed out of the wet bedsheets. V6 (Nurse) said the sheets are for the leaking ice machine. On March 19, 2025, at 10:13 AM, V5 (Maintenance/Housekeeping Director) stated that they repaired the ice maker machine on the second floor because it was not making enough ice. He was aware that the ice machine was leaking, and he was only notified the day before. The second floor has residents who are identified as ambulatory and has impaired cognition based on their most recent Minimum Data Set. These residents include R13, R14, R15, R16, R17, R18, R19. From March 18 to March 19, 2025, during observation on the second floor, there were residents observed ambulating in the hallway and day area. On May 19, 2025, at around 8:15 AM, R14 was observed wandering in the 2 North hallway where the ice machine was located, entering one bedroom to another of other residents, and attempted to open closed doors.

Based on observation, interview, and record review, the facility failed to provide timely incontinence care for residents who require assistance with toileting and hygiene. This applies to 3 of 4 residents (R1, R2, R3) reviewed for activities of daily living (ADL) care in the sample of 19. The findings include: 1. R1's Face sheet shows that R1 is [AGE] year-old who has multiple medical diagnoses including morbid obesity, personal history of urinary tract infection, chronic pain, depression, unspecified (mood) affective disorder, unsteadiness on feet, and weakness. On March 18, 2025, at 10:28 AM, a very strong urine odor was coming from R1's room. R1 was lying in bed, alert and oriented. R1's bed sheets, incontinence brief, and incontinence pad, were heavily saturated with urine, and were all stained with brownish discoloration from the urine. R1 also said she has not been changed yet this shift. R1 used the call light to ask for help, but the staff turned off the light stating she will come back for her. R1 said she placed the bedpan underneath herself to move her bowel. R1 said she (R1) has been lying on her bedpan for an hour now waiting for the CAN/Certified Nursing Assistant staff (V13) to come and assist her. On March 18, at 10:58 AM, V13 (CNA) stated that R1 can walk and go to the rest room but she's refusing. Every morning the staff find her wet and won't get up to the washroom. R1 has behavior she goes to the shower and ambulate to hallway when she wants to. R1 doesn't want to move, she wants staff to do everything for her when she feels like it. R1's Minimum Data Set (MDS) dated [DATE], shows R1 is alert and oriented, she's always incontinent, and requires substantial to maximal assistance for toileting hygiene. R1's care plan dated January 31, 2025, shows R1 has mixed bladder incontinence related to impaired mobility and obesity. This same care plan shows multiple interventions including check and change every 2 hours and as needed, and clean peri-area with each incontinence episode. 2.R2's Face sheet shows R2 is [AGE] year-old who has multiple medical diagnoses including weakness, unspecified dementia, non-pressure chronic ulcer of unspecified left lower leg limited to breakdown of skin. On March 18, 2025, at 1:15 PM, R2 was lying in bed, stated that she was last changed early this morning. She (R2) could not remember who changed her this morning because she was still half asleep. R2 turned on the call light and V19 (CNA) responded and checked R2. V19 said the last time she changed R2 was right after breakfast, because she was very busy getting up other residents. R2 was observed heavily saturated with urine, with pervasive urine odor, which overflowed from the incontinence brief to her incontinence pad. R2 also had a large bowel movement. R2's Minimum Data Set, dated dated dated [DATE], shows that R2 is completely dependent on staff for her toileting and personal hygiene. R2 was alert and oriented but forgetful. 3. R3's Face sheet shows R3 is [AGE] year-old who has multiple medical diagnoses including cerebral infarction dur to unspecified occlusion or stenosis of left middle cerebral artery, morbid obesity, unspecified mental disorder. On March 18, 2025, at 1:34 PM, R3 was resting in bed. R3 was alert, oriented but has difficulty understanding inquiries and instructions. R3 was heavily saturated with urine and had a bowel movement which was dry and pasty. V19 said that she has not changed R3. V19 stated she usually waits for R3 to tell her when she needed to be change. R3's MDS dated [DATE], shows R3 has short-term memory problem, and is completely dependent on staff for toileting hygiene. R3's care plan dated February 10, 20,25, shows R3 has functional bladder incontinence related to impaired mobility, and physical limitations. This same care plan shows multiple intervention including check and change every 2 hours and as needed, and to clean peri-area with each incontinence episode. On March 19, 2025, at 9:16 AM, V4 (Regional Consultant Nurse) stated staff must check and change residents for incontinence every 2 hours and as needed, to prevent skin breakdown, and promote comfort and dignity.

Based on observation, interview, and record review, the facility failed to follow physician orders for wound treatment and wound dressing changes as needed. This applies to 1 of 3 resident reviewed for wounds in the sample of 19. The findings include: R4's Face sheet shows R4 is [AGE] year-old who has multiple diagnoses including type 2 diabetes mellitus, unspecified dementia, infection of intervertebral disc, sacral and sacrococcygeal region, and unstageable pressure ulcer of the sacral region. On March 19, 2025, around 6AM, R4 was lying in bed. She has a wound dressing to sacral region which was heavily saturated with wound discharges and exudates. This wound dressing was dated 3/18/25 and was detached from R4 exposing her unstageable sacral ulcer. Surrounding area of the wound was wet with exudates. R4 was noted with a rectal tube that was leaking on the side with fecal matter near the exposed wound. V10 (Certified Nursing Assistant/CNA) changed the brief and said he did not notify the nurse about R4's need for dressing change because he was busy trying to complete his assignment. On March 20, 2025, at 10:43 AM, V8 (Wound Care physician) stated that V4's wound dressing should be change daily and as needed. When wound dressing becomes very soiled, the staff must immediately change the dressing as the exudate can cause potential skin breakdown. The weekly skin assessment dated [DATE], shows this unstageable wound is measured as Length (L) 10-centimeter (cm) x Width (W) 10 cm. Physician Order Summary (POS) with revision date of March 7, 2025, shows Cleanse sacrum with normal saline, apply medihoney, and cover with dry dressing every day shift and Cleanse sacrum with normal saline, apply medihoney, and cover with dry dressing as needed if dressing comes loose or becomes soiled.

Based on observation, interview, and record review, the facility failed to ensure that there is a physician order for self-administration of an inhaler medication, and failed to ensure that medication was administered to residents accurately as prescribed by physician. This applies to 2 of 7 residents (R1 and R5) reviewed for medication administration in the sample of 19. The findings include: 1. R1's Face sheet shows that R1 is [AGE] year-old who has multiple medical diagnoses including morbid obesity, recurrent major depressive disorder, unspecified (mood) affective disorder, chronic obstructive pulmonary disease, and asthma. On March 18, 2025, at 10:28 AM, R1 was resting in bed, there was a Symbicort inhaler at her bedside. R1 said she needed it. However, her Physician Order Summary (POS), does not have evidence of documentation that she may keep the medication at bedside. There was no updated care plan with regards to R1's self-administration of medication. 2. R5's Face sheet shows that R5 is [AGE] year-old who has multiple medical diagnoses including type 2 diabetes mellitus, unspecified dementia, dysphagia, oral phase, Vitamin D deficiency, hypertension, weakness, and cognitive communication deficit. On March 19, 2025, at 9:00 AM, V14 (Restorative Aid) was observed feeding R5. There were unidentified white very small circular granules, and some small pieces of irregular shape substances mixed and sprinkled to R1's pureed bread. When surveyor asked what it was, V14 said that she doesn't know. V14 said that she didn't know who set up the tray for R5. On March 19, 2025, at 9:04 AM, V3 (Assistant Director of Nursing/ADON) said that the white substance was substitute sugar. However, upon comparison of the sugar substitute to the unidentified substance, there was a difference in appearance/consistency. At around 9:10 AM, V6 (Nurse) who was the primary nurse of R5, was passing medication at the end of the 2-north hallway, far from the dining room. As V3 and surveyor approached V6, he (V6) informed surveyor and V3 that the unidentified white substances were R5's medications which V6 mixed in the food when R5 refused the medications with apple sauce. On March 18, 2025, at 12:55 PM, V19 said she had seen medications mixed in the residents' food when she collects meal trays from the bedroom and dining room, but unable to tell specific residents. Sometimes the resident does not eat, so the food is left untouched along with the meds. V19 said she had seen V6 (Nurse) do it. On March 19, 2025, at 9:16 AM, V4 (Regional Consultant Nurse) said inhaler medication can be left at bedside if there's an order and assessment of self-administration. The staff can mix the medication with the resident's meal if they are the one who will feed the resident to ensure that the medications are taken by the resident. Facility's Medication Administration Policy dated October 25, 2014, shows: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure sage administration of medications without unnecessary interruptions. Procedures: 7. The person who prepares the dose for administration is the person who administers the dose. 14. The residents are allowed to self-administer medication when specifically authorized by the attending physician and in accordance with procedures for self-administration of medication.

Based on observations, interviews and record reviews, the facility failed to implement physician's orders. This applies to 4 of 4 residents (R1-R4) reviewed for history of UTIs (urinary tract infections). The findings include: 1. R3's diagnosis includes UTI (urinary tract infection), prosthetic hyperplasia with urinary tract symptoms, retention of urine, & acute kidney failure. On [DATE] at 10:48 am, R3 was sitting in his wheelchair, his catheter bag was hanging from under the chair, and the bag and tubing was touching the floor. The urine was dark and cloudy. At this time R3's said that he had pain in his penis and testicles, and that he reported it to the staff. At 10:55 am V3 (Nurse) came into the room and saw that the bag and tubing was on the floor and tried to reposition them off the floor. V3 said that she was going to put R3's leg bag on him. V3 said that earlier she put the catheter bag under the wheelchair and R3 did tell her that his penis and testicles were hurting him. V3 said that she was going to notify the doctor. V3 did not change R3's catheter bag or tubing as per R3's [DATE] Physician's order. On [DATE] at 11:02 am, V7 (Nurse) was providing catheter care cleaning R3's penis and catheter tubing with 4 X 4 gauze dressing wet with normal saline. V7 did not use soap and water. R3 complained of pain in his penis and testicles. There was leakage around the opening of the penis and a brown substance both dry and wet around the tubing near the opening. V7 did not change R3's catheter bag and or tubing as per R3's [DATE] Physician's order. On [DATE] at 12:33 pm V8 NP (Nurse Practitioner) said that her expectations are that the nurses changed R3's catheters, bags, and tubing when it is clinically indicated such as when the urine was dark and cloudy, when R3 complained of pain, and when R3's catheter was leaking, just as the [DATE] physician's order shows. R3's physician's orders showed: [DATE] catheter care every shift. [DATE] record output from urinary catheter every shift. [DATE] change foley catheter for blockage and or leaking. [DATE] change catheter, tubing or bag when clinically indicated as needed. R3's EMARs (Electronic Medication Administration Records) were reviewed: November EMAR showed: No documentation for R3's output from [DATE] day shift through [DATE] night shift. R3's progress notes were reviewed, and no notes were found showing resident refused to wear a leg bag or that the catheter was changed on [DATE] or [DATE]. On [DATE] at 12:41 PM V2 DON (Director of Nursing) verified the above findings while looking at R3's electronic health records. V2 said that the nurse should have followed the orders to change the catheter and tubing on [DATE] and [DATE] because if not it could lead to an infection. V2 said, while looking at R3's lab results from [DATE] that it showed that R3 had bacteria in his urine. 2. R4's diagnoses include Type 2 diabetes, acute kidney failure, benign prostatic hyperplasia with lower urinary tract symptoms, chronic kidney disease stage 3, urinary tract infections, and pyuria. On [DATE] at 2:47 pm V5 (Nurse) provided catheter care for R4. When she cleaned R4's penis and catheter tubing, she only used normal saline. V5 did not use soap and water. R4's Physician's orders showed: [DATE] catheter care every shift. [DATE] catheter monitor output every shift. R4's EMARs (Electronic Medication Administration Records) reviewed: [DATE] EMAR showed: No output done for [DATE]th, 2024, at 10:30pm through [DATE]th, 2024, at 630 am. December EMAR showed: On [DATE] the staff did not change catheter securement device. On [DATE] at 12:41 pm V2 DON (Director of Nursing) while looking at R4's electronic health records, verified that the above treatments were not provided. V2 said that by not providing proper catheter care and not changing the securement device it can cause UTIs. 3. R2's diagnoses include type 2 diabetes, retention of urine, neuromuscular dysfunction of the bladder, and UTIs. On [DATE] at 1:07 pm V3 (Nurse) provided catheter care for R2. When she cleaned R2's penis, skin around suprapubic catheter and the tubing, she only used normal saline. V3 did not use soap and water as R2 physician's order showed. When V3 removed the dressing from around the catheter the date on the dressing showed ,d+[DATE]. R2's EMARs reviewed: November EMAR showed: No documentation showing R2's supra pubic dressing was changed on [DATE], [DATE] and [DATE]. Monitoring R2's output ever shift was not done on [DATE] Evenings, [DATE] 10:30pm, [DATE] 630 am, & [DATE] 2:30 PM. December EMAR showed: [DATE]th, 12th & 22nd no documentation for R2's urine output was done. January EMAR showed: On [DATE] at 10:30 pm no urine output documented. On [DATE] no output document for all three shifts. On [DATE] at 9:00 am Bactrim DS ,d+[DATE]mg was not given as ordered. On [DATE] at 12:41 PM V2 DON, while looking at R2's electronic health records, verified that the above treatments and medications were not provided. V2 said that the nurse should have used soap and water when providing catheter care as the order and the facility policy shows. V2 said that by the nurse not giving R2 his Bactrim as ordered could have caused him to get another UTI or his current UTI not be treated appropriately as the doctor ordered. V2 said as she looked in R2's record, R2's [DATE] UA showed that his urine was positive for bacteria, a moderate amount, and his [DATE] culture and sensitivity came back positive for pseudomonas and E. coli (Bacteria). V2 said that she is noticing a trend with the residents having UTI's and becoming septic. 4. R1 was discharged to the local community hospital on [DATE] for altered mental status and died on [DATE]. R1's diagnoses included hydronephrosis with renal and ureteral calculous obstruction, retention of urine, urinary tract infection, benign prosthetic hyperplasia with lower urinary tract symptoms, and kidney failure. R1's October EMAR showed: On [DATE] day shift, [DATE] day shift and [DATE] day shift there was no recording of urine output for R1. R1's November EMAR showed: On [DATE] at 10:30 pm, [DATE] at 630 am, & [DATE] at 630 am no recording of urine output for R1. R1's December EMAR showed: On [DATE] and [DATE] no recording of urine output for R1. On [DATE] at 12:41 PM V2 DON said that poor catheter care could be the cause of the UTI's and sepsis of all four residents. V2 said that it is a facility's policy that all nurses follow physicians orders and believes that the nurses do not follow the physician's orders it can contribute to the residents being hospitalized with UTI's and septicemia. The facility's Catheter Care policy dated [DATE] showed: The purpose of this procedure is to prevent infections of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor. Ensure that the catheter remains secure with a leg strap to reduce friction and movement at the insertion site, catheter tubing should be strapped to the resident's inner thigh. Report to the supervisor any complaints the resident may have of burning, tenderness, or pain in the urethral area. Supplies soap and water. For the male use a washcloth with warm water and soap to cleanse around the meatus. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately 4 inches outward. Remove gloves and discard into designated container. Wash hands and dry thoroughly, clean the bedside stand, wash and dry hands thoroughly. The following information should be recorded in the resident's medical records the date and time that the catheter care was given, the name and title of the individuals giving the catheter care all assessment data obtained when giving catheter care, character of urine such as color and odor, any problems noted at the catheter urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. The facility Suprapubic Catheter care policy dated [DATE] showed: The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Maintain an accurate record of the resident's daily output. Equipment: soap and water. Wash around the catheter site with soap and water, note if the resident has a drainage sponge around the stoma site, remove the drainage sponge before washing with soap and water, wash the outer part of the catheter tubing with soap and water. Document the date and time the procedure was performed, the name and title of the individual who performed the procedure, assessment data obtained during the procedure, character of the urine such as color and odor.

Based on observations, interviews, and record reviews, the facility failed to provide proper catheter care for 4 of 4 residents (R1-R4) that were reviewed for catheter care. The findings include: 1. R3's diagnoses includes UTI (urinary tract infection), prosthetic hyperplasia with urinary tract symptoms, retention of urine, & acute kidney failure. On [DATE] at 10:48 am, R3 was sitting in his wheelchair, his catheter bag was hanging from under the chair, and the bag and tubing was touching the floor. The urine was dark and cloudy. At this time R3 stated that he (R3) had pain in his penis and testicles, and that he reported it to the staff. At 10:55 am V3 (Nurse) came into the room and saw that the bag and tubing was on the floor and tried to reposition them off the floor. V3 stated that she was going to put R3's leg bag on him. V3 stated that earlier she put the catheter bag under the wheelchair and R3 did tell her that his penis and testicles were hurting him. V3 stated that she was going to notify the doctor. V3 did not change R3's catheter bag or tubing as per R3's [DATE] Physician's order. On [DATE] at 11:02 am, V7 (Nurse) was providing catheter care cleaning R3's penis and catheter tubing with 4 X 4 gauze dressing wet with normal saline. V7 did not use soap and water. R3 complained of pain in his penis and testicles. There was leakage around the opening of the penis and a brown substance both dry and wet around the tubing near the opening. V7 did not change R3's catheter bag and or tubing as per R3's [DATE] Physician's order. On [DATE] at 12:33 pm V8 NP (Nurse Practitioner) stated that her expectations are that the nurses changed R3's catheter, bag, and tubing when it is clinically indicated such as when the urine was dark and cloudy, when R3 complained of pain, and when R3's catheter was leaking, just as the [DATE] physician's order shows. R3's physician's orders showed: [DATE] catheter care every shift. [DATE] record output from urinary catheter every shift. [DATE] change foley catheter for blockage and or leaking. [DATE] change catheter, tubing or bag when clinically indicated as needed. R3's EMARs (Electronic Medication Administration Records) were reviewed: November EMAR showed: No documentation for R3's output from [DATE] day shift through [DATE] night shift. R3's progress notes were reviewed, and no notes were found showing resident refused to wear a leg bag or that the catheter was changed on [DATE] or [DATE]. On [DATE] at 12:41 PM V2 DON (Director of Nursing) verified the above findings while looking at R3's electronic health records. V2 stated that the nurse should have followed the orders to change the catheter and tubing on [DATE] and [DATE] because if not it could lead to an infection. V2 stated, while looking at R3's lab results from [DATE] that it showed that R3 had bacteria in his urine. 2. R4's diagnoses include Type 2 diabetes, acute kidney failure, benign prostatic hyperplasia with lower urinary tract symptoms, chronic kidney disease stage 3, urinary tract infections, and pyuria. On [DATE] at 2:47 pm V5 (Nurse) provided catheter care for R4. When V5 cleaned R4's penis and catheter tubing, she (V5) only used normal saline. V5 did not use soap and water. V5 only cleaned her hands twice while providing care. V5 washed her hands before she put on her gloves at the beginning of care, and after she was done providing care, she removed her gloves and washed her hands the 2nd time. V5 did not clean her hands after cleaning R4's penis and catheter tubing after she removed her gloves. V5 only replaced her dirty gloves with clean gloves and continued drying R4's penis, then again removed gloves and put on new gloves and attached the brief and placed R4's blanket on him with her dirty gloved hands. R4's Physician's orders showed: [DATE] catheter care every shift. [DATE] catheter monitor output every shift. R4's EMARs (Electronic Medication Administration Records) reviewed: [DATE] EMAR showed: No output done for [DATE]th, 2024, at 10:30pm through [DATE]th, 2024, at 630 am. December EMAR showed: On [DATE] the staff did not change catheter securement device. On [DATE] at 12:41 pm V2 DON (Director of Nursing) while looking at R4's electronic health records, verified that the above treatments were not provided. V2 stated that by not providing proper catheter care and not changing the securement device it can cause UTIs. 3. R2's diagnoses include type 2 diabetes, retention of urine, neuromuscular dysfunction of the bladder, and UTIs. On [DATE] at 1:07 pm V3 (Nurse) provided catheter care for R2. When she cleaned R2's penis, skin around suprapubic catheter and the tubing, she (V3) only used normal saline. V3 did not use soap and water as R2 physician's order showed. When V3 removed the dressing from around the catheter the date on the dressing showed ,d+[DATE]. R2's EMARs reviewed: November EMAR showed: No documentation showing R2's supra pubic dressing was changed on [DATE], [DATE] and [DATE]. Monitoring R2's output ever shift was not done on [DATE] Evenings, [DATE] 10:30pm, [DATE] 630 am, & [DATE] 2:30 PM. December EMAR showed: [DATE]th, 12th & 22nd no documentation for R2's urine output was done. January EMAR showed: On [DATE] at 10:30 pm no urine output documented. On [DATE] no output document for all three shifts. On [DATE] at 9:00 am Bactrim DS ,d+[DATE]mg was not given as ordered. On [DATE] at 12:41 PM V2 DON, while looking at R2's electronic health records, verified that the above treatments and medications were not provided. V2 stated that the nurse should have used soap and water when providing catheter care as the order and the facility policy shows. V2 stated that by the nurse not giving R2 his Bactrim as ordered could have caused him to get another UTI or his current UTI not be treated appropriately as the doctor ordered. V2 stated as she looked in R2's record, R2's [DATE] UA showed that his urine was positive for bacteria, a moderate amount, and his [DATE] culture and sensitivity came back positive for pseudomonas and E. coli (Bacteria). V2 stated that she is noticing a trend with the residents having UTI's and becoming septic. 4. R1 was discharged to the local community hospital on [DATE] for altered mental status and died on [DATE]. R1's diagnoses included hydronephrosis with renal and ureteral calculous obstruction, retention of urine, urinary tract infection, benign prosthetic hyperplasia with lower urinary tract symptoms, and kidney failure. R1's October EMAR showed: On [DATE] day shift, [DATE] day shift and [DATE] day shift there was no recording of urine output for R1. R1's November EMAR showed: On [DATE] at 10:30 pm, [DATE] at 630 am, & [DATE] at 630 am no recording of urine output for R1. R1's December EMAR showed: On [DATE] and [DATE] no recording of urine output for R1. On [DATE] at 12:41 PM V2 DON stated that poor catheter care could be the cause of the UTI's and sepsis of all four residents. V2 stated that it is a facility's policy that all nurses follow physicians orders and believes that the nurses do not follow the physician's orders it can contribute to the residents being hospitalized with UTI's and septicemia. The facility's Catheter Care policy dated [DATE] showed: The purpose of this procedure is to prevent infections of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor. Ensure that the catheter remains secure with a leg strap to reduce friction and movement at the insertion site, catheter tubing should be strapped to the resident's inner thigh. Report to the supervisor any complaints the resident may have of burning, tenderness, or pain in the urethral area. Supplies soap and water. For the male use a washcloth with warm water and soap to cleanse around the meatus. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately 4 inches outward. Remove gloves and discard into designated container. Wash hands and dry thoroughly, clean the bedside stand, wash and dry hands thoroughly. The following information should be recorded in the resident's medical records the date and time that the catheter care was given, the name and title of the individuals giving the catheter care all assessment data obtained when giving catheter care, character of urine such as color and odor, any problems noted at the catheter urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. The facility Suprapubic Catheter care policy dated [DATE] showed: The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Maintain an accurate record of the resident's daily output. Equipment: soap and water. Wash around the catheter site with soap and water, note if the resident has a drainage sponge around the stoma site, remove the drainage sponge before washing with soap and water, wash the outer part of the catheter tubing with soap and water. Document the date and time the procedure was performed, the name and title of the individual who performed the procedure, assessment data obtained during the procedure, character of the urine such as color and odor. The facility's Handwashing/Hand Hygiene policy dated [DATE] showed that the facility recognizes hand hygiene procedures as primary means to prevent the spread of infections among residents, personnel, and visitors. Hand hygiene should be performed before direct contact with residents after direct contact with residents before putting on gloves, before handling clean or soiled dressings gauze pads etc, before moving from a contaminated body site to a clean body site during resident care, before and after putting on PPE (personal protective equipment) including gloves, after contact with resident's intact skin, after handling used dressings, potentially contaminated equipment, ect., after contact with objects such as medical devices or equipment in the immediate vicinity of the resident that may be potentially contaminated, after contact with potentially infectious material., and after removing gloves.

Based on observation, interview, and record review the facility failed to ensure enough clean linens, blankets, towels, and wash cloths were available for the residents. This applies to all the 69 residents in the building reviewed for a homelike environment. Findings include: On 01/02/25 at 9:24 AM, V2 DON (Director of Nursing) stated the facility census is 69. Facility's Data Sheet dated 12/31/24 also indicated their total census is 69. On 12/31/24 at 10:56 AM, R1 stated that she has made a list of items that the facility doesn't have. R1 stated that there were no bed pads the previous night and facility staff had given her their last sheet. R1 stated there were no wash rags available and no Kleenex. R1's 12/30/2024 MDS (Minimum Data Set) showed R1 is cognitively intact. On 12/31/24 at 10:22 AM, R3 stated the facility did not have enough bed sheets. R3's 12/8/2024 MDS showed she is cognitively intact. On 1/02/25 at 10:47 AM, R5 stated the facility is short on linen. R5 stated they are supposed to change his linen every Monday and they have not been doing it. R5's 12/2/24 MDS showed he is cognitively intact. On 12/31/24 at 11:05 AM, R2 stated the facility does not have enough towels or linens. R2's 11/26/2024 MDS showed she is cognitively intact. On 12/31/24 at 9:10 AM, a tour was conducted with V2 (DON) on the first floor and the second floor. The facility did not have dedicated linen closets on the floors, instead, staff obtained linens from the linen carts on the floor. On 12/31/24 at 9:40 AM on second floor, one linen cart had six pillowcases, twelve sheets, and nine bath blankets. The cart contained no washcloths or towels. The other cart on second floor had three top sheets, one hospital gown, two blankets, five pillowcases, and five fitted sheets. No towels or washcloths were available. On 12/31/24 at 9:50 AM in the basement laundry area, two laundry aides were working (V3 and V4) and they were folding resident clothing. In the laundry area, there were a total of 5 bedsheets, one reusable bed pad, and 4 blankets. When asked where the facility keeps the surplus linen, V3 and V4 stated this is all we have. We are washing some. We already delivered the linens. On 12/31/2024 at 10:18 AM, the first-floor linen cart held four towels and two washcloths, seven pillowcases, and seven bath blankets. On 1/02/25 at 10:05 AM, R6 stated sometimes they don't have enough linens. R6 stated the facility needed a lot of linen, adding they change it only when it gets wet. At 10:23 AM, R4 stated that they don't change linens frequently. R4 stated he doesn't think they have enough linens. At 11:03 AM, R7 stated that facility is short of linens. On 12/31/24 at 10:35 AM, V5 (Maintenance Director/ Housekeeping Director) stated that he was aware that the facility needed surplus linen, stating We don't have any. V5 stated that the CNAs (Certified Nursing Assistants) were throwing the linen away. On 12/31/24 at 10:50 AM, V6 (CNA) and V7 LPN (Licensed Practical Nurse) were interviewed. V6 stated she doesn't know who is throwing linens and towels away, but they don't have enough towels to work with, and V7 agreed. On 01/02/25 at 10:01 AM, V16 (CNA) stated that we don't have enough linen. V16 stated that staff put the dirty linen in the trash bags and take it to the laundry. V16 stated that sometimes staff don't have linen until 2:00PM, so they cannot give their showers. On 01/02/25 at 10:20 AM, V18 (CNA) stated that staff don't have enough linens and towels, and every day what linen they do have, they get it late. V18 stated We are not throwing linens away. On 12/31/24 at 12:19 PM, V8 (CNA) stated how can we do showers if you don't have linen? V8 stated she does not throw away linens or towels. On 12/31/24 at 11:19 AM, V1 (Administrator) stated that the facility does not have any backup supplies of linens, blankets, or towels. V1 stated that the facility needs more supplies, especially in case of emergency. On 12/31/24 at 10:28 AM, V9 (CNA) stated that staff don't have enough linen to change beds. On 12/31/24 at 12:47 PM, V10 (Restorative Aid) stated they don't get linens and towels soon enough, and sometimes there is a delay. V10 stated it all depends on which supplies are needed, but there are times they are short. On 1/02/25 at 9:46 AM, V13 LPN (Licensed Practical Nurse) sometimes there is linen, and sometimes there is no linen. On 01/02/25 at 10:01 AM, V15 (CNA) stated some days there is linen and some days there is no linen, and most of the time, there is not enough clean linen. V15 stated that the Social Worker did an in-service about showers, and she told them we don't have enough towels, but she did not know what was done about it. On 01/02/25 at 9:55 AM, V14 (CNA) stated that sometimes we can't bathe the residents, or we don't have enough linens to make their beds. V14 stated she told V2 (DON) when V2 asked her why things were not done. V14 stated this just started since last year having a shortage. V14 stated she never throws linens away unless they are stained very badly. On 1/02/25 at 9:24 AM, V2 (DON) stated that she has asked Housekeeping and the Administrator to order more linen, and she has not seen any being ordered or purchased. V2 stated she didn't know if the funds were available to buy the linens. The facility's Laundry Services Policy dated 01/2024 showed under #3 that laundry service will maintain sufficient inventory of clean linen and personal laundry in good repair to meet the needs of the residents. Under #15, this policy showed The Environmental Service Director shall be responsible for assuring quality assurance activities are performed in accordance with the facility's approved Quality Assurance Plan.

Based on interview and record review, the facility failed to notify the POA (Power of Attorney) and physician of changes in condition. This applies to 1 of 1 resident (R1) reviewed for notification of changes. The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included vascular dementia, schizophrenia, acute embolism and thrombosis of vein, muscle disorder, Covid-19, weakness. R1's MDS (Minimum Data Set) dated 10/14/24 showed R1 had moderate cognitive impairment. R1 was transferred to the hospital on 12/01/24 and was admitted . On 12/11/24 at 10:05 AM V2 (Director of Nursing) stated that she could not locate any documentation in R1's medical record regarding the right heel DTI (Deep Tissue Injury). The nurse who discovered the right heel DTI should have documented in the EMR (Electronic Medical Record), called the doctor/NP (nurse practitioner) to get orders, and notified the family. With no one knowing about R1's right heel DTI, R1 could have developed an infection or sepsis, and the skin integrity would not be maintained. On 12/11/24 at 9:42 AM V4 (Wound Care Nurse) stated on 11/18/24 she first noticed that R1 had a black, hard, unmeasurable, closed area to his right heel. She did not call the doctor/NP because it was not opened. V4 stated they kept an eye on it to see if it would open or not. V4 stated she saw the right heel again on 11/25/24, and the area was the same as before, there were no changes. V4 stated she still did not call the doctor because it had no changes. V4 stated they did not apply a dressing or protective treatments to the right heel, they only put socks on R1. V4 stated after 11/25/24, she never saw R1's right heel again. V4 stated R1 never complained of pain. V4 stated the area on the right heel was a DTI. V4 stated she did not notify R1's POA or family of the DTI to the right heel. On 12/11/24 at 3:05 PM V6 (Nurse Practitioner) stated she was not aware of R1 having a right heel DTI. V6 stated the nurse should have informed her of the resident having a DTI to the right heel. V6 stated R1 not having a treatment to the heel could have possibly caused a wound infection. V6 stated she was not informed of R1's elevated heart rate on 11/30/24. An elevated heart rate is a sign of progressing infection, R1 would have needed a further work up, and maybe an antiviral. V6 stated she expects the nurses to notify her with any changes in conditions the residents may have so they can receive the proper treatment. V6 stated R1 did not receive the proper treatment. R1's Resident's Bath and Skin Report Sheet for November 2024 reviewed. The report sheet showed on 11/18/24 R1 had a blister to the right heel (DTI) that was black, hard, and closed. The same report sheet showed on 11/25/24 R1 continued to have a blister to the right heel that was black, hard, and closed. Physician orders for November were reviewed, no wound care orders. R1's progress notes showed no evidence of POA, or provider notified of right heel skin alteration. Treatment records for November 2024 were reviewed, no orders for right heel blister.

Based on interview and record review, the facility failed to provide needed wound care treatment services and manage abnormal vital signs for a resident with Covid. This applies to 1 of 1 resident (R1) reviewed for improper nursing care. The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included vascular dementia, schizophrenia, acute embolism and thrombosis of vein, muscle disorder, Covid-19, weakness. R1's MDS (Minimum Data Set) dated 10/14/24 showed R1 had moderate cognitive impairment. R1 was transferred to the hospital on 12/01/24 and was admitted . On 12/10/24 at 2:38 PM V2 (Director of Nursing) stated the nurses take vital signs and do a nursing assessment every shift for residents with Covid. The nursing assessment is documented in the progress notes every shift. We do not have a standard assessment. V2 stated R1 should have had some documentation regarding his condition. R1 had Covid and should have been screened. V2 stated the nurse documented on 11/30/24 that R1 had a heart rate of 110. She did not document anything. She should have notified the doctor or the NP (Nurse Practitioner) of the elevated heart rate. On 12/1/24 R1 was not found unresponsive but he was hypoxic with a lot of phlegm. On 12/11/24 at 10:05 AM V2 stated that she could not locate any documentation in R1's medical record regarding the right heel DTI (Deep Tissue Injury). The nurse who discovered the right heel DTI should have documented in the EMR (Electronic Medical Record), called the doctor/NP to get orders, and notified the family. With no one knowing about R1's right heel DTI, R1 could have developed an infection or sepsis, and the skin integrity would not be maintained. On 12/11/24 at 9:42 AM V4 (Wound Care Nurse) stated on 11/18/24 she first noticed that R1 had a black, hard, unmeasurable, closed area to his right heel. She did not call the doctor/NP because it was not opened. V4 stated they kept an eye on it to see if it would open or not. V4 stated she saw the right heel again on 11/25/24, and the area was the same as before, there were no changes. V4 stated she still did not call the doctor because it had no changes. V4 stated they did not apply a dressing or protective treatments to the right heel, they only put socks on R1. V4 stated after 11/25/24, she never saw R1's right heel again. V4 stated R1 never complained of pain. V4 stated the area on the right heel was a DTI. V4 stated she did not notify R1's POA (Power of Attorney) or family of the DTI to the right heel. On 12/11/24 at 1:40 PM V5 (Licensed Practical Nurse) stated she was the nurse taking care of R1 on 11/30/24. V5 stated R1 had a heart rate of 110 beats per minute that I documented in the EMR vitals. I did not call the physician. I should have called the physician to give him an update on the resident. I should have documented in the progress notes about the resident's condition. The resident could have had a heart attack with an elevated heart rate. The Covid policy is to do vitals every four hours and document the residents condition every shift. I should have had some form of progress notes in for the resident. V5 stated I assessed R1 on 12/1/24 around 11:30 PM, he was very congested, had a lot of phlegm, no fever, and he was coughing. He was alert, and not unresponsive. His oxygen saturations were 88-89 on room air. We sat him up, applied oxygen, and called 911. 911 arrived and transported him to the hospital. Stated resident never complained to her that his foot was in pain. V5 stated she was not aware of R1 having a DTI to his right heel. On 12/11/24 at 1:45 PM V3 (Infection Preventionist) stated the Covid protocol is vital signs every four hours and the Covid screening should be done every shift. The nurses document the Covid screening in the progress notes. If the resident does not have any changes or abnormalities, that should be documented in the progress notes. We do not have a standard form for Covid screening. for someone who has tested positive for Covid. We monitor every shift for any changes in vitals, mental status, level of consciousness. On 11/25/24 I tested all the residents in the building and R1 tested positive for Covid. He was put on transmission-based precautions. R1 had a change in condition on 12/2/24. He had an elevated heart rate, anxious, congestion, increased respiratory status. He was sent out 911. He was admitted to the hospital. On 12/11/24 at 3:05 PM V6 (Nurse Practitioner) stated she was not aware of R1 having a right heel DTI. V6 stated the nurse should have informed her of the resident having a DTI to the right heel. V6 stated R1 not having a treatment to the heel could have possibly caused a wound infection. V6 stated she was not informed of R1's elevated heart rate on 11/30/24. An elevated heart rate is a sign of progressing infection, R1 would have needed a further work up, and maybe an antiviral. V6 stated she expects the nurses to notify her with any changes in conditions the residents may have so they can receive the proper treatment. V6 stated R1 did not receive the proper treatment. R1's Physician Orders for November 2024 showed 11/25/24 educate patient's with Covid-19 about signs and symptoms of complicated disease. If they develop any of these symptoms, they will be referred immediately to the primary care provider. Transmission based precautions. Contact and Droplet Precautions dated 11/25/24. R1 Progress Notes dated 11/25/24 3:30 PM showed SWD (Social Worker Director) met with the resident's wife and daughter regarding isolation precautions. At the moment, all of the resident's wife and daughter's concerns and questions have been answered. SWD will remain available as needed. 11/25/24 10:40 PM IDT Note: resident tested + for COVID. Resident has been placed on transmission-based precaution (contact/droplet). Family/Provider/NOD (Nurse on Duty) aware. 11/29/24 11:35 AM ID NP (Infectious Disease Nurse Practitioner) Impression/Plan: -Monitor patient symptoms address as they occur. -Pt stable currently. No current signs or symptoms of respiratory distress. -Continue to monitor vital signs q4H. -Antiviral if needed. -Continue strict contact/droplet isolation precautions per CDC (Centers for Disease Control) and Facility protocol. -Contact ID if the resident experiences any changes in condition or worsening signs and symptoms of infection including fever or signs of respiratory distress. 12/02/24 12:19 AM Patient is + for Covid. He has congestion and heart rate elevated to 125, respiration rate 26. Oxygen sats were not obtained due to patient restlessness and could not keep the pulse ox on his finger. Provider called. Orders to send out patient to ER to evaluate. 911 called. DON, wife notified of transfer. No documentation in progress for interventions for elevated heart rate of 110 on 11/30/24 at 3:02 AM, and elevated heart rate of 107 on 12/01/24 at 10:53 AM. The facility unable to provide documentation. R1's Resident's Bath and Skin Report Sheet for October 2024 reviewed. The report sheet showed R1's skin was intact. Resident's Bath and Skin Report Sheet for November 2024 reviewed. The report sheet showed on 11/18/24 R1 had a blister to the right heel (DTI) that was black, hard, and closed. The same report sheet showed on 11/25/24 R1 continued to have a blister to the right heel that was black, hard, and closed. Treatment records for October and November 2024 were reviewed, no orders for right heel blister. No skin assessments in the EMR. The Facility's Acute Condition Changes - Clinical Protocol revised August 2008 showed: 1. The nurse shall assess and document/report the following: a. vital signs, f. onset/duration/severity. The Facility's Pressure /Skin Breakdown- Clinical Protocol Effective January 2017 showed Policy Specifications: 2. In addition, the nurse shall assess and document/report the following: a. Full assessment of skin condition including but not limited to location, stage, or partial/full thickness, length, width and depth, presence of exudates or necrotic tissue. D. Current treatments, including support surfaces. 4. The physician will help the staff define the type of an ulceration. 7. The physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents.

Based on observation, interview, and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 80 residents in the facility receiving dietary services. Findings include: On [DATE] 10:55 AM, V26 (Dietary Manager) stated 80 residents were served from dietary services on [DATE]. On [DATE] at 10:01 AM, the kitchen tour was conducted with V26. The dry storage contained a facility contained labeled [NAME] powder was dated [DATE]. On [DATE] at 10:08 AM, the walk-in cooler contained a shelf labeled employee items included two personal lunch bags with food items, an 18 oz bottle of barbeque sauce, three unlabeled cups take sauce cups two with red sauce one with green sauce. Sliced Jalapenos 64 ounces dated [DATE]. An open 16-ounce bottle of water. A blue bottle with blue straw containing brown liquid was without a label or date. Two unlabeled pies dated ,d+[DATE]. Relish 128 ounces without a date. The facility policy Food Storage dated [DATE] states, food and non-food supplies are to be clearly labeled. Leftover foods are labeled, dated, immediately place under refrigeration, and used within 72 hours or discarded. On [DATE] at 10:30 AM, the one red sanitizing buckets sanitizer solution tested at 400 ppm (Parts Per Million). The facility policy Sanitation and Infection Control dated [DATE] states, sanitizer solution should read at 200 ppm (parts per million). On [DATE] at 10:33 AM, the vents over the stove were covered with grease and dust. The metal wall behind the stove was greasy with brown greasy grime drippings. Covered shelves containing neatly stacked dishware declared clean by V26 Dietary Manager and V27 Assistant Dietary Manager were caked with yellow crusts, dried food, and small dead black bugs. On [DATE] at 10:46 AM, V27 Assistant Dietary Director was observed in the kitchen with her bangs exposed from under her hair net. The facility policy Sanitation and Infection Control dated [DATE] states, it is the facilities policy to store, prepare, distribute, and serve food in an acceptable manner as to prevent the growth of food borne pathogens. At all times, facilities shall be thoroughly cleaned and sanitized to protect against potential contamination including spoilage, unacceptable microbial growth, dust, unclean equipment or utensils, hair, flooding, drainage, chemicals, or other sources of contamination. On [DATE] at 12:08 PM, V33 Dietary Aide stated the temperature for the turkey sandwich should be 35 degrees or below. The turkey sandwich plate was taken from an open cart to be served during lunch was 64.8 degrees F (Fahrenheit). The facility policy Food Storage dated [DATE] states, all readily perishable foods or beverages shall be maintained at temperatures of 41 degrees F or below. On [DATE] at 10:55 AM, V26 Dietary Manager stated food items should be labeled with delivery date. Open food products should have the open date and use by date written on them. The delivery date tells us when the food item was delivered. The open on and use by date lets everyone know when it expires. Eating expired foods can cause food borne illness. Anyone coming through the kitchen door should have their hair covered. The entire head should be covered. to keep hair from getting in the food and contaminating it. I was told we can keep employee food in the kitchen refrigerator if it's labeled as employee food on the shelf. My supervisor the regional director told me it was ok for employees to have a shelf in the refrigerator. Employees food being stored in the kitchen refrigerator is subject to the same standards of labeling and storage.

Based on observation, interview, and record review the facility failed to maintain the kitchen dishwasher and sink in good repair. This applies to 80 residents in the facility receiving dietary services. Findings include: On 12/05/24 10:55 AM, V26 (Dietary Manager) stated 80 residents were served from dietary services on 12/3/24. On 12/03/24 at 10:33 AM, V26 was unable to run the dishwasher stating it is currently not working. The trough like sink near the dishwasher was filled with dirty water. Covered shelves containing neatly stacked dishware declared clean by V26 Dietary Manager and V27 Assistant Dietary Manager were caked with yellow crusts, dried food, and small dead black bugs. On 12/03/24 at 10:42 AM, V27 Assistant Dietary Manager stated the dishwasher and sink have been backing up and not working since June. A shop vac is used to remove the water from the sink when it backs up. Dishes are either washed in the three-compartment sink for resident use or we use paper / disposable plates. On 12/04/24 at 12:08 PM, V33 Dietary Aide states residents' meals are served on Styrofoam when the dishwasher is not working. V33 stated the dishwasher works off and on and is not currently draining. On 12/05/24 at 10:46 AM, V18 Maintenance Director stated he has been in the facility for a month and has called twice for the sink / dishwasher repair. V18 stated the recommendation was the floor needs to be dug up to repair the drainage problem. The dishwasher has been repaired but not the drainage problem so the dishwasher still cannot be used. On 12/05/24 at 10:53 AM, Kitchen sink for dishwasher was filled with dirty standing water. On 12/05/24 at 10:55 AM, V26 Dietary Manager stated her employment in the facility began in August and there have been issues with the sink and dishwasher ever since she started. On 12/05/24 02:47 PM, V1 Administrator stated he did not have quotes or work order repairs going back to June. V1 stated he approved repairs for the floor to be dug up and pipes replaced on 12/04/24 and corporate submitted the approval for repairs. On November 26, 2024, a service request was created by V1 Administrator for Drain cleaning. Comment- request V1 request for pipes in dietary kitchen underground piping leading from the sink drain is clogged or broken. Needs to be pumped out, and camera line and fix pipe 11/29. 12/3 timeline - the work for job is not yet completed -not approved. An August 23, 2024, work request was placed for the dishwasher broken wash gauge. On 10/8 timeline for repair quoted pending approval. On October 16, 2024, V1 submitted a request for repair of broken drainpipe. On 10/18 the quote was accepted. On 10/29 Repair technician comments the kitchen sink line is open to the pit, however the pit is full and needs to be pumped out. Coordination with a pump truck is needed. Will return when the pit is cleared and rod/ jet/ camera if needed from the pit out to the main. Customer is not approving further work. On November 5, 2024, V26 Dietary Manager submitted a work order for appliance in the kitchen that included the garbage disposal in the dishwasher. On 11/27 the repair timeline entry by V18 Maintenance Director update - set to complete. The facility policy Equipment Maintenance dated June 2023 states all food service equipment will be operated, maintained, serviced, and cleaned according to manufactures directions. The facility policy Sanitation and Infection Control dated June 2023 states, it is the facilities policy to store, prepare, distribute, and serve food in an acceptable manner as to prevent the growth of food borne pathogens. At all times, facilities shall be thoroughly cleaned and sanitized to protect against potential contamination including spoilage, unacceptable microbial growth, dust, unclean equipment or utensils, hair, flooding, drainage, chemicals, or other sources of contamination.

Based on interview and record review, the facility failed to provide a resident and/or their family/POA (POA/Power of Attorney) in writing of the reason for transfer to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 6 of 6 residents (R26, R35, R50, R68, R72, and R73) reviewed for discharge in a sample of 30. The findings include: 1. R26's Face Sheet showed R26 was admitted to the facility on [DATE]. R26 had multiple diagnoses which included multiple sclerosis, dementia, diabetes, emphysema, hypertension, and major depressive disorder. R26's MDS (Minimum Data Set) dated 11/04/24 showed R26 had severe cognitive impairment. R26's Progress Notes showed the following: 08/20/24 at 6:45 PM Writer called to resident room by CNA'S (Certified Nursing Assistant). Resident noted slow to respond to verbal stimuli, as her normal baseline is AOX4, ashen color to skin noted, skin diaphoretic warm to touch. Noted for bloody (dark red) stool or urine, unable to determine which orifice blood is coming from. Writer notified NP (Nurse Practitioner) on call, received T.O (Telephone Order) to transfer to (Hospital) for evaluation. Daughter notified of change of condition and new orders for transfer. 08/20/24 at 7:34 PM Report given to (Hospital), daughter notified of the hospital being transferred to. 08/24/24 at 8:50 PM Resident is [AGE] years old was admitted to (Hospital) for sepsis and GI bleed, she is a full code has NKA (No Known Allergies), regular diet with thin liquids, and oriented times one to two fall risk. Resident came with a foley due to excoriation, skin is intact. Resident has a history of heart failure, stroke, dementia, diabetes, hypertension, multiple scoliosis contracted. Resident was readmitted back to room [ROOM NUMBER]-2. Resident came back with the same medications treated for sepsis in the hospital. NP notified, orders carried out, family POA (Power of Attorney) notified, will be here tomorrow to visit resident. R26's After Visit Summary from the hospital showed R26's dates of admission to the hospital were 08/20/24 through 08/24/24. The electronic medical record showed no documentation of written notice of reason for transfer or discharge to the hospital given to the resident or POA. The electronic medical record showed no notification to the Ombudsman for transfer or discharge to hospital. Facility unable to provide written documentation to the resident, POA, and Ombudsman. 2. R50's Face Sheet showed R50 was admitted to the facility on [DATE]. R50 had multiple diagnoses which included benign neoplasm of right bronchus and lung, anemia, diabetes, congestive heart failure, and chronic obstructive pulmonary disease. R50's MDS dated [DATE] showed R50 had sever cognitive impairment. R50's After Visit Summary from the hospital showed R50's dates of admission to the hospital were 02/05/24 through 02/07/24. R50's Progress Notes showed the following: 02/05/24 at 11:20 AM Resident in bed, HOB (Head of Bed) elevated, alert and oriented, verbally communicates needs. On oxygen as needed, respirations are regular, even, and unlabored. Skin is warm and dry to the touch. No s/s (signs and symptoms) of distress or discomfort noted at this time. Incontinence care provided by staff. Resident was in the dining room noted not responsive but breathing. Resident was brought to the room assisted to bed. Resident started responding. (Ambulance) was called. Resident assessed by the NP. Resident was transferred to the ER (emergency room ) for evaluation. Family called, no answer. Call light within reach will continue to monitor. 02/07/24 at 10:51 AM Received resident in bed, alert and verbally responsive. Resident was admitted to facility from (Hospital) for syncope. Resident was brought to facility in a stretcher by (Ambulance), was readmitted back to room [ROOM NUMBER] bed two. Resident according to report had a dressing on her bottom. Upon assessment resident skin was dry but intact. Family and NP made aware. NP gave an order to continue the medications from the hospital. Orders carried out. The electronic medical record showed no documentation of written notice of reason for transfer or discharge to the hospital given to the resident or POA. The electronic medical record showed no notification to the Ombudsman for transfer or discharge to hospital. Facility unable to provide written documentation to the resident, POA, and Ombudsman. 3. R72's Face Sheet showed R72 was admitted to the facility on [DATE]. R72 had multiple diagnoses which included dementia, atherosclerotic heart disease, anxiety disorder, cognitive communication deficit, need for assistance with personal care, and hypertension. R72's MDS dated [DATE] showed R72 had moderately impaired cognition. R72's hospital records showed on 07/14/24 R72 had an emergency room to hospital admission. R72's After Visit Summary from the hospital showed she was discharged back to the facility on [DATE]. R72's Progress Notes showed the following: 07/14/24 at 6:10 PM Nurse was called to the room that resident was complaining of chest pain. Writer came, assessed resident, stated she was having pain to the left breast. Resident was assisted into a w/c (wheelchair) then to her bed. Resident complained of chest pain, Nitro given, 911 called. Saturation was in the 80's, a non-rebreather was administered. Saturation came up to 100%. 911 arrived. Resident was taken to (Hospital). 07/14/24 at 6:44 PM Resident was taken on a stretcher by 911 crew. NP on call was notified and POA by voicemail. 07/15/24 at 7:00 PM 88y (year) old female returned from hospital visit. Resident assist off the ambulance gurneyx2 assist. Resident refused to transfer to bed and chair. Resident up ambulating in room, gait unsteady. Staff attempts to assist resident with ambulating, resident very resistive. Staff stays at bedside for now, will continue to monitor. 07/15/24 at 7:25 PM POA notified of resident return to facility. The electronic medical record showed no documentation of written notice of reason for transfer or discharge to the hospital given to the resident or POA. The electronic medical record showed no notification to the Ombudsman for transfer or discharge to hospital. Facility unable to provide written documentation to the resident, POA, and Ombudsman. 44387 4. R73's Hospital Admission Face sheet shows that R73 was admitted to the hospital on 10/3/24 due to worsening confusion. R73 was found to have acute catheter associated UTI (Urinary Tract Infection). R73's progress notes of 10/3/24 at 11:06 PM states that resident was transported to the hospital. 5. R35's After Visit Summary shows that R35 was admitted to the hospital on 10/10/24 to 10/14/24 with the diagnoses of acute and chronic respiratory failure with hypercapnia. R35's progress notes of 10/10/24 at 3:06 PM states that resident was admitted at hospital for respiratory failure. 6. R68's After Visit Summary shows that R68 was admitted to the hospital on 10/17/24 to 10/24/24 with the diagnoses of complicated Urinary Tract Infection. On 12/5/24, V1 (Administrator) and V2 (Director of Nursing/DON) said they are not providing written documentation of the bed hold policy to the residents, family, or the ombudsman when the residents are sent to the hospital. The facility's Bed Hold and Readmission policy (effective 11/2016) states that residents, or their designated representative, shall be informed of this policy at time of admission, and the time of transfer to a hospital or therapeutic leave which extends beyond 24 hours. The facility provides written notification at the time of transfers as included in the designated state form. A specific bed may be held for 10 days for the recipient of Medicaid benefits in accordance with State Plan.

Based on observation, interview, and record review, the facility failed to provide in writing to the residents and/or their POA (POA/Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 6 of 6 residents (R26, R35, R50, R68, R72, and R73) reviewed for discharge in a sample of 30. The findings include: 1. R26's Face Sheet showed R26 was admitted to the facility on [DATE]. R26 had multiple diagnoses which included multiple sclerosis, dementia, diabetes, emphysema, hypertension, and major depressive disorder. R26's MDS (Minimum Data Set) dated 11/04/24 showed R26 had severe cognitive impairment. R26's Progress Notes showed the following: 08/20/24 at 6:45 PM Writer called to resident room by CNA'S (Certified Nursing Assistant). Resident noted slow to respond to verbal stimuli, as her normal baseline is AOX4, ashen color to skin noted, skin diaphoretic warm to touch. Noted for bloody (dark red) stool or urine, unable to determine which orifice blood is coming from. Writer notified NP (Nurse Practitioner) on call, received T.O (Telephone Order) to transfer to (Hospital) for evaluation. Daughter notified of change of condition and new orders for transfer. 08/20/24 at 7:34 PM Report given to (Hospital), daughter notified of the hospital being transferred to. 08/24/24 at 8:50 PM Resident is [AGE] years old was admitted to (Hospital) for sepsis and GI bleed, she is a full code has NKA (No Known Allergies), regular diet with thin liquids, and oriented times one to two fall risk. Resident came with a foley due to excoriation, skin is intact. Resident has a history of heart failure, stroke, dementia, diabetes, hypertension, multiple scoliosis contracted. Resident was readmitted back to room [ROOM NUMBER]-2. Resident came back with the same medications treated for sepsis in the hospital. NP notified, orders carried out, family POA (Power of Attorney) notified, will be here tomorrow to visit resident. R26's After Visit Summary from the hospital showed R26's dates of admission to the hospital were 08/20/24 through 08/24/24. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. 2. R50's Face Sheet showed R50 was admitted to the facility on [DATE]. R50 had multiple diagnoses which included benign neoplasm of right bronchus and lung, anemia, diabetes, congestive heart failure, and chronic obstructive pulmonary disease. R50's MDS dated [DATE] showed R50 had sever cognitive impairment. R50's After Visit Summary from the hospital showed R50's dates of admission to the hospital were 02/05/24 through 02/07/24. R50's Progress Notes showed the following: 02/05/24 at 11:20 AM Resident in bed, HOB (Head of Bed) elevated, alert and oriented, verbally communicates needs. On oxygen as needed, respirations are regular, even, and unlabored. Skin is warm and dry to the touch. No s/s (signs and symptoms) of distress or discomfort noted at this time. Incontinence care provided by staff. Resident was in the dining room noted not responsive but breathing. Resident was brought to the room assisted to bed. Resident started responding. (Ambulance) was called. Resident assessed by the NP. Resident was transferred to the ER (emergency room ) for evaluation. Family called, no answer. Call light within reach will continue to monitor. 02/07/24 at 10:51 AM Received resident in bed, alert and verbally responsive. Resident was admitted to facility from (Hospital) for syncope. Resident was brought to facility in a stretcher by (Ambulance), was readmitted back to room [ROOM NUMBER] bed two. Resident according to report had a dressing on her bottom. Upon assessment resident skin was dry but intact. Family and NP made aware. NP gave an order to continue the medications from the hospital. Orders carried out. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. 3. R72's Face Sheet showed R72 was admitted to the facility on [DATE]. R72 had multiple diagnoses which included dementia, atherosclerotic heart disease, anxiety disorder, cognitive communication deficit, need for assistance with personal care, and hypertension. R72's MDS dated [DATE] showed R72 had moderately impaired cognition. R72's hospital records showed on 07/14/24 R72 had an emergency room to hospital admission. R72's After Visit Summary from the hospital showed she was discharged back to the facility on [DATE]. R72's Progress Notes showed the following: 07/14/24 at 6:10 PM Nurse was called to the room that resident was complaining of chest pain. Writer came, assessed resident, stated she was having pain to the left breast. Resident was assisted into a w/c (wheelchair) then to her bed. Resident complained of chest pain, Nitro given, 911 called. Saturation was in the 80's, a non-rebreather was administered. Saturation came up to 100%. 911 arrived. Resident was taken to (Hospital). 07/14/24 at 6:44 PM Resident was taken on a stretcher by 911 crew. NP on call was notified and POA by voicemail. 07/15/24 at 7:00 PM 88y (year) old female returned from hospital visit. Resident assist off the ambulance gurneyx2 assist. Resident refused to transfer to bed and chair. Resident up ambulating in room, gait unsteady. Staff attempts to assist resident with ambulating, resident very resistive. Staff stays at bedside for now, will continue to monitor. 07/15/24 at 7:25 PM POA notified of resident return to facility. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. The facility's Bed Hold and Readmission Policy dated November 2016 showed- Policy: It is the policy of this facility to readmit residents after hospitalization s or temporary therapeutic leave when the resident requires services which can be provided by the facility. This may be accomplished by holding a specific bed or by making available the next semi-private accommodations in the event a resident does not desire to hold the specific bed. Standards: 1. Residents, or their designated representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours. The facility provides written notification at the time of transfer as included in the designated stated form. The notice to the resident or their representative will specify the facility's policy, the duration of the state bed hold policy and the reserve bed payment policy. 2. In the event of an emergency hospitalization the resident or their representative shall be notified by telephone or in person of this policy, within 24 hours, and asked to provide the facility with their decision. The staff member making the call or explaining the policy may accept verbal determination as to whether the resident desires bed hold or having their name placed on the reservations/waiting list and shall document same in the medical record and in the progress notes. Follow up written confirmation may be required. 44387 4. R73's Hospital Admission Face sheet shows that R73 was admitted to the hospital on 10/3/24 due to worsening confusion. R73 was found to have acute catheter associated UTI (Urinary Tract Infection). R73's progress notes of 10/3/24 at 11:06 PM states that resident was transported to the hospital. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. 5. R35's After Visit Summary shows that R35 was admitted to the hospital on 10/10/24 to 10/14/24 with the diagnoses of acute and chronic respiratory failure with hypercapnia. R35's progress notes of 10/10/24 at 3:06 PM states that resident was admitted at hospital for respiratory failure. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. 6. R68's After Visit Summary shows that R68 was admitted to the hospital on 10/17/24 to 10/24/24 with the diagnoses of complicated Urinary Tract Infection. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. On 12/5/24, V1 (Administrator) and V2 (Director of Nursing/DON) said they are not providing written documentation of the bed hold policy to the residents, family or the ombudsman when the residents are sent to the hospital.

Based on observation, interview, and record review, the facility failed to provide ADL care (Activities of Daily Living) for 5 residents (R20, R69, R10, R62, & R5) who are dependent on care for daily living in a sample of 30. The findings include: 1. On 12/3/24 at 10:51 am R10 was observed with long jagged nails, white flakes of skin on the right upper side of his gown next to his face and his face had dry flaking skin. R10's 11/12/24 MDS (minimum data set) section C showed that R10's cognition is severely impaired. R5's 11/12/24 MDS section GG showed that R10 is dependent on staff for personal hygiene. R10's 3/8/24 care plan showed that R10 is dependent on ADLs with approaches including provided assistance with ADLs as needed. On 12/05/24 11:02 AM V1 DON (Director of Nursing) said that nail care and skin care should be provided as needed. 2. On 12/03/24 at 10:10 AM R20 was observed with long jagged fingernails. R20's 11/24/24 MDS section GG showed that R2 needs partial/moderate assistance for hygiene from staff. On 12/05/24 at 10:15 AM V2 said R20 should not have long jagged nails because he could scratch himself. V2 looked at R20 EHR (Electronic Health Record) and said that she could not find any documentation showing that R20 has refused any ADL care. 3. On 12/03/24 at 10:36 AM R69 was observed with long jagged fingernails with a brown substance under the nails. R69's feet were observed with dry flaking skin. R69's 10/4/24 MDS section C showed that R69's cognition is severely impaired. R69's 10/4/24 MDS section GG showed that R69 needs setup or clean-up assistance from staff for personal hygiene. R69's 10/25/24 care plan showed that R60 is limited in his ability to perform his ADLs related to Alzheimer's and lack of coordination. On 12/05/24 at 10:26 AM V2 (DON) said that staff should provide nail care as needed because of hygiene, dignity, infection control and safety. V2 said that the resident can scratch themself and or others. V2 said that R69 does not refuse any ADL care and that there is no reason that his nails and skin were like that. V2 said that staff should provide lotion to the residents' skin every day and as needed. 4. On 12/03/24 at 10:19 AM R62 was observed with dry flaking skin on his feet and his fingernails were observed long, jagged and with a brown substance under the nails. On 12/05/24 at 12:34 PM R62 was observed with long nails with a brown substance under the nails and V20 CNA (Certified Nurses' Assistant) brought his lunch tray into him, set up his tray but did not ask R62 if he would like to have his hands cleaned before he ate. At 12:36 PM V20 said that she did not ask R62 if he wanted his hands cleaned before he ate because she had given him a bath that morning between 730 AM and 8 AM. V20 said that she had seen the brown substance under his nails and that she should have offered to clean his hands before he ate. R62's 9/12/24 MDS section C showed that R62's mental cognition is moderately impaired. R62's 8/15/24 care plan showed that R62 has a decline in self-care related to cerebral palsy with approaches including providing assistance with ADLs as needed. On 12/05/24 at 11:06 AM V1 (DON) said that staff should provide nail and skin care as needed. 5. On 12/03/24 at 01:33 PM R5 was observed in her room with dry flaking skin on her forehead and scalp, hair oily, and her chin and upper lip was observed with long facial hair. R5 said that her hygiene bothers her and makes her frustrated. R5 said that she has not had a shower, or bed bath in over a month. R5 said that it has been weeks since her hair was washed because the facility does not have enough staff. R5's 9/11/24 MDS section C showed that R5's cognition is intact. R5's MDS section GG showed that R5 needs supervision or touching assistance with personal hygiene. On 12/05/24 at 11:08 AM V1 (DON) said that R5 does not refuse care and staff should be providing hygiene and shaving her. The facility's Activities of Daily Living (ADL) policy dated 2/2023 the policy shows that in accordance with the comprehensive assessment the facility will provide care and services including hygiene, bathing, dressing, grooming. and oral care.

Based on observation, interview, and record review, the facility failed to ensure that a resident with a dementia diagnosis and a wander monitoring device was prevented from eloping from the facility in the night. This failure resulted in R1 exiting the facility unnoticed and unsupervised and walking across an intersection to a gas station until a person from the community notified the police. This failure resulted in Immediate Jeopardy (IJ). The Immediate Jeopardy was noted to begin on February 9th, 2023, when R1 eloped from the facility unwitnessed by staff. This applies to 2 out of 3 residents (R1, R2) reviewed for elopement risk in the sample of 8. V1 (Administrator) and V2 (Director of Nursing/DON) were notified of the Immediate Jeopardy on February 14, 2023, at 1:40 PM and the IJ template was provided by email. The facility's Immediacy Removal plan was accepted at 9:00 PM on February 14, 2023. Although the immediacy was removed on February 14, 2023, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of new procedures and Quality Assurance Monitoring. The findings include: 1. On 2/14/23 at 6:28 AM, V13 (Responding Police Officer) stated that he was dispatched at 12:22 AM on 2/10/23 and reached the area where R1 was located between 12:25 AM and 12:30 AM. V13 stated R1 was on the grassy area or sidewalk outside the gas station. V13 stated that R1 was very confused and did not know where she had come from. V13 stated he saw R1 had four numbers written on a paper in an opened envelope (mail) with the facility address on it. V13 stated that R1 told him that the four numbers were the passcode for the door in her facility. V13 stated R1 told him she saw someone put in the code, but she did not know who the person was. V13 stated R1 also had the pass code memorized. V13 stated R1 thought the gas station was an outlet for a cab station or train station. V13 stated R1 started talking about her son and could not remember his phone number. V13 stated he called the paramedics because he wanted someone to assess R1. V13 stated when R1 was returned to the facility, he talked to V6 (Registered Nurse/RN) and another unknown nurse and they could not tell him how R1 obtained the pass code and left the facility. V13's (Responding Police Officer) case report number 22-000094 report showed he was dispatched to the crossroads near the facility (a two-lane county highway which crosses a four-lane divided highway with a median) for a welfare check. The caller stated that there was a woman with a walker (R1) in the middle of the road on (named road) . [V13] spoke with [R1] who stated in summary: [R1] was trying to catch a train 'over there' (from gas station, and to another city). [V13] informed [R1] that the gas station was a gas station and not a place for transportation. [R1] could not remember who she was going to see, her address, how long she had been outside, or what direction she came from. When asked these questions, [R1] appeared to be confused and could not provide an answer. The case report continued While looking through the pockets of [R1's] walker, mail with the address of the nursing home was found. [V13] then asked [R1] if she came from the nursing home. [R1] stated to [V13] in summary: [R1] left that place because they did not treat her right. [V13] asked [R1] how she left the nursing home. [R1] stated to [V13] that she knew the passcode to the doors. [V13] observed the passcode written down on a piece of mail. The local paramedics contacted the nursing home and verified [R1]'s residency there. An employee from the nursing home told [V13] and paramedics they were not aware that [R1] had left the building. [V13] had paramedics transport [R1] to the nursing home . On 2/11/23 at 2:14 PM, R1 was asked where she got the code. R1 initially stated that an unknown man put the code in and let her out. R1 stated that she was [AGE] years old and could not remember and was unsure if she put the code in her mail, adding her memory was bad. R1 stated she was trying to get out of the building and was looking for the train station because she wanted to go home. R1 stated she cannot sleep at night and sometimes she wakes up at 4:00 AM. R1 stated that day (2/9/23), she woke up and asked the nurse for some water. R1 was unable to tell surveyor the name of the nurse, only stating she was a black nurse and that she hollered at me and did not talk to me in a nice tone. R1 stated she asked the nurse for some medication to help her sleep and the nurse told her to wait in the dining room. R1 stated she waited a long time and got fed up and walked out of the dining room. R1 stated she went to her room and put her coat on. R1 stated she was not going to bother with those nurses because they just laugh and talk the whole shift. As the conversation continued, R1 changed the story and stated she put the code in herself. R1 stated that someone gave it to me and she did not remember the name of who it was. R1 stated she knew why she had a wander monitoring device, stating it's because if I went away from the facility, staff would know where I was. R1 also stated she felt she was being targeted because she is a black woman. R1 stated she did not understand why the white residents were able to leave the facility and she was not. R1 stated she left the facility because she was upset and could not stand the attitudes of the staff. R1 stated she left the facility and crossed the street and reached the gas station. R1 said she saw a lot of lights and thought the gas station was the train station. R1 said she felt she was not doing anything wrong. On 2/14/23 at 8:15 AM, V1 (Administrator) stated there were five staff caring for 26 residents on the night shift on 2/9/2023: V14 (Licensed Practical Nurse/LN), V6 (RN), and V7, V15, and V16 (Certified Nursing Assistants/CNAs). On 2/15/23 at different times, surveyor attempted to reach out to V15 and V16 via phone. Surveyor was unable to reach them and left a message on their voicemail. V2 (DON) had stated that V14 would return to the facility after 2/19/23 because someone in her family was in an accident. Surveyor did not reach out to V14. On 2/11/23 at 3:46 PM, V6 (RN) stated she started her shift at 10:45 PM on 2/9/23 and worked until 6:30 AM on 2/10/23. V6 stated that R1 came to her at the beginning of the shift, asking for something to help her sleep. V6 stated R1 had already received her scheduled dose of melatonin and told R1 that she would look if she had orders for anything else to help her sleep, and R1 waited in the dining room. V6 stated that R1 did have an additional medication, so V6 went to the dining room and R1 was not there. V6 stated she went to R1's room and found her under the covers sleeping, so V6 did not disturb her. V6 stated that around 12:45 AM (on 2/10/2023), V6 received a call from the paramedics who told her that R1 was outside walking. V6 stated when the CNAs did a head count, they were unable to find R1. V6 stated she was unaware that R1 was on elopement precautions, and she did not know that R1 wore an electronic monitoring device. V6 stated that when V13 (Responding Police Officer) came to the facility, V6 was informed that R1 had crossed the street and was at the gas station. V6 stated that whenever she has worked on R1's floor R1 would be up at night, sometimes asking for snacks and ice water, and R1 would get upset if V6 didn't give it to her right away. On 2/14/23 at 2:36 PM, V6 (RN) confirmed that the last time she saw R1 was at 11:30 PM on 2/9/23 and R1 was in her room in bed. On 2/11/23 at 3:49 PM, V7 (CNA) stated she was the assigned CNA for R1 overnight on 2/9/23 into 2/10/23. V7 stated she was not aware that R1 was on elopement precautions or that R1 wore an electronic monitoring device. V7 stated she did not know what the electronic monitoring device was or what it is used for. V7 stated that she was in the dining room and R1 had come in and sat down. V7 stated R1 was waiting for sleeping medication and after a few minutes, R1 went back to her room. V7 stated she did not remember the exact time. On 2/11/23 at 6:15 PM, V2 (DON) stated they were able to identify the door that R1 exited because of the specific code she had written down. V2 stated that on average, R1 is probably awake three out of seven nights a week. V2 stated that when that door is closed and locked from 8:00 PM to 8:00 AM, on the outside of the door (to enter R1's unit) is a red button to press to enter the unit. V2 stated if someone wears a wandering device, it will alarm when the person with the device enters the unit, but the alarm will not sound if a person with a wandering device typed in the code and exits the unit. On 2/11/23 at 2:00 PM, surveyor went with V1 (Administrator), V2 (DON), and V4 (Maintenance Director) on an environmental tour and the front main doors were checked. A receptionist was behind a desk and the door was unlocked. V2 stated that after 8:00 PM and until 8:00 AM, there is no receptionist by the main door. V1 stated the front doors are not locked from the inside because they are fire doors. V1 stated that when R1 went out the front doors (after typing in the code and exiting her unit), the doors would not have alarmed because they are not egress doors (which would alarm and then open after 15 seconds). V1 stated there is no alarm on the door although it is locked from the outside starting at 8:00 PM to 8:00 AM. On 2/11/23 at 2:07 PM, V2 and V4 described the control panel for the door leaving R1's unit into the hallway leading to front desk and lobby area. V2 stated that the control panel is to control both the wander monitoring system and egress door. The control panel showed Exit Alarm Control Unit-Power, Signal, and Status and number keys. To the right of the unit was the keyhole for staff to lock and unlock the doors. On 2/11/23 at 2:13 PM, V4 (Maintenance Director) demonstrated how the electronic wandering device system works on the egress door that R1 used to exit. When V2 (DON) brought the device near the unlocked and opened door to leave the unit, the monitoring system sounded an alarm. V4 then closed and locked the door. When V2 brought the device near the closed, locked door to leave the unit, the alarm did not sound any warning. When V4 pressed the hand bar the door, the egress alarm sounded and after 15 seconds, the door opened. Then V4, still holding the wandering device, put in a code and opened the door with no alarm sounding. On 2/11/2023 at 4:09 PM, V2 stated that the receptionist closes the unit doors and uses a key to turn the alarm box into the locked position at 8:00 PM. V2 stated when the door is closed and locked, it functions as an egress door and not a wandering alarm. V2 stated I know that night (2/9/2023), the doors were locked. On 2/11/23 at 3:00 PM, V11 (LPN/Nursing Supervisor) stated that she relieved V6 (RN) on the morning of 2/10/23 after R1's elopement incident. V11 said she heard that R1 eloped from the facility by putting in the code. V11 stated that sometimes R1 will understand things and sometimes not. V11 stated R1 also gets agitated and hollers at the staff. V11 stated R1 wakes up frequently at night and demands ice water right away and if she doesn't get it right away, she stands right in front of you and yells. V11 stated R1 is confused most of the time and R1 wanders around the unit. V11 stated R1 even sneaks into the nourishment room and gets snacks. V11 stated R1 has a wandering device and walks all over, including all the way to the receptionist area and uses the bathroom there. V11 stated R1 is an elopement risk due to her wandering. On 2/10/23 at 10:55am, V25 (Nurse Practitioner) stated she assessed R1 the morning after the elopement incident. V25 stated R1 was at her baseline when it came to her memory and added R1 knows people to a certain extent but is at times very forgetful. V25 stated that R1 had told her that she was going to the gas station. Surveyor asked V25 what the potential outcomes could be if someone like R1 left the facility unsupervised at night. V25 stated There is serious danger. [R1] could have been injured, seriously hurt and could have fallen. She could have been injured by another person or vehicle. R1's Face Sheet showed her diagnoses include unspecified abnormalities of gait and mobility, weakness, history of falling, repeated falls, cognitive communication deficit, difficulty in walking, unsteadiness on feet, unspecified dementia- unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, essential hypertension, and cardiac arrhythmia. R1's 1/25/23 care plan shows R1 experiences bouts of wandering, seemingly oblivious to needs or safety. R1's listed goal is for R1 to wander safely within specified boundaries. R1's 1/27/23 approach showed Equip resident with a device that alarms when wanders. Check for proper functioning . A second 1/27/23 intervention showed when resident begins to wander, provide comfort measures for basic needs . R1's 1/28/2023 fall care plan showed R1 is at risk for falling related to a diagnosis of dementia, weakness, and history of falls. R1's 11/21/2022 cognition care plan showed she displays deficits in the following areas: repetition of three words, temporal orientation and recall during the 7 days look back period. On 2/11/23 at 4:09 PM, V2 stated R1 is confused and not consistent in her ability to recall things. V2 stated R1 liked to walk in the closed-in courtyard and get fresh air. V2 stated she saw R1 walking outside wearing a fleece jacket once in November 2022 when it was around 35 degrees Fahrenheit. V2 stated she thought it was not a good decision by R1 to wear only a fleece jacket and she needed a thicker coat. V2 stated R1 was not wearing appropriate clothes and shoes either. V2 stated she called the doctor and obtained an order to place the wandering device. R1's February 2023 POS (Physician Order Sheet) showed a 11/21/22 order to place a wandering device and to check it every shift. V2 stated R1 received the wandering device in November after the interdisciplinary team determined R1 should be put on elopement precautions. V2 stated that she was unable to provide any notes of when she found R1 outside wearing inappropriate clothing. On 2/11/23 at 5:30pm, V2 (DON) stated that staff should always make sure when they put the code in for the door that no one is around them. V2 stated if a confused resident elopes, she could get hit by a car, fall, be abducted, or be killed, adding R1's incident happened in February when there is cold and inclement weather. V2 said I understand the gravity of the situation. It's serious. At 6:00pm, V2 (DON) stated elopement information is in the orders and care plans and her expectation is that nurses should be communicating with each other and the CNAs. On 2/11/23 at 4:14pm, V10 (Social Services Director) stated that she now completes the Elopement Risk assessments upon admission, quarterly, and re-admission. V10 stated she was not the one who completed R1's Elopement Risk reviews and observation sheets on 1/27/22, 11/21/22, and 1/9/23, but she completed the one on 1/26/23. R1's 1/26/23 Elopement Risk review showed R1 is an elopement risk of 3, which means she is not at risk and a monitoring device was not placed on her. On 2/11/23, V10 continued she thought she checked yes when she checked R1 had no monitoring device for wandering after one was placed. V10 said she took over the assessments because she wanted to make sure they were accurate. V10 stated R1's assessment and prior assessments were not correct. V2 (DON) stated that she also disagreed with the assessments because if someone has a wander guard, then they should be classified as an elopement risk. V10 stated residents should have assessments at the time of admission, quarterly, when they return from the hospital, when a wander guard is placed, and whenever there is an elopement incident. R1's 11/21/22 Elopement Risk review also showed R1 is an elopement risk of 3, which means she is not at risk, and a monitoring device was not placed on her. R1's 1/9/23 Elopement Risk review further showed R1 does not have dementia, does not have memory problems, and is not an elopement risk. The review also showed R1 is an elopement risk of 1, which means she is not at risk, and a monitoring device was not placed on her. On 2/11/23 at 6:55 PM, surveyor went to R1's room with V2 (DON), and V18 (R1's Son) was visiting her. Written on one of the pages in R1's purple notebook was 1251 to go out building. R1 changed her story and stated she saw someone put the code in and could not tell who it was. Surveyor asked R1 if she wrote the code on a piece of mail too and R1 stated she couldn't remember. V18 stated, I'm not surprised that (R1) would write the code down. She's very detailed. She was a court reporter. R1's 1/3/23 MDS (Minimum Data Set) showed R1's Brief Interview for Mental Status score was 04, meaning she is severely cognitively impaired. The same MDS showed R1's functional status as able to walk independently using a walker or wheelchair. The facility's undated Code Pink Elopement policy showed Elopement is defined when a resident's whereabouts is unknown. All nursing personnel are responsible for knowing the whereabouts of residents they are assigned to care for .Resident is not permitted to leave the building alone unless the attending physician has given an order to go out on pass without supervision. The policy continued Residents who have been identified as cognitively impaired and who have been assessed as an elopement risk will be provided with an alert elopement device or be placed in an area of the facility that has a door alarm device with audible sound . The policy described risk factors that will be assessed when determining for elopement risk: a. Independent ambulating with or without assistance. b. Pre-admission or history of elopement. c. Purposeful exit seeking. d. Restless, aimless pacing. e. Verbalization of wanting to leave the facility and/or go home .g. A cognitive impaired individual who is a follower. h. Inability to differentiate safe from unsafe situations. I. Diagnosis of Alzheimer's Dementia .J. Inability or refusal to follow instructions. R1's February 2023 Physician Order Report does not include an order permitting R1 to leave the building without supervision. On 2/11/23 at 4:14 PM, V2 (DON) stated that R1 and R2 were the only residents who had wandering devices and were on elopement precautions. 2. On 2/11/22 at 6:51 PM, R2 was seen wearing a wandering device on his leg. R2's February 2023 POS showed an 11/18/22 order to check his wander monitoring device three times a day. R2's Face Sheet showed he came to the facility on [DATE]. R2's Elopement Risk assessment was done on 5/22/18 and R2 scored a 4, indicating he was at risk for elopement. The next two elopement risk assessments completed were dated 11/8/19 and 12/30/19. In May 2021 and August 2021, R2 had no Elopement Risk assessments, and no Elopement Risk assessment was completed after R2 tried to elope on 9/30/22. No elopement risk reviews were completed at all in the year 2022 for R2. R2's elopement risk assessment dated [DATE] shows R2 was incorrectly scored as a 3, indicating he is not at risk. R2's 2/11/23 Elopement Risk assessment also scored him scored a 3. R2's Face Sheet showed diagnoses of cerebral infarction, altered mental status, insomnia due to medical condition, psychotic disorder with delusions due to known physiological condition, unspecified dementia- unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, unspecified psychosis not due to a substance or known physiological condition, muscle weakness, other speech and language deficits following unspecified cerebrovascular disease, and other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease. R2's 1/16/23 MDS score was 06, which means R2 is severely cognitively impaired. The same MDS showed R2 uses a wheelchair, he walks independently in his room and the corridor, and his balance is steady at all times when walking, turning around, or rising from a seated to a standing position. R2 has an 11/9/19 dementia care plan and a 5/21/18 care plan that showed Resident makes attempts to leave the facility. R2's 5/14/2018 fall care plan showed he is at risk for falls related to weakness and confusion and he ambulates with a slow gait and without an assistive device. R2's 12/2/19 care plan showed he may display maladaptive behaviors and mood distress due to his bipolar diagnosis. R2's progress notes document the following: On 9/30/22 at 9:30 AM, (R2) was noted to have walked outside of gate by patio. When (R2) saw writer approach, he started to return to patio area. When asked where he was going, he smiled and said he was not going anywhere. (R2) returned to patio area and into building with nurse on duty. Discussed with (R2) the danger of walking in areas around building that could be unsupervised and unpaved . On 9/30/23 at 10:30 AM, Writer spoke with (R2's) sister. She stated she already spoke with (R2) after speaking to nursing staff. She stated (R2) wants to go out and get a job . She knows and has explained to (R2) that it is not feasible for (R2) to get a job in community . On 9/30/22 at 11:00 AM, (Nurse Practitioner note) wrote of R2 Chief complaint/Reason for this visit: Attempted elopement .seen today by request of nursing staff .Per nursing staff, attempted to elope this morning. Per (R2), he was trying to 'get out of here and get a job.' Laughs and states, 'I got caught.' Understands this was not appropriate. Reports he is feeling well. Per nursing staff, has attempted this one other time. Was redirected with good response. On 9/30/22 at 3:48pm, (R2's) sister added that she removed all gym shoes from (R2)'s belongings and replaced with stiff bottomed slippers. She stated that she felt he would not try to go anywhere if he did not have any gym shoes. Writer made sister aware that (R2) was wearing gym shoes today. On 2/11/23 at 4:15pm, V2 (DON) stated if R2 had a wander guard placed on 11/18/22, then there should have been an elopement risk assessment after that. V2 stated she disagreed with R2's Elopement Risk assessments from 1/19/23 and 2/11/23, adding R2's score should have been at least a 4 because he's an elopement risk and he wears a wander device. The Immediate Jeopardy that began on February 9, 2023, was removed on February 14, 2023, when the facility took the following actions to remove the immediacy: Corrective Actions Taken: R1 was immediately placed on 1:1 supervision. Elopement risk assessment was performed on 2/10/23. Care plan was updated pertaining to the elopement on 2/10/23. Family contacted and gave consent to transfer R1 to a facility with locked unit. Outside company is installing new systems and alarms on doors. All residents with electronic monitoring devices checked for placement and function. Wandering device alarm codes changed and functioning. Exit doors were checked by maintenance director for the patency of alarms. Signage was placed on lobby entrance and key code pads alerting everyone to ensure that no residents are near the door when entering or exiting the unit and facility. Interdisciplinary team reviewed residents to determine risk for wandering/elopement and accuracy of evaluation and update as needed. All residents' elopement risks were re-assessed. Resident elopement risk binder updated. Staff in-serviced and placed at nurse's station and front desk. All employees have been and will be in-serviced prior to starting their next shift. Elopement drills have been conducted on all shifts. Emergency QA (Quality Assurance) meeting was held on 2/15/23 with Medical Director pertaining to elopement and intervention in place.

Based on observation, interview and record review, the facility failed to transfer resident in a safe manner. This resulted to the resident (R4) sustaining acute hematoma in the left lateral leg which required an emergency embolization procedure. This applies to 1 of 3 residents reviewed for transfer in the sample of 9. The findings include: R4 is a [AGE] year-old resident who has multiple medical [DIAGNOSES REDACTED]. R4's Minimum Data Sheet ((MDS) dated [DATE] showed that R4 is alert and oriented and requires extensive assistance with transfer. On 9/15/20 at 2:10 PM, R4 was resting in bed with her left lower leg wrapped with wound dressing. R4 gave the following statement: I was going to sit in the chair. V11 (Certified Nursing Assistant/CNA) and V12 (Nurse) transferred me from bed to the chair with a white sheet/white blanket. While they were hoisting me from bed to chair, V11 lost her grip on the sheet which was holding my left leg, causing my leg to hit the left leg of the chair. It was so painful, I screamed, and I saw my left leg getting bigger and swelling up. They called the ambulance and I was brought to the hospital. I underwent an immediate procedure (embolization) to stop the bleeding. The doctor told me that I sustained 3 holes in my arteries and if the arteries did not get fixed, I would have lost my life or my leg. I know what a gait belt is and they (V11 and V12) did not use it on me during that time. I didn't tell anyone here about what really happened because I don't want to put anyone in trouble and I get along well with them (staff) here. But I had to tell the doctor in the hospital the truth when they interviewed me so they could figure it out what treatment they're going to give me. On 9/16/20 at 9:55 AM, R4 gave the same statement that she had given the day before with regards to her leg incident. At 10:22 AM, V5 (Wound Care Nurse) provided wound care to R4. R4's dressing has blood stains which had seeped through from her hematoma. When V5 removed the dressing, it revealed a dark purplish/blackish hematoma in her left lateral leg, located just below the side of the left knee extending down by the ankle which measured as Length (L) 25.5 centimeter (cm) x 15.8 (cm). There were two openings (one in the upper and one in the lower part) in the hematoma which were excreting dark red blood. R4 was in pain and anxious during wound care as evidence by her grimacing facial expression and intermittent verbal expression of pain. On 9/16/20 at 10:20 AM, V11 (Certified Nursing Assistant/CNA) stated that she and V12 (Nurse) transferred R4 from bed to chair with a gait belt. R4's feet were both on the floor, but she was not fully bearing her weight. About 2-5 minutes later of sitting in the chair, R4 started screaming in pain. R4's left leg started to fill up and was getting bigger. V11 called V12 immediately. V11 also stated that there was no incident that happened during transfer and she didn't know why it happened to R4's left leg. On 9/16/20 at 12:35 PM, V12 (Nurse) stated that she (V12) and V11 transferred R4 into the chair with a gait belt. R4 couldn't fully stand. R4 was able to put her feet on the floor and pivot. She only had partial weight bearing. R4 did not hit her leg anywhere during transfer. When R4's leg started filling up with fluids, she was not crying but she looked nervous. On 9/16/20 at 1: 25 PM, V13 (Wound Care Physician) gave the following statement: R4 has wound in her leg which is a hematoma. V13 asked R4 what had happened to her leg but R4 told him that she didn't know. There are two openings in the hematoma one in the superior and one in the inferior area. V13 saw it on 9/15/20 and measured it as (L) 25.3 cm x (W) 17 cm. R4's hematoma can only be caused by trauma unless R4 is taking a serious anti-coagulant (blood thinner) medication. However, R4 has no anti-coagulant except for the Aspirin. R4's laboratory result showed that her INR and PTT are normal. So V13's conclusion is that the hematoma could have happened due to trauma. Hospital Record dated 8/31/20 Showed: R4 was admitted with left lower extremity acute hematoma. R4 states that she was being moved in bed when the left lateral side of her leg below the knee hit the side of the bed. R4 stated that she has instantaneous pain and noticed very quickly that the leg began to swell. R4 was brought into the emergency room for further evaluation. On arrival a large left lateral leg below the knee hematoma was noted. Hemoglobin was within normal limits. CT angios done showing subcutaneous hematoma. Physician reviewed this with [MEDICATION NAME] radiologist. Ultimately R4 was taken to [MEDICATION NAME] radiology lab where embolization of the left anterior tibial artery runoff was done. Procedure: Arterial Embolization CT [MEDICATION NAME] to Left Lower Extremity Findings: A soft tissue mass present in the anterior left lower leg measuring 23 cm x 11 cm x 4 cm. The mass is mostly soft tissues with serpiginous calcification and enlarged venous structures noted throughout. The mass extends to the skin. The mass does not extend to the deep fascia osseous structures of the lower leg. Impression: Soft tissue mass may represent hematoma. Radiology: Left leg History: Significant swelling following trauma. Findings: There is a significant soft tissue swelling along the anterior aspect of the leg likely representing hematoma. Facility's Policy and Procedure for Safe Lifting and Movement of Residents showed: - In order to protect the safety and wellbeing of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of the residents. Policy Interpretation and Implementation: - Mechanical lifting shall be used for any resident needing a two person assist. Except during emergency or unavoidable circumstances, manual lifting is not permitted.

Based on observation, interview and record review the facility failed to monitor and notify the physician of a deteriorating wound. As a result, R1's sacral area deteriorated to multiple unstageable wounds. R1 was admitted to the hospital, treated with Intravenous antibiotic therapy and scheduled for surgical debridement. This applies to of 3 residents (R1) reviewed for wounds in the facility. The Findings Include: The Face Sheet says R1 was admitted on [DATE] with the following pertinent Diagnosis: [REDACTED]. On 3/12/2020 at 3:50PM, V11(Hospital Nurse) showed pictures via computer of R1's sacral wounds. The pictures dated 3/10/2020 depicted 2 large excoriated areas with red and pink tissue, and one large opened area with necrotic/black tissue inside. V11 said R1 is on IV antibiotics for wound infection and will have surgical debridement on 3/13/2020. The computer documented the following measurements of the wounds, 1). 11.5 cm in length by 3 cm in depth 2). 9.5 cm in length by 5 cm in depth 3). 5 cm diameter opened wound. On 3/12/2020 at 4:13PM, R1 was in bed at the hospital with, V13 (Husband of R1) at her side. R1 had a midline to the left arm and intravenous antibiotic was infusing. R1 had a indwelling urinary catheter in place. R1 could not answer questions. V13 said R1's sacral area started as a small area about 3 cm in length, but it declined and no one did anything about. V13 said R1's undergarments would be soaked and wet with urine, you could wring the urine out like a mop. V13 showed pictures of 3 large sacral wounds on his cell phone dated 3/10/2020. V13 said on March 10, 2020 the nursing home wanted to send R1 out for a high potassium level, I was there and took these pictures before R1 was transferred to the hospital. We have been married for [AGE] years, I took the pictures, look at what they did to her. V13 said now R1 has a urinary bag is on IV antibiotics and needs surgery to cut the black dead tissue away from this large wound. V13 said he was at the nursing home everyday and told everyone about the wet undergarments but could not remember any names. All Progress Notes were reviewed from 12/11/2019 to 3/10/2020. Progress Note dated 2/18/2020 says, during incontinent care resident noted with dark purplish/black area to the left outer buttock. Skin intact around the area, small amount of bloody drainage noted. Physicians Ordered dated 2/18/2020 says mupirucin 2% to right upper buttock cleanse with normal saline, pat dry apply [MEDICATION NAME] and cover with a dry dressing daily and as needed; start [MEDICATION NAME] 875 milligrams twice a day, the [MEDICATION NAME] was discontinued/complete on 3/2/2020. Again R1 was hosptalized on [DATE] and started on IV antibiotics for wound infection at the hospital. Wound Evaluation Notes dated 2/18/2020, 2/26/2020 and 3/4/2020 were reviewed. The wound care doctor documented the last time R1 was examined 3/4/2020, monitor, apply barrier cream to slight excoriation peri-wound area; hardness remains purple in the upper 3/4 area. There is no documentation of the wounds eruption or decline, no documentation about worsening excoriatiation, no documentation about notifying the physician of the declining wounds. The treatment did not change for R1's wounds. On 3/12/2020 at 11:17AM, V5 (Wound Care Doctor) said he saw R1 and R1 had a hard, indurated abscess/boil like area most likely from bacteria. V5 said R1 was started on antibiotic ointment and oral antibiotics. V5 was not notified of the abscess/boil/blisters's erosion. On 3/12/2020 at 1PM, V8 (Nurse) sent R1 out on March 10, 2020. V8 said R1 had a hard boil that was treated with ointment. On 3/13/2020 at 8:37AM, V3 (Wound Care Nurse). V3 said she was not in the facility due to medical reasons since 2/24/2020 and no descriptive wound notes were entered since 2/24/2020. After reviewing the hospital pictures of R1's sacral wounds, V3 said, the moisture associated skin [MEDICAL CONDITION] was not there when she saw the wound in February of 2020, but notes that the doctor saw slight excoriation on 3/4/2020. V3 said the blister erupted and has tissue protruding from the wound. I can see it needs debridement. V3 said it is not clear when the blister erupted or when the [MEDICAL CONDITION] worsened, the doctor should have been notified. V3 said she will start to re-educate the nurses on monitoring changes in wound status and notifying the doctor. Wound Care Plan dated 2/18/2020 says to monitor for signs and symptoms of infection such as pain, odor, changes in exudate characteristics or redness, [MEDICAL CONDITION], or [MEDICAL CONDITION]. Notify physician if observed. Observe lesion characteristics weekly to monitor for effectiveness of treatment. Notify physician if lesion shows evidence of decline.

Based on interview and record review the facility failed to provide assistance to a resident identified as high risk for falls, needing two-person physical assistance and use of gait belt during the transfer to promote resident safety. The applies to 1 of 3 residents (R5) reviewed for falls in the sample of 10. This failure resulted in R'5s fall during a one-person assisted transfer, which was also without the use of a gait belt that resulted in the fracture of R5's femur (thigh bone). The findings include: R5 was admitted to the facility (MONTH) 22, (YEAR). R5's [DIAGNOSES REDACTED]. R5's MDS (February 24, (YEAR)) showed she was cognitively intact with a BIMS score of 12 of 15. R5's MDS also showed (R5) required extensive assistance of two staff when transferred from bed to chair or wheelchair. R5's fall risk assessment (dated (MONTH) 19, (YEAR)) showed R5 was at high risk for falling. The facility initial and final reportable documents showed that R5 had a fall incident on (MONTH) 13, (YEAR) at 7:47AM: The final report stated in part, Staff rendering care were interviewed and the staff stated that they were transferring R1 from the bed to the wheelchair when (R5's) legs gave out. Staff assisted (R5) and lowered (R5) to the floor. Staff stated R1 did not fall. Staff stated that they lowered (R5) to the floor . X-ray revealed right femur fracture. The report documented the physician was notified and gave orders to send R5 to the hospital for further evaluation, and R5 was admitted to the hospital. R5's medical records were reviewed and showed that on (MONTH) 15, (YEAR), R5 fell while being transferred from the bed to the wheelchair, while being assisted by one staff. The records showed the fall resulted in a [MEDICAL CONDITION] end of R5's right thigh bone, which required hospitalization for treatment. April 16, (YEAR) at 4:15PM, R5 stated (R5) fell but couldn't remember how. R5 had a cast on R5's right leg (from her thigh to foot.) R5 stated they put the cast on when I went to the hospital after I fell , she would be glad when it is removed, stating it's hard to move around with it. April 18, (YEAR) at 9:45AM, V2 (Director of Nursing) confirmed R5's fall occurred when V13 (CNA) transferred R5 alone and without the use of a gait belt. V2 stated there should have been two staff making the transfer. V2 also stated V13 should have used a gait belt, and stated V13 did not use a gait belt during the transfer. V2 stated it was facility policy for a gait belt to be used during transfers. April 19, 2019 at 5:15PM, regarding prevention of R'5 fall with fracture, V14 (R5's Physician) stated it would have been better if there were two staff during the transfer, and confirmed that a gait belt should have been used during the transfer. The facility provided their policy which required the use of a gait belt during transfers. The Safe Patient Lifting Policy (undated) stated: Gait belt usage is mandatory for all resident handling The gait belt will be considered a part of the certified nursing assistant's uniform.

Based on observations, interviews and record reviews, the facility failed ensure the use of gait belt during transfer of one resident (R1), which resulted in R1 sustaining a fracture to the right arm. Facility also failed to ensure proper use of gait belt during transfer for R3, R4 and R5 who were all reviewed for assistance of activities of daily living (ADL). Findings include: 1. R1 is an [AGE] year old female who had multiple medical [DIAGNOSES REDACTED]. R1's Change in Condition Form Dated 3/16/14 indicated: Staff will not transfer R1 by holding under the right arm. Will place wheelchair to left of bed and assist R1 to transfer per Z1's (R1's family) request. Nurse's Notes dated 5/5/14 at 5:00 AM indicated: R1 was being assisted up (from bed to shower chair in the bedroom) for shower. E5 (Certified Nursing Assistant/CNA) informed E4 (Nurse) that E5 put her left arm into under R1's right arm and then placed her (E5) right arm under R1's left arm/ waist area to turn R1 towards E5. While doing so a pop sound was heard per R1 from the right shoulder. Physician and Z1 (R1's Family) notified. R1 was sent to the hospital. E5's Incident Report statement dated 5/5/14 indicated: "On my last round in the midnight shift, I (E5) had to shower R1. The shower chair (back) was against the wall next to R1's bed to see it would not move. I had R1 in sitting position on side of bed. I placed my right arm under R1's left arm, and my left arm around R1's waist under her (R1) right arm. As I raised R1 from bed and as R1 uses her one foot to help pivot, we (E5 and R1) heard R1's right shoulder pop. So I sat R1 back down on bed and laid R1 down. I got E4 (Nurse), she called physician and called ambulance. Hospital Records dated 5/5/14 indicated: R1 is alert and oriented times three, and has expressive aphasia. R1 states she was being transferred by staff into the bathroom. Staff (E5) grabbed her arm. R1 felt a pop. R1 complains of right shoulder humerus pain. Radiology Report indicated: Acute comminuted and displaced fracture of the proximal humerus through the surgical neck. On 5/6/14 at around 5:05 PM, R1 was lying in bed (in the hospital). R1 was alert and oriented able to express self. R1's right upper arm was covered with bruise. R1 stated staff grabbed her in the arm to transfer her (R1) in the shower chair then she felt and heard a pop from right shoulder, staff did not placed a gait belt on her. On 5/6/14 at around 5:10 PM, Z1 (R1's Family) stated, staff called Z1 at home and told her that staff were transferring R1 to the shower chair when they heard a pop. R1 was in a lot of pain when she got into the hospital. On 5/7/14 at 6:52 AM E4 (Nurse) stated, E5 (CNA) came up to her and reported about R1's incident. E4 did physical assessment, physician and family were notified. E4 added there was no gait belt on site, E5 should have used a gait belt during transfer. On 5/9/14 at 10:45 AM E8 (Nurse) stated, R1 was on a stand pivot assist with gait belt use. 2. On 5/7/14 at around 6:10 AM, E9 (CNA) assisted R4 with morning care. E9 transferred R4 to the wheelchair. Gait belt was applied loosely and slipped above the waistline by the breastline during transfer. 3. On 5/7/14 at 7:25 AM, E10 (CNA) assisted R5 with morning care. E10 transferred R5 to the wheelchair. Gait belt applied by the arm pit due to mass in the abdomen, however E10 assisted R5 up by single handedly holding the gait belt at the back of R5 with only E10's right hand while E10 was on R5's left side.. 4. On 5/7/14 at 7:45 AM, E11 (CNA) transferred R3 to wheelchair. Gait belt loosely applied by the abdominal area. E11 then assisted R3 up by holding the gait with right hand at the back of R3, while E11's hand was holding R3 by her (R3's) right arm pit. On 5/7/14 at around 8:45 AM, E2 (Restorative Director stated, gait belt must be around the waist, snugged but not to tight and not too loose. Enough to slipped staff's fingers in between resident's body and gait belt. Staff should not lift resident under their arms. If staff lift resident under the arm can potentially cause bruising or dislocation in the arms/shoulders. Staff must look in the resident's care tracker for type of care resident should received, or CNA staff should ask the nurses for resident care information. On 5/7/14 at around 10:30 to 11:00 AM Z2 (Physical Therapy Area Manager) stated, use of gait belt is universal, it must be use by anyone/everyone who's being transferred with assistance, it is use to assist with transfer for resident who are unsteady. Gait belt is supposed to be around the waist. It should not be in the arm pit, if it's slipping up it's supposed to be re-adjusted. Hold front and back of gait belt for balance or bring resident to a standing position by grasping belt with both hands while remaining upright. Staff member to place feet apart, one foot forward than the other and slightly bend knees to assure solid posture. Z2 then demonstrated to surveyor this procedure. On 5/9/14 at around 10:55 AM E12 (Nurse) stated, she (E12) had been telling CNA staff frequently to use gait belt to the residents during transfer, because staff are not habitually using gait belt. Facility's Gait Belt policy and procedure indicated: When: Gait belt are to be used at all times while assisting a resident in getting in/out of bed, on/off commode or walking in the room or on the unit. Where: Gait belts are placed snuggly around the resident's waist. Why: Gait belts prevent injury of both the resident and caregiver and promote safety in the facility. How: - Gait belts are placed around the resident's waist.

Based on observations, interviews and record reviews, the facility failed to: a. Provide one resident (R6), who is confused, on fall and elopement precautions, with adequate supervision and monitoring to prevent her elopement from the facility and traveling on the highway in her wheel chair. b. Ensure that an exit door was adequately monitored and secured to prevent residents at risk for elopement from leaving the facility without appropriate supervision (R6 and R8). This applies to two of four residents (R6 and R8) reviewed for elopement precautions in the sample of eight. This failure resulted in one resident (R6), who also has multiple physical deficits (such as: inability to communicate her needs or ask for help, and stroke with paralysis), being in danger from being hit by a motor vehicle, sustaining possible serious injuries, or physical harm. The immediate Jeopardy was identified on 9/04/12 at 3:30 PM, and E1(administrator) was informed. It began on 08/29/12. The immediacy was removed on 9/04/12 at 6:30 PM, when the facility started implementing a plan to ensure all the nursing staff received ongoing training and implementation of safety measures to ensure residents are supervised and monitored to prevent possible elopements. The facility remains out of compliance at a level 2 due to the need to evaluate the staff response to training and implementation of safety measures, as well as policy and procedure. Findings include: 1. Review of the facility ' s Incident Reports documented the following on 8/29/2012: " 6:15 PM ... Location: Outside of the facility ... Reported: Daughter (of R6) ... Describe exactly what happened ... Patient (R6) was observed on 394 (Highway) by (R6's) Daughter and was returned to facility. Patient (R6) exit building via chapel (exit door in front of chapel) ... " The video tape, from the surveillance camera for the exit door by the facility's chapel, was reviewed on 8/31/12. R6 can be observed wheeling herself in her wheel chair out the door of the facility, and away from the building on 8/29/12 at 5:53 PM. However, none of the facility ' s staff were observed supervising R6, or providing R6 with any intervention needed to prevent her (R6's) elopement. The facility is observed to be located by Highway 394, which had a posted speed limit of 55 miles per hour. This section of Highway 394 has a light to control the flow of traffic, but it requires a pedestrian to be cognitively alert to safety cross the street. The exit door by the chapel was observed on 8/29/12 and 8/30/2012. Residents and visitors were observed entering and exiting the facility without any alarms being heard on 8/29/12 and 8/30/12. R6's daughter (Z2) was interviewed on 9/04/12 by phone. When asked about any possible elopement occurrence for R6, Z2 reported being aware of two occurrences. Z2 said approximately a month ago after visiting her mother, as she was pulling away from the parking lot, she looked in her rear view mirror and observed her mother leaving the facility unsupervised from the door near the chapel. Z2 said she escorted her mother back into the facility and informed staff. Next on 8/29/12 at 6:15 PM, Z2 turned off Highway 394 on to the road by the facility, saw a person in the middle of the road in a wheel chair, coming toward her car and Highway 394 . Z2 stated as her car got closer to the person in the wheel chair, she was shock to realize it was her mother (R6). Z2 said she was angry that her mother is on fall and elopement precautions, but facility's staff was not monitoring her (R6). Also, Z2 expressed feared that her mother (R6's) was allowed to be in a dangerous situation without the ability to ask for help. Z2 said R6 could have gotten hit by a car, abused by strangers, or fallen out of her wheel chair and got hurt as she hit the ground. Z2 observed alarms (chair alarm and electronic monitoring bracelet on her ankle) on R6's body, but she could not understand how staff failed to supervise and monitored her mother. When Z2 drove her mother back to the facility, she said that facility staff were unaware that R6 had left the building. E15 was the receptionist on duty when R6 eloped from the facility on 8/29/12. E15 was interviewed by phone at the facility on 8/31/12 at 3:15 PM. E15 described part of the receptionist's duties is to monitor the exit doors, and ensure no resident on precaution leaves the building without appropriate supervision. However, E15 told surveyor she did not observe or was aware of R6 leaving the building. E15 said, On 8/29/2012 " R6 was sitting by the chapel. She (R6) usually sits back by the chapel ... The other receptionist was showing me something on the computer, she (R6) may have gotten past me ... I don't know how far she went or how she got out the door. They said she had been trying to get out earlier that day ... " E15 reported that R6 tried to get out the facility one other time at the beginning of the summer using the exit door by the chapel. R6 has an electronic monitoring device on her ankle that can prevent her exiting the building. However, E15 said the exit door by the chapel, where R6 usually sat, did not have the electronic monitoring device on it. So, R6 could exit the building without her electronic monitoring device being engaged to prevent her (R6) from leaving the facility. E14 was R6's nurse on 8/29/12. E14 was interviewed on 8/31/12. E14 described R6 as being wheel chair bound because she had a stroke and cannot walk. E14 reported that R6 had history of falls and wandering. So, E14 said R6 had a chair alarm and a bracelet on her ankle to prevent possible elopement. However, E14 said she was not aware of R6's elopement until R6's daughter brought her back to the facility. At 2:39 PM on 8/31/12, E19 (Certified Nursing Assistant, CNA) was interviewed. E19 reported leaving on 8/29/12 around 4:15 PM because of family emergency. E19 said she did not know who was responsible for her work assignment. E19 said she reported to the nurse she was leaving. E19 stated she did not see R6 before she left off duty, nor gave report to another CNA. E19 reported that R6 had a history of [REDACTED]. E19 also described R6 as wanting to walk, and being unable to stand because of right sided paralysis. E9 was the CNA who cared for R6 on 8/29/12, after E19 left the unit. E9 was interviewed on 8/04/12 at 2:20 PM by phone. E9 reported that E19 had R6, but she had to leave to address a family emergency, and so there were only four CNA instead of five. E9 stated: " I started serving trays to residents ... I went to feed my resident ... Then I went to answer a call light and to toilet a resident " E9 said she did not see R6 leave the unit and she was not aware that R6 left the building until the nurse manager informed her. When asked how R6 manage to get out of the building, E9 said she " assume " that R6 took the elevator to the first floor and got out. However, E9's interview indicated she was not available to monitor and supervise R6 as required to prevent her (R6's) elopement. E18 (who is another CNA working on 8/29/2012) was interviewed on 8/31/12 at 4:11 PM. E18 reported seeing R6 eating dinner and wheeling herself out of the dinning room. But, E18 said she did not have R6 and was unaware when R6 left the unit. R6 was observed on the second floor on 8/31/12. R6 was observed to be wheel chair bound. R6 had a chair alarm and transmitter bracelet on her ankle. When asked questions, R6 was unable to communicate. Review of R6's Physician Notes (7/20/12 to 8/17/12), Admission and Physician order [REDACTED]. Review of R6's Monthly Nursing Assessment & Data Collection, dated 8/06/12, documented that R6 required extensive assistance to transfer, was wheel chair bound, and had contractures of the left hand. Staff also documented that R6 spoke in a manner that is unclear to others. Review of the initial Psychosocial Assessment/MDS Supportive Documentation Tool & Progress Note, dated 7/28/11, denotes "R6 wears a transmitter because she tries to go out of the facility." Review of R6's MDS (Minimum Data Set) Assessment, dated 7/19/12, documented R6 as severely cognitively impaired. Review of R6's care plan, dated 4/20/12 and 7/2012, documented R6 is "cognitive impairment" because of her "poor decision making, problems with memory, recall and understanding others." Further review of R6's care plan documented R6 "is at risk for elopement", and this concern is a focus in her care. However, the nursing interventions are not specific on the manner in which facility staff is monitoring and supervising R6 from eloping. For example, one of the intervention is to get R6 to participate in activities. But, there is no documentation of what activity staff plan to get her (R6) to engage in or when they plan to get her involved. The care plan also lack specifics on identifying which of the various members of the nursing team would be responsible for ensuring the intervention to monitor and supervise R6 was done. Review of R6's Fall Circumstance, Assessment, and And Intervention Note documented R6 is on fall precaution because she has a history of falling. R6 fell in the facility in April of 2011 and sustain a fracture. She fell as recently as June 2012 and sustained extensive facial bruising. Review of R6's nursing notes and social services notes lack documentation of interventions implemented to monitor and supervise R6 2. Review of the facility's Incident Reports documented R8 eloped via the exit door near the chapel on 6/10/2012. R8 is a confused resident, who is on fall precaution because of physical limitation, with [DIAGNOSES REDACTED]. The Incident Report documented the following for R8: " 6:15 PM ... Location found: Chapel Parking lot ... Who found resident (R8): 2 visitors ... " Included in the R8's Incident Report, dated 6/10/12, was documentation of statements from the receptionist (E15) on duty. The following was documented: " On Sunday (6/10/2012) there were two birthday parties in the villas (assisted living side). The entire guest were coming and going out the chapel doors. A visitor told me a man needed help. When I went out to assist, I saw it was R8. I went out to the parking lot and brought him back in ... (to the facility) " R8 was observed on 8/31/12 to be wheel chair bound and confused. E15 was the receptionist on duty when R8 eloped from the facility on 6/10/12. E15 was interviewed by phone at the facility on 8/31/12 at 3:15 PM. E15 said she did not observed or was aware when R8 left the building. E15 said she became aware of R8 leaving the building when a visitor told her that a resident was in the parking lot needing help. When asked why the visitor felt R8 needed help, E15 stated that the visitor described R8 saying: " Help me! " Then, E15 said she found R8 out in the parking lot sitting in his wheel chair. E15 stated that R8 cannot communicate well. But when she asked where he (R8) was going, R8 said he was getting out of the facility. While interviewing members of the nursing staff on 8/31/2012, they display a lack of awareness of which residents were on elopement precaution and the location of this information. One nurse (E13) stated she knew residents were on elopement precautions because she observed the transmitters on their ankles. E6 (clinical care coordinator) went to the computer to show the surveyor that care information in the computer included information about the resident's elopement status. However, only one out of the three residents on elopement precaution had the information documented to alert staff. On 8/31/12 at 12:05 PM, the maintenance director (E16) was interviewed in the all purpose room near the chapel. E16 is responsible for checking and maintaining the facility's electronic monitoring devices used on the residents and facility's doors. However, E16 had no evidence of implementing a plan/schedule of checking the electronic monitoring system (transmitter's bracelets and door detectors) as recommended by the manufacture, such as: performing " mock " drills. This did not ensure that the facility's electronic monitoring system was tested and verified to be operational for the safeguard of wandering residents. The manufacture's manual for the facility's electronic monitor systems was reviewed. This manual provided the following instructions for staff: " ... We strongly recommend that the system be tested on minimum weekly bases to verify that it is operating properly. This should consist of a " mock " escape attempt routine for each monitored zone, and should also include testing of all transmitters, as specified in this manual. " ... FAILURE TO DO SO COULD JEOPARDIZE THE RELIABLE AND/OR CONSISTENT OPERATION OF THE CODE ALERT SYSTEM. " Review of the facility's Procedure Guideline for Alarm Checks had the following instructions documented for staff: " a. ...a door alarm check schedule and designate a person and alternate to complete the alarm check task. " Review of the facility's Elopement Policy documented the following: Procedure: ...3. A plan of care will be developed and implemented for each resident identified as having the potential to leave the facility... 7. A check will be completed of alarmed doors and resident alarms to ensure proper function..." However this policy was not being followed by facilities staff. R6's care plan lack clear plan to provide R6 with supervision and monitoring she needed. Also, there was no evidence of the facility's electronic monitoring system being consistently and systematically checked to ensure it was functioning. During the a meeting with administrative staff (including the executive director (administrator)/E1 and director of nursing/E2) on 8/31/2012 and 9/04/2012, the above concerns were discussed with them. Up to exit on 9/11/2012, the facility did not present any evidence to support that staff provided R6 with the supervision she needed to prevent her (R6's) elopement from the facility. E1 did present the removal plan on 9/04/2012 The removal plan was accepted on 9/11/2012, after an on-site visit to confirmed the facility took the following actions: 1. All resident in the facility are at risk to be affective. So, all residents were assessed on 9/04/12 for potential/risk for exit seeking behaviors. 2. Any resident identified as at risk for exit seeking had their care plans updated, the elopement risk profile implemented and transmitter bracelet applied. 3. The resident's elopement risk profiles were also updated. The resident ' s elopement risk profile provide the nursing staff quick access to who is at risk for exit seeking, and detail information on how to care for the residents. 4. Resident's elopement profiles will be reviewed daily by the Unit Managers starting on 9/04/12. 5. A master list of residents at risk for exit seeking was developed. 6. All new residents identified as exit seekers have been place on the Elopement Risk Master list. 7. The Elopement Risk Master List and elopement profiles will be maintained in a binder (AKA the walking club book), which will be kept at each nursing station and front reception desk. 8. physician's orders [REDACTED]. 9. All transmitters on the residents, door alarms and functional operations of the electronic monitoring system were checked by the Plant Operational Director on 8/31/12. 10. On 8/31/12 the door exiting the Healthcare campus (facility) had an electronic alarm system applied. This will prevent entrance to the Assisted Living portion of the campus without the use of a keypad code. 11. The Policy and Guidelines for Elopement Risk Reduction was updated to include the use of the " Existing Seeking Circumstance " Assessment Tool to help develop and identify interventions to monitor and prevent residents from eloping on 9/04/12. 12. All facility staff was in-service, on all shifts, starting on 8/31/12 and 9/04/12 on the electronic alert system, answering of the alarms, elopement policy and procedures. 13. The licensed Nurses and CNA's , on all shifts, were in-service starting 8/31/12 and 9/04/12 on resident ' s elopement profiles. 14. The Licensed Nurses, on all shifts, were in-service, starting on 8/31/12, about the Exit Seeking Circumstance Form 15. Starting on 9/04/12, the plant operation staff was in-service on the procedures for documenting the operational status, checking and maintaining the functioning of the facility ' s electronic monitoring system (Per Manufacture's Recommendations). 16. The Medical Director was informed of the Immediate Jeopardy, and consulted on this action plan and policy updates on 9/04/12. 17. The DHS (Director of Health Services/Director of Nursing) and/or designee will audit nursing staff on all shifts, using F323 tool (Attachment J) to: randomly check nursing staff knowledge of the location of the walking club book (elopement book), identification of residents at risk for elopement, and checks for transmitter bracelets on residents. This monitoring will be done, starting 9/04/12, five times per week for 4 weeks, then 2 times per week for 4 weeks, then weekly for 2 months. 18. The Director of Plant Operation and/or designee will auditor and monitor for completion of electronic door alarm system checks 3 times per week for 4 weeks, then 2 times per week for 4 weeks, then weekly for 2 months (Starting 9/04/12). 19. The ED and/or designee will conduct Elopement drills weekly, starting 9/04/12, for 30 days and monthly there after. 20. The DHS, Director of Plant Operations, ED (Executive Director/Administrator) and/or their designee will report findings of above audits to the Quality Assurance /QA&A monthly for 6 month. 21. The QA&A will monitor audits for 6 months or until 100 % compliance is achieved. The QA&A will also make any recommendations to the Plan of Correction as needed.

Based on observation, record review, and interview the facility failed to: 1. Ensure a thorough assessment was done on admission to the facility for R4's left hip surgical wound. 2. Ensure R4's left hip surgical wound site was assessed, monitored for signs and symptoms of infection, and documented on daily. 3. Prevent infection of R4's left hip surgical wound site. 4. Develop a plan of care to address care, treatment, and monitoring of signs and symptoms of infection to R4's left hip surgical wound site. 5. Ensured nursing staff washed their hands at appropriate times and did not contaminate items during wound care treatment. (R1 and R2) Due to these failures R4's left hip surgical site became infected and R4 suffered severe and increased pain to the surgical site. R4 was admitted to a nearby hospital where he was diagnosed with [REDACTED]. This is for 1 resident in the sample of 4 (R4) cited for assessment, monitoring, and documentation of a wound and 2 residents in the sample of 4 (R1 and R2) cited for infection control procedures during wound care. The findings include: Review of R4 's admission face sheet showed R4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital documentation dated 1/17/12 showed R4 came to the hospital emergency room with [DIAGNOSES REDACTED]. R4 was admitted to the hospital at this time and a left hip replacement was performed. 1. Facility documentation showed R4 was admitted to the facility on [DATE]. Nursing documentation on admission showed there was no thorough assessment of R4's left hip surgical site. Nursing documentation on the Skin Impairment Assessment form dated 1/20/12 showed R4 had staple sutures to the site but the number of sutures was not documented and there was no documentation the sutures were intact. In addition, there was no documentation of the appearance of the wound margins. Documentation showed there was no signs and symptoms of infection. Review of physician's orders showed R4 was to have a dressing change daily to the site on the 7-3 shift. 2. Nursing documentation dated 1/21/12 (7-3 shift) showed "Left hip surgical site, staples intact (number of staple sutures not documented), no drainage, surrounding skin intact. No complaints of pain." Nursing documentation dated 1/22/12 (7-3 shift) showed, "L hip surgical site, staples intact (no number documented), treatment per M.D. order. Surrounding skin intact, no redness, no [MEDICAL CONDITION], no complaints of pain." On 1/23/12 nursing documentation only showed, "No complaints of pain or discomfort. L hip dressing dry and intact." There was no further documentation of the appearance of the surgical site from 1/22/12 to 1/25/12. 3. On 1/25/12 Z1 (wound doctor) assessed R4's wound. Z1's documentation showed R4's surgical wound had redness with a moderate amount of serosanguinous drainage. Z1 also noted R4 experienced pain with cleaning of the wound. R4 was sent to a nearby emergency room for evaluation of the left hip surgical wound. R4 returned to the facility on the same day (1/25/12) with orders to continue dressing change daily to the site. No further nursing documentation was found regarding daily assessment of R4's left hip surgical wound site for 1/26 or 1/27/12. The next nursing documentation found was dated 1/28/12 at 1:00 p.m. which noted the following: "Noted very large amount of brown drainage to L hip. Pt. complains of severe pain to L hip. Pt has more pain than usual. Pt is lethargic and weak. Pt's urine is brown color." R4 was transferred to the hospital on [DATE] at 2:00 p.m. and returned to the facility at 10:00 p.m. with orders for 2 antibiotics (Keflex and [MEDICATION NAME]). At 12:00 midnight R4 complained of difficulty urinating and was sent back out to another hospital on [DATE]. emergency room documentation showed R4 had a large amount of foul smelling serous drainage. R4 was admitted to the hospital with [REDACTED]. Hospital progress notes dated 1/30 and 1/31/12 continued with documentation that R4's left hip incision had large/copious amounts of serosanguinous and/or purulent, foul smelling drainage. Progress note documentation showed R4 was also in severe pain rating his pain at a 10 of 10 on a pain scale of 1-10. R4 was given IV [MEDICATION NAME] for pain and IV antibiotic therapy. Review of a hospital Infectious Disease Consult dated 1/31/12 showed documentation from the Infectious Disease physician for R4 of "Postoperative infection with gross purulent drainage from the incision, and I [MEDICAL CONDITION] syndrome given the bandemia and intermittent [MEDICAL CONDITION] tachypnea." Review of hospital lab culture of R4's left hip wound dated 1/30/12 showed results of "many staph aureus and proteus mirabilis" bacteria. Review of hospital blood cultures for R4 dated 1/30/12 showed positive results of "staph aureus" in R4's blood which verified Infectious [MEDICAL CONDITION] syndrome. 4. Review of the facility's plan of care for R4 showed no care plan was developed for the care, treatment, or monitoring for signs and symptoms of infection of R4's left hip surgical wound site. 5. On 2/28/12 at 11:45 a.m. E4 (LPN) was observed performing a dressing change to R1's left lower leg wound. When E4 removed R1's old dressing she did not remove her gloves or wash her hands before cleaning and dressing the site. During interview with R1 at this time R1 stated, "My dressing is supposed to be changed one time a day. It's not always changed once a day. Sometimes it is not done every day. It depends on who's on duty. I'm not going to remind them to change the dressing." Review of treatment sheet documentation for R1 and R2 showed dressing changes were not documented as being done every day as ordered. On 2/28/12 at 1:20 p.m. E5 (LPN) was observed performing wound care on R2's left heel. E5 removed the old dressing from R2's left heel by cutting the dressing off with her bandage scissors. After E5 removed the old dressing she laid the bandage scissors on R2's bed, thereby contaminating the bed. The old dressing had a large amount of bloody drainage on it. When removing R2's old dressing, a section of the bloody dressing was stuck to R2's heel and E5 had to saturate the dressing and peel it off with her gloved hand. E5 changed gloves but did not wash her hands after removing the old bloody dressing. E5 also had R2's treatment sheet in the room with her which she laid on R2's bed and later on R2's overbed table, thereby contaminating the treatment sheet and the overbed table. Interview with E2 (Director of Nurses) on 12/29/12 at 11:20 a.m. noted E2 to say the nurses are to do a thorough assessment of all wounds of residents on admission to the facility. E2 stated R4's left surgical wound site should have been assessed, monitored for signs and symptoms of infection, and documented on daily. E2 stated a plan of care should have been developed for the care and treatment of [REDACTED]. Review of the facility's policy on Wound and Skin Care included to "Reevaluate dressing and skin integrity every shift." Review of the facility policy on Handwashing notes "Handwashing shall be regarded by this organization as the single most important means of preventing the spread of infections. The policy Interpretation and Implementation included: All personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. The policy noted several situations in which appropriate 10-15 second handwashing must be performed. This included: -After handling used dressings, contaminated equipment, etc... -After contact with blood, body fluids, excretions, secretions, mucous membranes, or non intact skin. -After handling items potentially contaminated with blood, body fluids, excretions, or secretions. -After removing gloves. The policy also notes, "The use of gloves does not replace handwashing."