Every finding on record at The Heights of North Houston

Based on observations, interviews, and record review, the facility failed to ensure the personal privacy during personal care for 1 (Resident #1) out of 1 residents reviewed for privacy.-The facility failed to ensure CNA M closed the door and/or the privacy curtain while providing incontinence care to Resident #1, on 6/17/26.This failure could place the residents at risk of not having their personal privacy maintained during personal care, and a decrease in dignity.Findings included: Record review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with epilepsy (seizures), acute embolism/thrombosis of the RLE (clot), drug induced dyskinesia (shaking), morbid obesity, and functional quadriplegia (unable to use arms/legs).Record review of Resident #1's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 which indicated normal cognition. The resident was dependent (helper does all of the effort, resident does none of the effort) for toileting. According to the assessment, the resident was always incontinent of bowel and bladder.Record review of Resident #1's Comprehensive Care Plan, dated 9/17/2025 revealed a Focus: Resident #1 had a self-care deficit, poor physical endurance, seizure disorder with medication noncompliance. The interventions revealed that toileting hygiene required 1 person assist, she was dependent, and she was bedbound and did not transfer to the toilet. Focus: Resident #1 had incontinence r/t physical limitations. Interventions included incontinent care assistance every shift and as needed.In an observation on 6/17/26 at 10:32am, Resident #1 was lying flat on her back in bed without a brief on, with her genitals exposed. CNA M was providing incontinence care to Resident #1 with the resident's door open and the privacy curtain open.In an interview on 6/17/26 at 10:39am, CNA M said she left the door open because she gets claustrophobic. She said not closing the door or curtain is a dignity issue for the resident and the resident would be embarrassed.In an interview on 6/17/26 at 10:47am, Resident #1 said she did not know the door was open and the curtain was open. She said she did not like the curtain and the door left open because someone could have seen her and that made her feel bad.In an interview on 6/17/26 at 4:01pm, the DON said she expected staff to give privacy to the residents when they were cleaning them, which could have entailed closing the blinds, closing the privacy curtain, or closing the door. She said without doing one of those, it became an issue of privacy/dignity for the resident.Record review of the facility's policy and procedure on Resident Rights (revised February 2021) read in part: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:.be treated with respect, kindness, and dignity.privacy and confidentiality. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.Record review of the facility's policy and procedure on Perineal Care (revised February 2018) read in part: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Provide privacy as appropriate, such as closing doors/curtains, drape resident.

Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections that includes written standards, policies, and procedures for the program for 2 (Resident #2, Resident #3) of 4 residents reviewed for infection control. 1. ADON B failed to perform proper hygiene when she touched the tube and button device for the G Tube for Resident #2. ADON B failed to wash her hands prior, failed to wear gloves, and failed to wash her hands after for a resident on enhanced barrier precautions. 2. ADON B failed to perform proper hygiene when she opened the brief for Resident #3. ADON B failed to wash her hands prior, failed to wear a gown, and failed to wash her hands after for a resident on enhanced barrier precautions. These failures placed residents at risk for spread of infection through cross-contamination. Findings included: 1. Review of Resident #2's Face Sheet dated 5/19/2026 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Parkinson's Disease (progressive neurodegenerative disorder), Choroidal Degeneration (vision impairment), Presbyopia (difficulty focusing on close objects), Need for assistance with personal care, Anxiety Disorder (excessive and persistent feelings of anxiety and fear that can interfere with daily activities), Dysphagia (Difficulty swallowing), Hyperlipidemia (High cholesterol), Hypokalemia (low levels of potassium), Hypercalcemia (high levels of calcium), Dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), Essential Hypertension (High blood pressure), Kidney Failure, Cognitive Communication Deficit (impaired due to underlying cognitive difficulties, rather than a primary problem with language or speech). Review of Resident #2's MDS assessment dated [DATE] revealed the resident did not have a BIMS score because the resident has cognitive impairments and is rarely/never understood. The resident had a feeding tube (a plastic tube placed through the skin of the abdomen into the midsection of the small intestine). Review of Resident #2's Care Plan dated 2/17/2026 revealed Resident #2 required a feeding tube and was placed on Enhanced Barrier Precautions. Use Enhanced Barrier Precautions during high contact care activities for residents with feeding tube. Staff and visitors must wear gowns and gloves for high contact care. On 5/19/2026, at 2:59 p.m. ADON B was observed entering Resident #2's room. Resident #2 had an enhanced barrier precaution sign posted outside of her door ADON B was observed not wearing gloves when adjusting the g tube and pushing the button on the device. ADON B left the room without washing her hands. 2. Review of Resident #3's Face Sheet dated 5/19/2026 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis of Dysphagia (Difficulty swallowing). Review of Resident #3's Care Plan dated on 02/12/2025 revealed Resident #3 required a feeding tube and was placed on Enhanced Barrier Precautions. Use Enhanced Barrier Precautions during high contact care activities for residents with feeding tube. Staff and visitors must wear gowns and gloves for high contact care. On 5/19/2026 at 3:01 p.m. ADON B was observed entering Resident #3's room. Resident #3 had an enhanced barrier precaution sign posted outside of his door. Resident #3 stated that he was not dry. ADON B did not wash hands prior to putting on gloves. ADON B did not put on a gown. ADON B inspected Resident #3's diaper and opened it. ADON B checked the groin area to ensure the diaper was not wet. ADON B removed the gloves. ADON B left the room without washing her hands. An interview with DON D on 5/19/2026 at 10:15 a.m. revealed that all nursing staff received in-service training on infection control policies. She stated that she did not know a single staff who would not wear gloves while doing incontinent care. She stated she could not imagine that was happening. An interview with Physician E on 5/19/2026 at 3:25 p.m. revealed that for a resident on enhanced barrier the staff should wear gloves and gown when touching any part of the feeding tube. She stated that for a resident on enhanced barrier who was having their diaper checked the staff should have worn the gloves and gown because that was considered incontinent care and was a requirement of the enhanced barrier precautions. She stated that the staff should have washed their hands before putting on the gloves and gown, and then washed their hands gain afterwards. She stated that even if you are checking the diaper to see if a resident was wet or soiled that it still counted as incontinent care because you are touching their diaper because of incontinent care. She stated that when going from one residents room to another after performing care to a resident in a manner that required the staff to wash their hands or wear gloves they should have washed their hands or worn their gloves. An interview with ADON B on 5/19/2026 at 3:53 p.m. revealed that all nursing staff received in-service training on infection control policies. She stated that she wears gloves to provide incontinent care on residents with enhanced barrier. She stated when physically providing contact the staff should put gloves and a gown on. She stated, if someone was on enhanced barrier and the staff are not touching the resident then they do not need to wear the gloves and gown. She stated that if staff are going to touch a resident who is on enhanced barrier precautions then staff should put on the gloves and gown. She stated that staff should wash hands before putting on the gloves and wash hands afterwards or use the hand sanitizer. She stated that for someone who was on enhanced barrier precautions with a feeding tube staff should wear gloves if staff are adjusting the tubing that was closest to the body only. She stated that if the feeding tube device was beeping then staff do not have to wear gloves if staff are going to hit the button on the device to put it on hold because it was further away from the body. She stated that she did not think staff have to wear gloves just because staff are messing with tubing. An interview with DON D on 5/19/2026 at 4:00 p.m. revealed ADON B should have known to wear gloves when touching the g tube for Resident #2. She stated that ADON B was the one who trained the staff during the facility infection control in-services. She stated that she did not think the way that ADON B checked a residents diaper did count as incontinent care because ADON B only opened the diaper to check. She stated ADON B should have washed her hands between visiting different residents. An interview with Physician F on 5/20/2026 at 10:15 a.m. revealed that for a resident who was on enhanced barrier precautions with a feeding tube the staff should always wear gloves per infection control policy when touching any part of the feeding tube or device. He stated that the staff should also wash hands before putting on the gloves and after taking the gloves off. He stated that it was unacceptable to go from one resident to another without washing hands in between. Review of facility policy dated 02/2025 and titled Enhanced Barrier Precautions reflected the following: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resistant care activities . Policy Interpretation and Implementation:Enhanced barrier precautions are used as an infection prevention and control intervention to reduce transmission of multi-drug resistant organisms to residents.EPB's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.Gloves and gown are applied prior to performing the high contact resident care activity.Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include:(c) Transferring, (f) Changing briefs(g) Device care or use (feeding tube) Review of facility policy dated 2001 and titled Infections - Clinical Protocol reflected the following: Treatment/Management3. With the physician or provider's guidance, the staff will provide supportive measures as needed, such as supplemental fluids, oxygen, holding or tapering problematic medications, additional assistance with activities of daily living.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (Resident #2) reviewed for pain. - The Facility failed to ensure Resident #2's pain was assessed and treated prior to wound care treatments causing the resident to cry out when touched or moved. An immediate Jeopardy (IJ) was identified on 03/26/2026. The IJ template was provided to the facility on [DATE] at 5:22 PM. While the Immediacy was removed on 03/30/2026 at 4:54 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures placed residents at risk of increased or unmanaged pain and actual harm. Findings Include: Record review of Resident #2's admission record dated 3/25/26 reflected Resident #2 was a [AGE] year-old female, who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia (a decline in mental ability), Hypertension, and Major Depressive Disorder. Record review of Resident #2's admission MDS dated [DATE] revealed a BIMS of 00 which indicated severe cognitive impairment. Resident #2 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for the following areas: Roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having 1 unstageable (full thickness wound with unknown depth, as the base of the wound becomes obscured by necrotic or dead tissue) pressure injuries upon admission. Record review of Section V of the MDS related to Resident #2's CAA had no care area triggers for pain and had no care planning decision made for pain. Record review of Resident #2's care plan dated revision on 03/25/26 revealed she had a left heel DTI (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear), Right Heel DTI, Pressure Wound to Sacrum,(large triangle shaped bone located at the base of the lumbar vertebrae) Bruise/discoloration/ open blister to right knee, Left Heel Ulcer Pressure Injury, and Right Bunion DTI. Resident #2 had no care plan for pain Record review of Resident #2's order summary revealed the antibiotic medication Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for Sacral wound for 7 Days with an active order date of 03/25/2026. Record review of Resident #2's physician order recap summary dated 3/31/26 revealed an active order dated 1/12/26 for Acetaminophen Tablet 500 MG. Give 1 tablet by mouth every 6 hours as needed for Pain Do not exceed 3 gm acetaminophen from any source in 24 hr. period. Record review of Resident #2's physician order recap summary dated 3/31/26 revealed an active order dated 3/16/26 for Wound Care Pressure Injury to Sacrum Unstageable cleanse with (sic)Dakin's and pat dry. Apply (sic)Dakin's soaked wet to moist gauze as primary dressing. Cover with a border gauze as secondary dressing twice daily and prn every night shift and every day shift for wound care. Record review of Resident #2's medication administration record dated March 1, 2026, through March 31, 2026, revealed she had not been administered any Acetaminophen for pain since 03/06/2026 although the resident received wound care 2 times a day. Record review of Resident #2's undated wound care report revealed she had a left heel DTI, Right heel DTI, and unstageable sacrum pressure ulcer.During an observation of Resident #2 while wound care was attempted on 03/25/26 at 1:52PM, when asked if Resident #2 had been assessed for pain, Treatment Nurse said yes and then said she would have to check with LVN A. When asked if Resident #2 had been medicated for pain, Treatment Nurse said she would have to check with LVN A. Resident #2 was observed wincing when rolled to her left side for positioning to perform wound care and said, [NAME] Dios Mios (Oh my God), and her eyebrows were furrowed. CNA A and CNA B stopped moving her. CNA A stated, I think it's because she's laying on the wound and CNA A stated it's back here and it usually drains a lot. When surveyor asked CNA A and CNA B how Resident #2 communicated CNA A said she believed Resident #2 spoke Spanish. CNA B said she believed Resident #2 spoke English. The Treatment Nurse said she was new to her role and was unsure which language Resident #2 communicated in and would have to check. When asked how did staff assess or ask her about her pain, CNA A said she was unsure. Surveyor asked if the CNAs smelled an odor to which CNA A replied, yes, it's the wound. CNA A said Resident #2's wounds often drain and stated the drainage on the back of Resident #2's exposed brief was from the wound. CNA B attempted to undo the brief, but Resident #2 continued to wince and began to moan so all care was stopped after surveyor intervention. Surveyor observed a brownish green circular spot through the back of the brief and the foul odor remained. The treatment nurse said the wound had an odor since she started a week ago and had some necrotic or dead tissue inside and around the edges that could be the cause of the odor. Surveyor also observed towels located on top of pillows that were used for positioning Resident #2's wounds to her bilateral heels. One of the towels was covered in a brownish red discharge. During the positioning and repositioning of Resident #2 in an attempt to perform wound care, she felt warm to touch. Surveyor touched the leg of Resident #2 with a gloved hand, and the resident appeared to feel warm; both CNAs A and B stated the resident felt warm/hot to the touch. The treatment nurse also felt Resident #2 and stated that the resident felt warm to touch. Surveyor asked treatment nurse if the resident had been medicated for pain and if her temperature or vital signs had been assessed and the treatment nurse stated she did not know, she would have to ask the charge nurse; LVN A. LVN A was called to the bedside by the treatment nurse to ask if Resident #2 had been medicated and she stated there was no indication that the resident had been in pain or needed her vital signs assessed. LVN A stated she would check the resident's temperature since Surveyor and 2 CNAs thought Resident #2 felt warm without ever touching or assessing Resident #2 herself. LVN A took Resident #2's temperature with a contactless forehead scanning thermometer and said aloud, Resident #2's temperature was 98.2 degrees and normal. LVN A said she was unsure if Resident #2 had anything prescribed for pain and would have to check the orders. During an interview with the Administrator and DON on 03/25/2026 at 4:10pm the DON stated the staff are expected to assess for pain whether it is verbal or assessing for grimacing, and there was a pain scale. The DON stated that if there was not an order for pain management for a resident, staff were to call the physician if they were noticing any signs or symptoms of pain. The DON stated when providing wound care, the staff were supposed to assess for pain prior to performing the treatment, throughout the treatment and after the treatment. She stated if a resident were non-verbal, the staff were to use a PAIN AID (A validated, observer-based toll used to measure pain in patients with severe dementia)assessment tool to check for facial expressions and moaning throughout the treatment. She stated the wound care nurse or treatment nurse was responsible for assessing pain prior to wound care. Record review of Resident #2's Physician orders on 03/25/2026 at 5:00PM revealed the resident was sent to the hospital for altered mental status and abnormal labs. During a telephone interview with Wound Care NP on 03/26/2026 at 12:37 pm she stated she spoke with Resident #2's NP yesterday and was informed that Resident #2's wound had a smell. She stated Resident #2 did have an increase in dead tissue and she took some of the tissue out of the sacral wound last week, and the treatment that she was providing caused the tissue to lift, which could cause an odor. She stated Resident #2's NP put her on antibiotic Doxycycline, just in case it was needed. She stated she had planned to assess the residents' wounds that morning, but she was informed that the resident was sent out the hospital yesterday. She stated she was only treating 2 wounds, the sacral wound and left foot/heel wound. She stated last week the facility had no wound care nurse, so she completed her rounds with a tech (unknown name or title). She stated Resident #2 was frequently combative and frequently refused wound care and would kick and bite while trying to provide wound care. She said she did not consider the behavior as a possible reaction to pain. She stated Resident #2 was not eating or drinking, had been highly combative, and refused wound care in the past few weeks. She stated Resident #2 had never complained of any pain while she performed wound care. She stated the resident was usually already positioned for her when she provides treatment. She stated she was told by facility staff (unknown) that the family did not want Resident #2 to be heavily medicated, so the resident was only prescribed Tylenol. In a follow-up telephone interview with CNA B on 3/26/26 at 1:52 pm CNA B said she never worked with Resident #2 before 3/25/26and there was an odor when she changed her brief earlier in the day and whenever she was repositioned to her side with the surveyor at the bedside. CNA B said Resident #2 felt very warm to her and she was surprised when LVN A came to the bedside to take her temperature and she had no fever according to the digital reading. CNA B said Resident #2 had 1 wound bandage on her bottom, 1 wound bandage on her left foot and 1 wound bandage on her right foot. CNA B said on 3/25/26all of the bandages or wounds seemed to drain either green, brown or red drainage and when the Treatment Nurse was trying to prepare to do the wound care, Resident #2 looked like she was in pain because she opened her mouth real wide like she wanted to scream and then closed it slowly when they tried to reposition her. CNA B said she did not recall Resident #2 saying anything in Spanish. In a follow-up telephone interview with CNA A on 3/26/26 at 1:58 pm she said she only came into Resident #2's room to help the Treatment Nurse who was new. CNA A said she was not the aide assigned to Resident #2 that day and was only helping out. CNA A said that CNA B was the aide assigned to Resident #2 and when surveyor asked if anyone smelled a bad odor when she and CNA B rolled Resident #2 to her side, CNA A said she smelled something and it smelled like it could have been the wound because it did not smell like feces or urine. When asked if Resident #2 felt warm or hot when she helped roll the resident to her side, CNA A said that Resident #2 felt warm and that Resident #2 made faces, like pain faces when she was moved and rolled over. CNA A said Resident #2 did not talk and she did not remember the resident saying anything or moaning but the resident did look like she was in pain and she did feel warm CNA A said LVN A came in and took the resident's temperature and said she was fine and left the room and then the Treatment Nurse stopped everything and went to tell LVN A to give Resident #2 something for pain. CNA A said that she and CNA B then repositioned Resident #2 off of her bottom where the wound was. CNA A said she recalled Resident #2 had 3 dressings on that day, 2 on her feet and 1 on her bottom. In a telephone interview with LVN A on 3/26/26 at 2:57 pm she said she went to Resident #2's room because the Treatment Nurse said the surveyor was in the resident's room asking about pain medication and Resident #2 had nothing scheduled. LVN A said that when she entered the room the surveyor said Resident #2 felt hot, so she went out of the room to get a thermometer and went back and took Resident #2's temperature. LVN A said she touched Resident #2 and she felt fine to her and her temperature was 97. LVN A said she was nervous and under pressure with the surveyor asking her questions about Resident #2 at the bedside. LVN A said that the Treatment Nurse kept asking her questions about Resident #2's vital signs and language and pain medications and she felt overwhelmed and like they all wanted her to give the resident Tylenol for pain. When asked if she assessed Resident #2 for pain herself LVN A kept repeating that she felt pressure and stress and was nervous. When asked if she had assessed Resident #2 at any point during her 12 hour 6am-6pm shift, LVN A said she must have at some point during her shift and Resident #2 was fine or had no signs or symptoms of pain or fever or she would have provided prescribed interventions or called the physician. In a telephone interview with Resident #2's RP on 3/26/26 at 5:34pm she said they were only told by facility staff that Resident #2 was sent to the hospital because of abnormal labs and no one from the facility mentioned any wound odor or infection and no one at the facility told her about antibiotics being ordered for the wound. Resident #2's RP said she believed staff were at least giving her medications for pain and fever and was shocked when she re-played the electronic monitoring device video in the room to see staff performing or trying to perform wound care without medication. Requested copy of video evidence and did not receive prior to facility exit. Record review of facility policy procedure titled Pain Assessment and Management revealed in part: Assessing Pain 1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care and treatment.2. Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition. Identifying the Causes of Pain 1. Residents may experience pain from several different causes simultaneously.2. In addition, common procedures such as moving the resident, physical therapies, or wound care can cause the resident pain.3. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including:a. musculoskeletal conditions:(1) degenerative joint disease;(2) rheumatoid arthritis;(3) osteoporosis;(4) fractures; and(5) amputation.b. skin/wound conditions:(1) pressure, venous or arterial ulcers; and(2) surgical incision Defining Goals and Appropriate Interventions 1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, type and severity of pain.2. Pain management interventions shall address the underlying causes of the resident's pain.3. For those situations where the cause of the resident's pain has not been or cannot be determined, current standards of practice for managing pain are followed to help determine appropriate options. This was determined to be an Immediate Jeopardy (IJ) on 03/26/2026. The Administrator was notified on 03/26/2026. The IJ template was provided to the facility on [DATE] at 5:22 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 03/27/2026 at 3:00PM. The plan of removal reflected the following: PLAN OF REMOVAL:F 697 Name of Facility: Date: 03/27/2026According to the IJ Template, the facility failed to ensure that pain management was provided for Resident #2. Immediate Action:Resident #2 was discharged on 03/25/2026 at 8:39pm to the hospital after a repeat laboratory test resulted in a critical level of elevated sodium. Resident remains hospitalized at this time. Upon re-admission, Resident #2's treatment orders will be amended to include prior to treatment being completed, resident will be evaluated for pain and medicated if indicated during evaluation. C.N.A A, B, and LVN A, and facility treatment nurse have all received additional 1:1 education specific to all issues identified in the preliminary fact analysis. Nursing leadership, DON and designee(s) immediately conducted facility rounds on all residents to ensure no unreported or undocumented changes in pain levels were present. Additionally, all wound care orders were audited to ensure pain management orders are present as indicated; no issues were found. All residents with wound care orders have corresponding pain management orders. Date of completion:3/27/2026 Nursing leadership, DON and designee(s) completed house wide pain assessments. No new pain was identified; any reported pain was communicated to the charge nurse for medication administration if indicated and follow up assessment was completed to ensure effectiveness. Date of completion: 3/27/2026 Licensed nurses were provided with re-education by the DON and designee(s) on change in condition, pain assessment and management, administering pain medications, pain-clinical protocol which specifically includes-: 4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning as well as review of the critical element pathway for pain recognition and management. Date of completion: 3/27/2026 All additional nursing staff were provided with re-education by the DON and designee(s) on recognizing resident change of condition or status to include any changes in resident pain levels as well as proper protocol of reporting of any identified change of condition or status by using the STOP AND WATCH Alert in PCC, point of care documentation and/or communicating directly with their charge nurse. All staff who are not working will be re-educated prior to working next scheduled shift. Date of completion: 3/27/2026 Facility Administrator and Director of Nursing were both educated by the Divisional [NAME] President of Operations on the following: Standards of Care, Pain Management and Quality Oversight. Date of completion: 3/27/2026 Person(s) Responsible: DON/Designee Date: 3/27/2026 Completion: 3/27/2026 Systemic response: Action: All licensed nurses received immediate re-education on the facility protocol for the following: * Change of Condition or Status * Pain Assessment and Management* Administrating Pain Medication * Pain-Clinical Protocol*Use of e-Interact Change in Condition UDA, STOP AND WATCH Alerts All non-licensed nursing staff were re-educated on resident change of condition or status, proper reporting and STOP AND WATCH Alert system. All staff who are not working will be re-educated prior to working next scheduled shift.Comprehensive knowledge of all presented education will be validated by employee completion of Quiz and acknowledgement of the following:*Recognition of changes in condition*Proper notification procedures*Pain Assessment and Management Person(s) Responsible: Don/designee Date: 3/27/2026 Completion: 3/27/2026 Action: Review of the pain assessment and management policy: Facility reviewed and validated the current policy to ensure alignment with regulatory requirements. No changes are required at this time. Person(s) Responsible: Regional Nurse Consultant Date: 3/27/2026 Completion: 3/27/2026 Monitoring Response:Audit:*Daily change in condition/pain assessment audits x 30 days:*DON/designee will review 24-hour summary report and nurse progress notes*DON/designee will ensure all changes are reported to the provider and documented during audit. *DON/designee will review all completed pain assessments daily to ensure completion prior to treatments being administered. *Audit results will be reviewed by IDT/QAPI weekly during Friday morning meetings to ensure compliance. Any identified issues will be addressed and communicated to the provider immediately. Person(s) Responsible: DON/designee Date: 03/27/2026 Completion: 3/27/2026 Ad-Hoc meeting was conducted with medical director on 3/26/2026 via phone regarding immediate jeopardy. The Plan of Removal was confirmed for the IJ by monitoring from 03/26/2026 through 03/30/2026 as follows: Record review on 3/26/2026 at 10:15 am of DON and designee audits of facility rounds on all residents to ensure no unreported or undocumented changes in pain levels were present and none were identified during the rounds per the audit tool and resident medication administration records. Record review on 3/26/26 at 10:55 am of facility wound care order audits with no issues identified per facility documentation. Record review on 3/26/26 at 11:03 am of facility audit of pain management orders with no issues identified per facility documentation. Record review on 3/26/2026 at 11:14 am of facility audit for all residents with wound care orders who had corresponding pain management orders that had been documented as updated or clarified if not in place. Record review on 3/27/26 of DON and ADON audits of facility wide pain assessments Record review on 03/20/26 of Comprehensive knowledge of completion of the following quizzes: Recognition of changes in condition, Proper notification procedures, and Pain Assessment revealed all licensed and non-licensed staff had completed quizzes. During interviews on 03/28/2026, 03/29/26 and 03/30/26 between 7:00AM and 6:00PM with licensed nurses and non-licensed staff (8 LVNs, 3 RNs and 6 MA, and 14 CNA's who worked both 6:00AM-6:00PM shift and 6:00PM-6:00AM shift, staff were all knowledgeable of the step-by-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool and for unlicensed staff reporting any changes in condition to the nurses. Treatment Nurse, ADON, and DON said that for verbal residents they can assess pain on a scale of 1-10 and for non-verbal residents they can assess pain using a PAINAD scale for facial expressions. All licensed nurses gave examples of non-verbal signs/symptoms or cues for pain which could be crying, breathing heavy or fast, wincing, and flinching and that they should evaluate for any pain signs or symptoms prior to, during and after a procedure or treatment. All licensed staff at that time said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, they would initiate SBAR for pain and notify the MD and RP for the resident. The Administrator was informed that the immediacy was removed on 03/30/2026 at 4:54PM. The facility remained out of compliance at a scope of pattern at a severity level of no actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 (Residents #3 and #4) of 6 residents reviewed for pharmaceutical services. The facility failed to ensure accurate administering of all drugs and biologicals to meet the needs of Resident #4, whomissed 2 doses of Lidocaine External Patch 4% on 03/25/26 and 03/26/26 resulting in resident being sore, was administered high dosages and low dosages of Tramadol and Resident #4 putting her at risk of overdose, and Resident #3 was administered insulin outside of her parameters which could cause her to go into hyper or hypoglycemia. MA C and LVN G failed to administer Resident #4's Lidocaine External Patch 4 % during the scheduled time. MA C, RN D, RN F, and MA H failed to administer Resident #4's Tramadol HCL 50 MG Oral tablets per physician orders, who received both 50 mg AND 100 mg doses of Tramadol, 1-3 times a day from 3/21/26 through 3/25/26 LVN B failed to administer Resident #3's Rezvoglar Kwik Pen 100 unit/ml solution pen injector insulin within herscheduled parameters on 6 separate dates. This failure could place residents at risk for adverse side effects, illness, and possible hospitalization. Findings included: Record review of Resident #4 face sheet dated 03/12/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Parkinson'sDisease with Dyskinesia (involuntary, erratic writhing movements) and pain in right hip. The resident has a BIMS scoreof 2, which indicated severe cognitive impairment. Record review of Resident #2's care plan dated revision on 03/17/26 revealed the resident had pain related to chronic comorbidities. Record review of Resident #4's physician order summary dated March 2026 revealed the following orders for the narcotic pain medication Tramadol: traMADol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug*Give 1 tablet by mouth three times a day for pain. and traMADol HCl Oral Tablet 100 MG (Tramadol HCl) *Controlled Drug* Give 100 mg by mouth three times a day for pain until 03/27/2026.Record review of Resident #4's physician order summary also revealed the following order for topical pain medication: Lidocaine External Patch 4 % (Lidocaine) Apply to right hip topically one time a day for pain. Record review of Resident #4's Controlled Substance Log on 3/25/26 at 1:56pm revealed: Tramadol HCL 50 MG OralTablet Take 1 tablet by mouth 3 times daily (8:00am, 12:00 Noon and 8:00pm) was not administered correctly on 5 different dates; the correct dosage was not administered, there were staff signatures missing and times were missing. Record review of Resident #4's Controlled substance log on 03/25/26 revealed Tramadol HCL 50 MG Oral tablets were not administered as order between 03/22/26-03/25/26. Observation and interview of Resident #4 at 11:34 am on 3/25/26 revealed she was lying in bed and repeatedly rubbing her right hip/thigh in a circular motion. Resident #4 was shaking her legs, in a twitching motion and her eyebrows were furrowed. When asked if she was itchy or sore the resident replied sore. CNA-I said she would tell the nurse. There was no lidocaine patch observed. Record review of Resident #4's medication administration record on 3/25/26 at 12:32pm revealed MA-C documented she had administered Resident #4's Lidocaine External Patch 4 % (Lidocaine) Apply to right hip topically one time a day for pain. At 8:00 am on 3/25/26. In an interview/observation on 03/25/26 at 1:18PM with Resident #4 observed lying in bed rubbing her right thigh in a circular motion and continuing to shake her legs in a repetitive twitching motion. When asked if she was in pain, she stated, sore. Resident #4 had a frowned facial expression and there was no lidocaine pain patch on her right hip or thigh. Due to the resident's cognitive ability, Surveyor was unable to complete a full interview. This was the second observation of the resident not wearing the pain patch on 3/25/26. In an interview with MA C on 3/25/26 at 1:36pm MA C said she did not have Resident #4's pain patches on her medication cart at the time Resident #4 was supposed to receive the lidocaine patch, so she signed that she gave it and meant to go get the lidocaine patch and return to Resident #4 and apply it, but she forgot. MA C said she would go and tell the nurse in charge and apply the lidocaine patch for Resident #4. MA C said she was not sure if Resident #4 was in pain or if she had been in pain since 8:00am. MA C said she should not have documented that she administered Resident #4's pain patch without actually applying the patch as ordered. In an observation and interview on 3/26/26 at 12:48pm with the DON, Resident #4 was observed lying in bed on her right sideand when DON and LVN G repositioned Resident #4 to her left side, exposing her right hip and thigh, Resident #4 began repeatedly rubbing her right hip and thigh in a circular motion and began shaking her legs. There was no pain patch observed on her right hip/thigh or her left hip/thigh. There were no patches observed in or on the residents' bedding. Record review of Resident #4's medication administration record on 3/26/26 revealed RN D documented she had administered Resident #4's Lidocaine External Patch 4 % (Lidocaine) Apply to right hip topically one time a day for pain. In an interview with RN D and DON on 3/26/26 at 5:05pm RN D said that she did not administer Resident #4's pain patch or any other medication because she was not assigned to Resident #4. RN D said that LVN G had borrowed her computer earlier in the day because his computer needed to be charged and she had not documented medication administration for Resident 4. The DON said she would need to further investigate EMR glitches and said she would have to follow up with LVN G regarding the signed for lidocaine patch. The DON said aloud that perhaps the resident was somehow rubbing the patch off but agreed that Resident #4 had no lidocaine pain patches on as ordered per the 12:48pm observation. Record review of Resident #4's Controlled substance log on 3/25/26 revealed on 03/21/26 at 4:00PM Two Tramadol HCL 50 MG Tablets were administered; there was no signature indicating who administered the narcotic medication. Record review of Resident #4's Controlled substance log on 3/25/26 revealed on 03/22/26 at an illegible time, two Tramadol HCL 50 MG tablets were administered, and 3/22/26 at 3:00PM two Tramadol HCL 50 MG were administered, there were no signatures indicating who administered the medications and there was no third dose as ordered. Record review of Resident #4's Controlled substance log on 3/25/26 revealed on 03/23/26 ADON administered Two Tramadol HCL 50 MG tablets at an unknown time, and on 3/23/26 at 12:00 pm only one Tramadol tablet was administered and on 3/23/26 MA-H administered only one Tramadol HCL 50 MG tablet at 7:54pm Record review of Resident #4's Controlled substance log on 3/25/26 revealed on 03/24/26 MA-C administered two Tramadol HCL 50 MG at 9:37AM, two Tramadol HCL 50 MG at 1:21PM, and then MA-H administered two Tramadol HCL 50 MG at 3:18PM. Indicating Resident #4 received 200 mg of narcotic pain medication within a 2-hour period. Record review of Resident #4's Controlled substance log on 3/25/26 revealed on 03/25/26 MA-C administered two Tramadol HCL 50 MG at 9:09AM and two Tramadol HCL 50 MG at 12:24PM. During an interview on 3/25/26 at 2:45PM with Administrator and DON they said they were unaware of any pain medication issues with Resident #4 and would look into what happened with her lidocaine patch and tramadol. The DON said MA C had been suspended while they further investigated the concerns. Both said residents should receive medication as ordered or else they could continue to have pain. Record review of Resident #3's face sheet on 03/26/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side (complete paralysis and weakness on the left non-dominant side), Type 2 Diabetes Mellitus without complications, and Hypertension. The resident has a BIMS score of 04, which indicated severe cognitive impairment. Record review of Resident #3's order summary revealed Rezvoglar KwikPen( a long-acting, medication used to treat diabetes and provides basal insulin [slow-release medication that keeps blood glucose levels consistent particularly betweenmeals and while sleeping] for 24 hours with once daily dosing) 100 UNIT/ML Solution pen-injector Inject 32 unit subcutaneously at bedtime for hypoglycemia. There was no diagnosis documented in Resident #3's diagnoses for hypoglycemia. Record review of Resident #3's MAR/TAR dated March 2026 revealed the following: Rezvoglar Kwik Pen 100 unit/mlsolution pen injector insulin was scheduled to be administered at 8:00 PM, and it was not given according to physician orderson 6 different days; the insulin was given at 12:23AM, 12:35AM, 1:51AM, 10:39PM, 10:42PM, and 12:46AM. Record review of Resident #3's MAR dated March 2026 revealed LVN B documented administering Rezvoglar KwikPen 100 unit/ml solution pen injector insulin outside of the scheduled parameters between 03/04/26 and 03/17/26 which caused Resident #3's blood sugar to fluctuate up and down for the entire month of March 2026, with her lowest blood sugar result 66mg/dL and her highest blood sugar result was 332mg/dL. Record review of Resident #3's blood sugar log dated March 2026 revealed the following entries: 3/30/2026 12:13 pm 93.0 mg/dL 3/30/2026 07:58 am 91.0 mg/dL 3/29/2026 08:53 pm 309.0 mg/dL 3/29/2026 05:31 pm 101.0 mg/dL 3/29/2026 11:25 am 98.0 mg/dL 3/28/2026 08:10 pm 283.0 mg/dL 3/28/2026 11:59 am 181.0 mg/dL 3/28/2026 07:27 am 97.0 mg/dL 3/27/2026 08:33 pm 169.0 mg/dL 3/27/2026 05:03 pm 220.0 mg/dL 3/27/2026 01:12 pm 250.0 mg/dL 3/27/2026 07:39 am 103.0 mg/dL 3/26/2026 08:33 pm 137.0 mg/dL 3/26/2026 06:05 pm 127.0 mg/dL 3/26/2026 12:45 pm 137.0 mg/dL 3/25/2026 09:55 pm 213.0 mg/dL 3/25/2026 02:06 pm 125.0 mg/dL 3/25/2026 07:20 am91.0 mg/dL 3/24/2026 09:16 pm 332.0 mg/dL 3/24/2026 05:42 pm 135.0 mg/dL 3/23/2026 07:49 pm163.0 mg/dL 3/23/2026 05:52 pm 180.0 mg/dL 3/23/2026 11:58 am 87.0 mg/dL 3/23/2026 11:58 am 87.0 mg/dL 3/22/2026 08:17 pm 253.0 mg/dL 3/22/2026 06:22 pm 178.0 mg/dL 3/22/2026 01:06 pm 135.0 mg/dL 3/22/2026 07:24 am 175.0 mg/dL 3/21/2026 09:11 pm 201.0 mg/dL 3/21/2026 05:50 pm 112.0 mg/dL 3/21/2026 11:04 am 100.0 mg/dL 3/21/2026 07:16 am 98.0 mg/dL 3/20/2026 11:33 pm 288.0 mg/dL 3/20/2026 11:22 am 172.0 mg/dL 3/20/2026 07:35 am 81.0 mg/dL 3/19/2026 07:48 pm 246.0 mg/dL 3/19/2026 04:16 pm 119.0 mg/dL 3/19/2026 11:25 am 136.0 mg/dL 3/19/2026 06:42 am 92.0 mg/dL 3/18/2026 05:56 pm 246.0 mg/dL 3/18/2026 07:58 am 143.0 mg/dL 3/18/2026 12:36 am 170.0 mg/dL 3/17/2026 05:17 pm 143.0 mg/dL 3/17/2026 12:12 pm 163.0 mg/dL 3/17/2026 07:10 am 84.0 mg/dL 3/16/2026 08:11 pm 221.0 mg/dL 3/16/2026 04:21 pm 181.0 mg/dL 3/16/2026 11:24 am 178.0 mg/dL 3/16/2026 07:14 am 68.0 mg/dL 3/15/2026 07:46 pm 309.0 mg/dL 3/15/2026 04:04 pm 211.0 mg/dL 3/15/2026 11:35 am 204.0 mg/dL 3/15/2026 07:27 am 98.0 mg/dL 3/14/2026 08:42 pm 160.0 mg/dL 3/14/2026 04:09 pm 173.0 mg/dL 3/14/2026 11:21 am 215.0 mg/dL 3/14/2026 07:44 am 66.0 mg/dL 3/13/2026 10:42 pm 246.0 mg/dL 3/13/2026 04:58 pm 238.0 mg/dL 3/13/2026 12:00 noon 219.0 mg/dL 3/13/2026 08:11 am 118.0 mg/dL 3/12/2026 09:17 pm 223.0 mg/dL 3/12/2026 04:44 pm 172.0 mg/dL 3/12/2026 11:40 am 166.0 mg/dL 3/12/2026 07:32 am 81.0 mg/dL 3/11/2026 07:46 pm 270.0 mg/dL 3/11/2026 04:44 pm129.0 mg/dL 3/11/2026 11:51 am 122.0 mg/dL 3/11/2026 08:07 am 114.0 mg/dL 3/10/2026 08:06 pm 107.0 mg/dL 3/10/2026 05:53 pm126.0 mg/dL 3/10/2026 12:53 pm 204.0 mg/dL 3/10/2026 08:07 am 118.0 mg/dL 3/9/2026 10:39 pm 288.0 mg/dL 3/9/2026 05:21 pm 238.0 mg/dL 3/9/2026 04:52 pm 157.0 mg/dL 3/9/2026 09:34 am 70.0 mg/dL 3/8/2026 05:09 pm 170.0 mg/dL 3/8/2026 12:35 pm 255.0 mg/dL 3/8/2026 09:00 am 151.0 mg/dL 3/8/2026 12:51 am 273.0 mg/dL 3/7/2026 08:51 pm 194.0 mg/dL 3/7/2026 05:01 pm 189.0 mg/dL 3/7/2026 12:43 pm 175.0 mg/dL 3/7/2026 08:23 am 77.0 mg/dL 3/6/2026 09:07 am 187.0 mg/dL 3/6/2026 05:07 pm 133.0 mg/dL 3/6/2026 11:32 am 120.0 mg/dL 3/6/2026 08:33 am 97.0 mg/dL 3/5/2026 08:13 pm 248.0 mg/dL 3/5/2026 05:56 pm 139.0 mg/dL 3/5/2026 10:20 am 111.0 mg/dL 3/5/2026 12:35 am 199.0 mg/dL 3/4/2026 05:54 pm 106.0 mg/dL 3/4/2026 12:14 pm 167.0 mg/dL 3/4/2026 07:40 am 87.0 mg/dL 3/4/2026 12:23 am241.0 mg/dL 3/3/2026 05:54 pm225.0 mg/dL 3/3/2026 08:00 am 227.0 mg/dL 3/3/2026 04:09 am 153.0 mg/dL 3/2/2026 08:20 pm 153.0 mg/dL 3/2/2026 05:39 am 158.0 mg/dL 3/2/2026 12:40 pm 201.0 mg/dL 3/2/2026 07:37 am 88.0 mg/dL 3/1/2026 08:04 pm 166.0 mg/dL 3/1/2026 4:48 pm 200.0 mg/dL 3/1/2026 11:45 am 232.0 mg/dL 3/1/2026 07:40 am 102.0 mg/dL Record review of Resident #3's MAR dated March 1, 2026 revealed, there were no orders for Resident #3's blood sugar checks. Record review of Resident #3's MAR dated March 1, 2026 -March 31, 2026, revealed on 03/04/26 RN D, a day shift nurse, documented in the resident's progress note that the resident's blood sugar was taken again at 7:40 AM and it was 87. Record review of Resident #3's MAR dated March 1, 2026 -March 31, 2026, revealed on 03/03/26 Resident #3 was scheduled to receive Rezvoglar Kwik Pen 100 unit/ml solution pen injector insulin at 8:00 PM, LVN B, a night shift nurse, documented that it was administered on 03/04/2026 at 12:23AM and the resident's blood sugar was recorded as 241 at that time. Record review of Resident #3's MAR dated March 1, 2026 -March 31, 2026, revealed on 03/04/2026 Resident #3 was scheduled to receive Rezvoglar Kwik Pen 100 unit/ml solution pen injector insulin at 8:00PM; LVN B documented that it was administered on 03/05/2026 at 12:35AM; the resident's blood sugar was 199. Resident #3's blood sugar was taken again around 7:30AM and was 111. Record review of Resident #3's MAR dated March 1, 2026 -March 31, 2026, revealed on 03/08/2026 Resident #3 was scheduled to receive Rezvoglar Kwik Pen 100 unit/ml solution pen injector insulin at 8:00PM; LVN B documented that it was administered on 03/09/2026 at 1:51AM; the resident's blood sugar was 273, the resident's blood sugar was taken again at 7:30AM and was 70. Record review of Resident #3's MAR dated March 1, 2026 -March 31, 2026, revealed on 03/09/2026 Resident #3 was scheduled to receive Rezvoglar Kwik Pen 100 unit/ml solution pen injector insulin at 8:00PM; LVN B documented that it was administered on 03/09/2026 at 10:39PM, the resident's blood sugar was 288, the resident's blood sugar was taken again 03/10/26 around 7:30AM and was 118. Record review of Resident #3's MAR dated March 1, 2026 -March 31, 2026, revealed on 03/13/2026 Resident #3 was scheduled to receive Rezvoglar Kwik Pen 100 unit/ml solution pen injector insulin at 8:00PM; LVN B documented that it was administered on 03/13/2026 at 10:42PM, the resident's blood sugar was 246, the resident's blood sugar was taken again on 03/14/26 at 7:30AM and was 66. Record review of Resident #3's MAR dated March 1, 2026 -March 31, 2026, revealed on 03/17/2026 Resident #3 was scheduled to receive Rezvoglar Kwik Pen 100 unit/ml solution pen injector insulin at 8:00PM; LVN B documented that it was administered on 03/18/2026 at 12:36AM, the resident's blood sugar was 170, it was taken again on 03/18/26 at 7:30AM, the resident's blood sugar was 143. Observation of electronic video monitoring from Resident #3's room dated 03/04/2026 revealed LVN B administering Resident #3's Rezvoglar Kwik Pen 100 unit/ml solution pen injector insulin scheduled for 8:00 pm at 12:05 am. Resident #3 was also observed to have a gastrostomy tube in place. There was no diagnosis of Resident #3's gastrostomy status. In an interview with LVN B on 3/26/26 at 7:03pm she said she worked Resident #3's unit and had provided care for Resident #3 including administration of her insulin. LVN B said she had not been late administering Resident #3's insulin and worked the night shift at the facility 6pm-6am. LVN B said bedtime medications are usually given between 7pm and 9 pm and include insulins which could be short acting or long acting. LVN B said she recalled Resident #3's insulins should be given around 8pm or 9pm. LVN B said the parameters for administering medications including insulin were one hour before and one hour after the scheduled time. When asked what a potential risk to a resident could be receiving a medication such as insulin outside of medication administration parameters, she replied, if it were a long-acting insulin, the resident's blood sugar could drop too low within 2-3 hours. LVN B said she was unaware of any issues with Resident #3's blood sugar and she had no reason to administer a medication and go back later to document the administration. In an interview with the DON on 03/28/26 at 10:30AM, she stated her expectations are for medications to be administeredper state guidelines and their facility policy which is to administer the medications according to the Physicians' orders. She stated she reviewed the Controlled Substance log for Resident #4 and noted the concern of the incorrect administration of the dosages however she did not notice that the medication times were incorrect (dosages were administered at 1:21PM and 3:18PM). She stated the risk of the resident's medication being administered that close together could cause the resident to overdose. She stated she had not completed an audit on all of her nurses. She stated she was not aware that residents were receiving insulin outside of their parameters. She stated the risk of residents not receiving insulin as scheduled would be an increase or decrease of their blood sugar and she reported it was very dangerous. She stated she ensures that medications are being administered properly by reviewing the Narcotic logs and making sure that all medications are signed out and administered. Record review of the facility's policy titled Administering Medications revised dated April 2019 revealed: Medications are administered in a safe and timely manner, and as prescribed.4. Medication are administered in accordance with prescriber orders, including any required time frame.7. Medication are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident #2) reviewed for infection control, in that: -CNA J failed to wear PPE for EBP, when she provided incontinent care to Resident #2. These deficient practices could place residents at-risk for infection, sepsis, and hospitalization due to cross contamination. Findings included: Record review of Resident #2's admission record on 03/25/26 reflected a [AGE] year-old female, who admitted to the facility on [DATE] with a primary diagnosis of unspecifiedDementia (a decline in mental ability), Hypertension, and Major Depressive Disorder. The resident did not have a diagnosis for wounds. Record review of Resident #2's admission MDS dated [DATE] revealed a BIMS of 00 which indicated severe cognitive impairment. Resident #2 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for the following areas: Roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having 1 unstageable pressure injuries upon admission. Record review of Resident #2's care plan dated revision on 03/25/26 revealed she had a left heel DTI, Right Heel DTI, Pressure Wound to Sacrum, Bruise/discoloration/ open blister to right knee, Left Heel Ulcer Pressure Injury, and Right Bunion DTI. The resident was also care planned for Enhanced Barrier Precautions Staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier precautions are recommended for residents known to be colonized or infected with MDROs as well as those who are not confirmed to have MDRO (e.g. residents with wounds or indwelling medical devices)- this was initiated on 03/15/2026. Record review of Resident #2's Physician Orders revealed the following orders: - Enhanced Barrier Precautions: Staff must use gowns and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier precautions are recommended for residents known to be colonized or infected with MDROs as well as those who are not confirmed to have MDRO (e.g. residents with wounds or indwelling medical devices)- every shift for Enhanced Barrier Precautions In an observation on 3/12/26 at 2:01PM, Surveyor approached Resident #2's room and knocked on the door (the door was open, Resident #2 resided in B side). The curtain was closed and CNA J stepped out and stated she was doing resident care. CNA J was observed with black scrubs, she did not have on a gown. Surveyor waited outside of the room until CNA J completed incontinent care. There was EBP signage observed outside of the residents room. In an interview on 3/12/26 at 2:06PM with CNA J she stated she was changing Resident #2 when surveyor knocked on the resident's door. She stated there was signage on the resident's door for Enhanced Barrier Precautions which indicated that PPE was needed when providing care. She stated she was not sure if the signage was for Resident #2 or her roommate. She stated she had never worn PPE in the past while providing Resident #2 care and that she had only worn PPE while providing care to the roommate. When asked if Resident #2 had wounds, she stated she was not sure. She stated the risk of not wearing PPE was infection. In an interview on 03/12/26 at 2:41PM with LVN K she stated she was assigned to the hall Resident #2 was on. She stated PPE was required when providing direct care to Resident #2 because she had wounds. She stated CNAs had access to the resident's plan of care in Point click care(the facilities electronic health records system) which indicated if PPE is required for a resident or not. She stated there is also signage outside of the resident's room indicating if PPE was needed. In an interview on 03/12/26 at 4:09PM with the DON she stated her expectations were for PPE to be worn when residents require PPE. She stated the risk of it not being worn was infection. Record review of the facility's policy and procedure on Enhanced Barrier Precautions (Revised 3/2024) read in part: Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug-resistant organisms(MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention toreduce the transmission of multi-drug-resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact residentcare activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposedto before entering the room).b. Personal protective equipment (PPE) is changed before caring for another resident.c. Face protection may be used if there is also a risk of splash or spray.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:a. dressing;b. bathing/showering;c. transferring;d. providing hygiene;e. changing linens;f. changing briefs or assisting with toileting;g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); andh. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/orindwelling medical devices regardless of MDRO colonization.a. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasisulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears.b. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies.

Based on interview, and record review the facility failed to have an established system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 (CR #1) of 5 residents reviewed for pharmacy services. - The facility failed to document CR #1's ABH cream on her May 2025 MAR. - The facility failed to document CR #1's Morphine on her April 2025 MAR. - The facility failed to document CR #1's Morphine on her May 2025 MAR. These failures could place residents at risk for inaccurate administration of medication, over medication, or drug diversion. Findings include: Record review of #CR 1's undated face sheet reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses of senile degeneration of brain (also known as dementia: progressive decline in cognitive function, impacting memory, reasoning, and daily tasks), type 2 diabetes mellitus (body does not make insulin or resists it), Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia with psychotic disturbance (dementia with seeing/hearing/believing things that are not real), generalized anxiety disorder, adjustment disorder with anxiety and depressed mood (anxiety and depressive symptoms in response to a stressor), insomnia (unable to sleep), polyneuropathy (nerve pain), palliative care (hospice), and hypertension (high blood pressure). Record review of #CR 1's Quarterly MDS Assessment, dated 4/29/25, reflected she had a BIMs score of 2 out of 15, which indicated severely impaired cognition. The MDS also revealed she had fluctuating inattention and disorganized thinking (lack of coherence, clarity, and logic). She was substantial/max assistance (helper does more than half the effort) with all of her ADLs. CR #1 was frequently incontinent of bowel and bladder. The MDS revealed CR #1 was on an antipsychotic (medications to manage psychosis and other psychotic disorders), antianxiety, opioid, and an anticonvulsant, and she was on hospice. Record review of #CR 1's Comprehensive Care Plan, dated 1/24/25 revealed a Focus: Admit to facility with Hospice for dx: senile degeneration of the brain (Initiated: 1/27/25). The goal was to have comfort, quality of life and dignity protected and honored. The interventions included administering medications/treatments as recommended by the doctor, coordinating care with the hospice team, and having the hospice nurse coming to visit. Focus: CR #1 required anti-anxiety medication r/t senile degeneration of brain and h/o anxiety/agitation (Initiated: 1/24/25, Revised: 6/24/25). The goal was to have no complications r/t anti-anxiety meds through review date. The interventions included multiple GDRs, administering meds as ordered, family education, and monitoring side effects. Focus: CR #1 required psychotropic (medications that affect mental state) medications (Initiated: 1/24/25, Revised: 6/24/25). The goal was to experience less than daily behavioral episodes of targeted behaviors. Interventions included administering ordered medications, diverting attention, and educating family on behaviors. Focus: CR #1 was at risk for pain r/t senile degeneration of brain (Initiated: 1/24/25, Revised: 6/24/25). The goal was to maintain a tolerable comfort level through the review date. Interventions included administering medications to relieve pain. Record review of #CR 1's Physician's Orders revealed the following orders from MD G: - Morphine Sulfate Oral Solution 20mg/5ml, Give 2.5ml PO Q4hr PRN pain, SOB. Ordered on 3/18/25. - ABH 1mg/25mg/1mg/1ml mg/ml (Ativan [treats anxiety] 1mg, Benadryl [helps with sleep] 25mg, Haldol [helps with hallucinations] 1mg) Apply to inner wrist topically at bedtime r/t dementia with psychotic disturbance. Ordered on 5/7/25. - ABH 1mg/25mg/1mg/1ml mg/ml (Ativan 1mg, Benadryl 25mg, Haldol 1mg) Apply to inner wrist topically Q4hr PRN for anxiety. Ordered on 5/7/25. Record review of CR #1's April 2025 MAR revealed the following days/times of Morphine administration documentation: - 4/2/25 at 10:26am - 4/4/25 at 2:15am - 4/19/25 at 9:34am Record review of CR #1's April 2025 Morphine Controlled Drug Receipt/Disposition Form revealed the following missing dates/times of administration: - 4/3/25 at 12:00pm - 4/12/25 at 3:00pm - 4/13/25 at 10:00am Record review of CR #1's May 2025 MAR revealed no documentation of Morphine administration. Record review of CR #1's May 2025 Morphine Controlled Drug Receipt/Disposition Form revealed the following missing dates/times of administration: - 5/28/25 at 11:30am - 5/28/25 at 3:30pm - 5/28/25 at 11:30am Record review of CR #1's May 2025 MAR revealed the following dates/times of ABH cream administration: - 5/1/25 at 10:25pm - 5/2/25 at 6:31pm - 5/3/25 at 8:35pm - 5/4/25 at 12:37am - 5/4/25 at 7:38am - 5/4/25 at 3:37pm - 5/5/25 at 9:38am - 5/5/25 at 10:03pm - 5/6/25 at 8:58am - 5/6/25 at 7:42pm - 5/7/25 at 8:13pm - 5/8/25 at 8:28am - 5/9/25 at 12:08am - 5/10/25 at 7:40pm - 5/11/25 at 7:10pm - 5/12/25 at 8:16pm - 5/13/25 at 3:52pm - 5/15/25 at 7:10am - 5/15/25 at 7:29pm - 5/16/25 at 9:24pm - 5/16/25 at 11:29pm - 5/17/25 at 10:44pm - 5/18/25 at 9:49pm - 5/19/25 at 1:00pm - 5/19/25 at 9:13pm - 5/20/25 at 2:56pm - 5/20/25 at 9:23pm - 5/21/25 at 10:13am - 5/21/25 at 7:18pm - 5/22/25 at 11:00am - 5/22/25 at 8:12pm - 5/23/25 at 8:01pm - 5/24/25 at 8:10pm - 5/25/25 at 9:10am - 5/25/25 at 7:22pm - 5/26/25 at 10:13am - 5/26/25 at 7:34pm - 5/27/25 at 10:37am - 5/27/25 at 8:02pm - 5/29/25 at 2:36am - 5/29/25 at 7:06pm - 5/30/25 at 7:12pm - 5/31/25 at 8:59pm Record review of CR #1's May 2025 ABH Controlled Drug Receipt/Disposition Form revealed the following missing dates/times of administration: - 5/7/25 8:30am - 5/10/25 8:00pm - 5/12/25 7:00am - 5/14/25 11:00pm - 5/24/25 3:00am - 5/25/25 1:00pm - 5/28/25 8:00am - 5/28/25 2:00pm - 5/28/25 8:00pm CR #1 passed away on 6/24/25, and was unable to confirm receipt of medication. In an interview with the DON on 6/26/25 at 1:30pm, she said the staff members probably forgot to check off the medication on the MAR but gave the medication to CR #1. She said she was starting in-services on filling out the MAR and accurate documentation on the Controlled Substance Log. In an interview with LVN R on 6/26/25 at 1:50pm regarding the missing entries on the Controlled Drug Log for CR #1, she said she did not remember what happened, but she was pretty sure she gave the medication and forgot to document it on the MAR. Attempted to interview LVN S on 6/26/25 at 3:35pm but was unsuccessful. His mailbox was full, and a message could not be left. In an interview with the DON on 6/27/25 at 10:30am, she said she stayed late on 6/26/25 and audited all of the Controlled Substance Logs with resident's MARs to ensure accuracy. She said she also performed in-services with all staff on the importance of accurate documentation. She said there was not a procedure in place to check the Controlled Drug Log against the resident's MAR, but she did QAPI it and now the logs would be checked 2-3 times a week. She said if the Controlled Drug Log did not match the resident's MAR, it could indicate a drug diversion. In an interview with RN D on 6/27/25 at 12:55pm, she said she remembered she gave the first dose of ABH on 5/25/25 at 9:00am to CR #1 and it did not work so she had to go back later and give another dose around lunch time after CR #1 slapped a CNA in the face. She said it was crazy trying to get CR #1 to calm down and she must have forgotten to check the medication off on the MAR. In a telephone interview with LVN A on 6/27/25 at 1:12pm regarding missing entries on the MAR for CR #1, she said she must have forgotten to check them off. She said she was usually pretty good about her controlled medication documentation but sometimes CR #1 was hard to handle, and she would have to hurry and give her medications, and she must have forgotten to chart it. In a telephone interview with LVN R on 6/27/25 at 2:04pm regarding missing entries of Morphine on CR #1's MAR, she said she was pretty sure she wasted the Morphine at 11:30am on 5/28/25 and that was why there were 2 entries for 11:30am. She said she was pretty sure she gave it at 3:30pm. Record review of the facility's policy and procedure on Controlled Drugs (Revised January 2023) read in part: To provide guidance on the process where Controlled Drugs are inventoried and administered as required by state and federal agencies. When administering a controlled medication, identify the medication in the resident eMAR, review the control sheet and indicate the remaining accordingly. Administer the medication and sign the eMAR and control sheet accordingly. The eMAR should not be signed until after the medication administration. Record the results of medications administered as necessary. Maintain a declining inventory record per resident per drug on all Controlled drugs. Records should be accurate and include: Name of the resident .Date and time of administration .If a medication was missed, not administered, was not refused the nurse should complete a medication error report. Admin/DNS/Designee will notify local and state [agencies] if appropriate . Record review of the facility's policy and procedure on Medication Administration (Revised January 2023) read in part: Resident medications are administered in an accurate, safe, timely, and sanitary manner .Initial the electronic administration record after the medication is administered to the resident.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. The facility failed to ensure the kitchen vents above the steam table was free from dripping condensation on 05/07/2025. This failure could have the potential to affect residents who ate food from the facility's kitchen placing them at risk of foodborne illness. Findings included: Observation on 5/7/2025 at 11:35 AM - 12:03 PM of the kitchen vents, revealed 4 vents positioned above the steam table with condensation droplets. During the observation a cart with small bowls was placed near the steam table (used for plating side dishes). Condensation from the vents fell onto the cart with the small bowls. The plate warmer was placed under a vent that had condensation droplets and condensation dropped on the plate warmer. The thermostat in the kitchen was set on 74 degrees Fahrenheit. Interview on 5/7/2025 at 12:00 PM, the Dietary Mgr . said the Maintenance Supervisor came in daily to inspect the sanitation of the kitchen. She said the kitchen was cleaned daily but had not noticed the vent condensation and the task was not a task to check off on the kitchen sanitation audit document. She said the condensation on the vents could drop into the food and cause cross-contamination. She said she told the Administrator about the condensation over six months ago. Interview on 5/7/2025 at 12:05 PM, the Dietician A said she had not looked up to see the condensation on the vents above the steam table. She said her monthly checks monitored for dust on the vents and she did not review the vents for condensation during meal service. She said the condensation could cause food-born illnesses and affect the resident if it dropped into the food. She said she would need to ask the administrator or maintenance about how to stop the condensation and who was responsible. Interview on 5/7/2025 at 12:42 PM, the Maintenance Supervisor said he checked and cleaned the vents above the steam table monthly. He said he was aware of the condensation but had advised the dietary staff not to put the air-condition thermostat under 72 degrees, because that will cause the condensation when the stove was on. Interview on 5/7/2025 at 2:55 PM, the Administrator said the condensation that formed on the vents above the stem table / prep station could have dropped into the food and put the residents at risk for a food born illness. He said he would close the vents to prevent the condensation from forming to prevent the cross-contamination of the droplets falling into the food. The Administrator further said there was no specific policy that addressed the vents in the kitchen. He said maintenance and the kitchen staff were responsible for ensuring the vents were free from condensation and debris. Record review of the undated pest control policy titled General Kitchen Sanitation revealed the following: Policy: The facility recognizes that foodborne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness . Record review of facility QA Monitor Report dated 4/7/2025 and completed by Dietician A revealed the following: .General appearance of kitchen clean: floors, walls, ceilings, vents, . Answer - Yes.

Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility reviewed for infection control. The facility failed to provide documentation regarding regular or periodic testing and monitoring of environmental control limts, such as PH levels, temperature levels and disinfectant levels according to their policy and procedure regarding their water management plan. This failure could place residents at risk of exposure to Legionnaires' disease (a serious type of lung infection caused by Legionella bacteria which can live in standing water within facility water systems). Findings include: In an interview on 5/7/25 at 3:02 p.m. the Infection Preventionist said she was unsure who oversaw the water management program but would find out. In an interview on 5/8/25 at 10:41 a.m. the Administrator said Legionella could grow in hot water and the systems. He said if the facility had a drain line that had not been used in a while, he would pour bleach down the line or disinfect the drain. He said the facility did not test the water for Legionella and the CDC said there was no requirement to test it. He said if there was a confirmed case of Legionnaires disease the facility would be required to test the water daily. He said the corporate team would manage the testing. He said the facility did not have a process in place to measure outcomes. In an interview on 5/8/25 at 10:57 a.m. the DON said she did not have anything to do with the Legionella program. In an interview on 5/8/25 at 11:34 a.m. the Administrator said there was no documentation to provide regarding Legionella. In an interview on 5/8/25 at 11:52 a.m. the Administrator said the facility was not documenting information regarding Legionella but would start. Record review of the facility's Legionnaires' Disease: Detection, Response, Prevention policy dated March 2022 read in part, .The Community will utilize sound clinical and infection control practices to quickly identify and treat any potential Legionnaires' related illnesses. Sound engineering, preventative maintenance and housekeeping practices will be utilized to minimize the risk of exposing residents and team members to the legionella bacteria . Minimizing Growth of Legionella in the Domestic Water System: o Do not use shower rooms as permanent storage unless the unused piping has been removed. o Flush toilets and run faucets for a minimum of 30 seconds in all vacant resident rooms periodically. o For resident rooms, or other rooms with plumbing fixtures that are used for offices and/or storage, flush toilets and run faucets and showerheads for a minimum of 30 seconds periodically. o Visually inspect all cooling towers, as applicable, on a quarterly basis for debris or biofilm or slime build-up. If biofilm or slime is noted, drain the tower, clean and disinfect. Perform annual water quality testing for all cooling towers. o Visually inspect all decorative fountains, as applicable, on a quarterly basis for biofilm or slime build-up. Check PH to assure within acceptable range of 6.5 to 8.5 where disinfectants are most effective. Place chlorine tab dispenser in fountain. If biofilm or slime is noted, drain the fountain, clean and disinfect. o Perform annual water quality testing for all enclosed, air-cooled chiller systems, as applicable. o At the start of cooling season, inspect all HVAC units. Place chlorine tablets in condensate drain pans to prevent slime build-up. When checking filters periodically, inspect drain pans for slime build-up and place additional chlorine tablets as needed. o All visual inspections, cleaning, and water testing will be documented using the TELS preventive maintenance system. o Please note that neither CDC nor CMS guidelines require periodic testing of water for actual Legionella bacteria, unless there is a known Legionnaires case in the community. Regular or periodic testing and monitoring as related to this policy refers to environmental control limits, such as PH levels, temperature levels and disinfectant levels. If a Legionnaires case is identified, state agencies may require or request actual sampling for Legionella .

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program to remain free of pests on 1 of 1 kitchen. The facility failed on 05/08/2025 to ensure the dishwashing area was free from 1 roach observed. This failure could place residents at risk of food borne illnesses and unsanitary conditions in the kitchen which could result in a decline in health. Finding included: During an observation on 5/8/2025 at 9:51 AM revealed a medium size roach crawling on the automatic dishwasher's sanitation and detergent tubing while in use. In an interview on 5/8/2025 at 9:52 AM, the Dietary Aide A said she saw the roach crawling on the dishwasher. She said there were cleaning duties to keep the kitchen clean and sanitized. The interview was interrupted by the Dietary Manager. In an interview and observation on 5/8/2025 9:52 AM, the Dietary Manager said she saw the roach, and then she killed the roach that was crawling on the dishwasher. She said there is monthly pest control and is not sure how the roach was in the kitchen. She said the live roach placed residents at risk for contaminating clean dishes in the dishwasher area. She said she and the staff clean daily to prevent pest from being in the kitchen. She said all dietary staff were responsible for reporting pest to the maintenance so the pest control company could address it on the next visit. Record review of the facility pest control receipt dated 5/2/2025 revealed the pest control company was at the facility on 5/2/2025. The pest control treatment included the kitchen and the targeted pest included roaches. Record review of the undated pest control policy titled General Kitchen Sanitation revealed the following: Policy: The facility recognizes that foodborne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness . 13. Have a professional pest-control program in place . Record review of facility policy titled Physical Environment date 2/2017 (revised 1/2023) revealed the following: Pest control - The community maintains an effective pest control program so that the community is free of pests and rodents. An effective pest control program is defined as measures to eradicate and contain common household pest (e.g., roaches .)

Based on observations and interviews, the facility failed to ensure the right to a safe, clean, comfortable and homelike environment for 3 of 4 resident bathrooms (room [ROOM NUMBER], 218 and 411) reviewed for environmental concerns in that: The facility failed to maintain a clean and homelike environment on 05/6/2025 as followed: -The toilet in room [ROOM NUMBER] was not kept clean and had a large yellow stain in the bowl. -The toilet seats in rooms [ROOM NUMBERS] had yellow stains. -The floors in the bathroom of room [ROOM NUMBER] were not in good condition. The floors were covered in black tread tape (tape that prevents slipping) that was peeling off and no longer intact. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is was unpleasant, unsanitary, and unsafe. The findings included: An observation on 5/6/2025 at 12:22pm in room [ROOM NUMBER] revealed the toilet seat had yellow staining in patches and streaks covering the seat. An observation on 5/6/2025 at 2:15pm in room [ROOM NUMBER] revealed the bathroom floors were covered in black tread tape (tape that prevents slipping). The strips were peeling and coming off the floor. The strips were no longer intact. The toilet had a yellow stain in the bowl where the water sits and up to the water line. An observation on 5/8/2025 at 9:02am in room [ROOM NUMBER] revealed the toilet seat had yellow staining in patches and streaks covering the seat. In an observation and interview on 5/8/2025 at 10:45am, The Housekeeping Regional Supervisor stated he worked for a contracted company that was responsible for housekeeping services. When we viewed the toilet in room [ROOM NUMBER], there was yellow discoloration in the bowl where the water sits and up to the water line. The Housekeeping Regional Supervisor flushed the toilet, and the yellow stain was still in the bowl. He said the chemicals they used to clean the toilets were not as strong as they used to be. He said the facility had hard water and caused discoloration. He said they used pumice stones on stains like this one, but they tried not to use it too much because it could damage the porcelain. We observed the tread tape on the floor. He said they mop over the strips. He said he knew it was not the best outcome, acknowledging the strips were peeling. He said if anyone wanted to remove the strips, maintenance staff would need to take care of it. He said they use the power scrub devise on the floors but could not remove the stripping. In an interview on 5/8/25 at 1:25pm, the Maintenance Director stated the tread tape in the bathroom of room [ROOM NUMBER] were placed there at the request of a former family member a few years ago. He said they were only located in one bathroom. He said the toilet seat in room [ROOM NUMBER] and 411 need to be replaced. He said the toilet seat was yellowed and may be a result of the chemicals they use to clean them. He said facility staff did an audit of the bathrooms not too long ago, and these toilet seats may have been missed. In an interview on 5/8/25 at 3:00pm, the Maintenance Director stated the toilet in room [ROOM NUMBER] has been cleaned with bleach to remove the yellow stain in the bowl. He said the contract housekeeping company cannot use harsh chemicals, including bleach, therefore it was not removed before today. He stated the housekeeping staff usually told him when something needed to be bleached and he will do it himself.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 6 medication carts (100 hall nursing cart) and 1 of 15 resident rooms (Resident #2)reviewed for drug labeling and storage. 1- The facility failed on 05/07/2025 to ensure prescribed medication, not belonging to Resident#2 be left bedside tray, unattended. 2. The facility failed to ensure on 05/07/2025 the following was not left on top of the 100 Hall Nursing Cart unattended: 1 unused lancet (small plastic cylinders containing a sterile steel needle), 1 unopen insulin pen needle and 5 alcohol prep pads (1 torn open with pad exposed and 4 unopen). These failures could place residents at risk of adverse medication reactions and drug diversions. Findings included: 1.Record Review of Resident #2's face sheet revealed a [AGE] year-old female admitted to the facility on , 09/01/2021. The diagnoses included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other lack of coordination, paraplegia, unspecified, other cerebral infraction, cellulitis of left finger, type 2 diabetes, Alzheimer's disease with early onset. There were no diagnoses revealed that would relate to the usage of the prescribed medication found on Resident #2's bedside tray. Record Review of Resident #2 quarterly Minimum Date Set dated on, 03/31/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 to indicate they were cognitively impaired. Resident #2 is dependent on staff for, oral hygiene, toileting hygiene, shower/bathe, and upper body dressing as they are unable to complete the activity on their own. Record Review of Resident #2 Medication Administration Record revealed no prescribed medication by the name of, Ketoconazole Shampoo 2% to be used on skin during bathing or showering. Record Review of Resident #2 Care Plan revealed no skin issues, concerns, or focus that would relate to the prescribed medication found on Resident #2 bedside tray. The care plan did reveal Resident #2 focus is having fragile skin and is at risk for skin injury, treatment is applied when ordered, with a last update of 01/13/2025. Observation on 05/07/2025 at 8:23am of the Resident #2 surrounding areas on their side of the room, it was noticed there was food on the floor and Resident #2 bedside tray. It was discovered Resident #2 has a prescribed medication that was a bright orange red substance oozing out of the bottle. The labeling of who the prescribed medication belonged to was torn off. The only legible writings on the prescribed bottle, Ketoconazole Shampoo 2% . In an interview with Resident #2 on 05/07/2025 @ 8:23am, the resident was observed to be awake and awaiting for breakfast to be served. Resident #2 was asked if they were aware of the prescribed medication bottle on their bedside tray and they stated, yes. Resident #2 stated they were unsure of who the medication belongs to but was used on skin before. Resident #2 could not remember how long ago or the staff who used the prescribed medication. In an interview with LVN B on 05/07/2025 @ 9:17am. LVN B was preparing to give medication to resident when they were asked about prescribed medication left on Resident #2 bedside tray. LVN B stated they were unsure how the prescribed medication got on the bedside tray, and they never seen it before. LVN B stated that he has not used the prescribed medication on the resident and was unsure who or why it would have been left on the resident bedside tray. LVN B confirmed that he did not know who the prescribed medication belonged to, as it was illegible. LVN B stated that because he doesn't know why the medication was there, he would need to speak with the DON, where he proceeded to take the prescribed medication off Resident #2 bedside tray and inform the DON of the findings. In an interview with DON on 05/07/2025 @ 9:55am stated they were conducting an in-service now (at this time) regarding medications, labeling, and storage. DON stated the medication was not prescribed to the resident but did make contact the doctor and expressed the resident could benefit from the medication and received an order for the prescribed medication, specifically for the resident because she does have dermatitis. The DON was unsure of who the medication belongs to. The DON stated they have never seen the prescribed medication in the resident room or on the bedside tray. The DON stated there was no one residing at the facility who is was currently prescribed to take the medication. The DON also stated they are unsure if the medication was used on the resident or how long the prescribed medication has been on the resident bedside tray. The DON stated the risk of a resident using another resident medication or a medication that was not prescribed to them can have side effects, which could harm the resident. In an interview with CNA L on 05/08/2025 @ 10:51am stated they were assigned to Resident #2 today and is normally assigned to the 400 hall. CNA L stated when bathing Resident #2 there is not a specific lotion or skin soap that used. CNA L stated that there was a time a red-like substance was used on Resident #2 during bathing but could not remember when or if it was prescribed medication. CNA L stated the soap and lotions are given to the CNAs before bathing/showering residents, and they do not see where the soap or lotions come from because it is already placed in a clear container. 2. During an observation on 05/07/25 at 1:07 PM revealed the 100-hall nursing cart unattended for approximately 2-3 minutes positioned halfway down the hall with the following on top: LVN A was talking to unknown person at the beginning of the hall, with her back to the cart. One unknown resident was self-propelling himself down the hall in the direction of the cart. Unattended Nursing Cart: o 1 unused lancet (small plastic cylinders containing a sterile steel needle). o 1 unopen insulin pen needle. o 5 alcohol prep pads (1 torn open with pad exposed and 4 unopen pads). In an interview on 5/7/2025 at 1:15 PM LVN A said she left the cart to retrieve batteries for the glucometer (instrument for measuring the concentration of glucose (sugar) in the blood. She said she should have placed the supplies (lancet, insulin pen needle and alcohol prep pads) inside of the cart. She said it was her responsibility to ensure the cart was locked and supplies were secure. She said she was trained to keep medical supplies secured and locked in carts to prevent misuse. She said the residents were at risk for injury if they tried to use the needles or misused the alcohol pads. In an interview on 5/8/2025 at 8:25 AM, the DON said the nursing cart supplies should be kept inside of the secured nursing carts until they are ready to be used by the nurses. The DON said the nurses should have unsecured alcohol pads, lancets and insulin pen needles presented a risk to the residents, and they could injury themselves. She said LVN A should have kept the nursing cart in line of site if supplies were on top and not secured. Record review of the facility's policy titled, Medication cart use & storage and Biologicals dated 3/13/19 (revised January 2023) revealed, .Responsible Disciplines -Licensed nurses . 1. Security - The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use . avoid placing medications on top of the cart unless pulling medications from the cart. The only exception would be if the cart and medications are within the direct line of sight of the authorized personnel. Note: Best practice is to avoid leaving medication on top of the cart .

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision to prevent accidents for 1 (CR #100) of 1 resident reviewed for adequate supervision. -The facility failed to provide adequate supervision and training of the staff when they incorrectly identified CR #100 as having left the facility with a family member on 05/22/2023 but later identified him as eloped on 05/23/2023. This failure placed residents living in the facility at risk of harm due to avoidable accidents by inadequately monitoring and documenting resident whereabouts, with the potential of the residents eloping from the facility while still requiring care and treatment. This noncompliance was identified as Past Non-Compliant. The IJ began on 5/22/23 and ended on 5/24/23. The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to state entrance. On 02/29/2024 at 10:54 a.m., facility administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the administrator by email. Findings include: Record review of CR #100's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses include cerebral infarction with aphasia, dysphagia, lack of coordination, cognitive communication deficit, depression, and anxiety. Review of CR #100's MDS (Minimum Data Set) dated April 28, 2023, section C revealed a BIMS (Brief Interview for Mental Status) score of 7. Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and one person assisting with bed mobility, transferring and toilet use. It also revealed resident requires limited, one-person assistance with dressing, eating and personal hygiene. Record review of CR #100's care plan dated 05/03/2023 revealed: 1. Focus: I have impaired cognitive function/dementia or impaired thought process r/t (related to) aphasia following acute CVA (cerebral vascular accident, a stroke) . -Goal: I will improve current level of cognitive function . -Interventions: 1. Keep my routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion .2. Ask yes/no questions in order to determine my needs. 2. I am at risk for discharge concerns r/t resident not able to stay at SNF (Skilled Nursing Facility) -Goal: Resident .will not experience AMA (this stands for against medical advice, used when a resident discharges from a health care institution against the advice of their doctor), or will not experience any negative outcomes as a result -Interventions: 1. Coordinate a care plan meeting as indicated. Include resident/patient and representative as indicated. 2. Refer to Social Services as needed. Record review of CR #100's progress notes dated 5/22/23 revealed RN B recorded resident as D/C (discharged ) home but no nurse progress notes or documentation detailing where the resident went to after he was last seen at the facility on 5/22/23. Record review of facility's grievance log from March 2023 to February 2024 revealed no concerns from CR #100 or family members. Record review of the facility's daily staffing sheet for May 22, 2023, when CR #100 eloped from the facility revealed that LVN C was working on resident's hall on day shift and RN B was working on resident's hall on night shift. Record review of LVN A's statement dated 5/23/23 revealed that she received a report from the day nurse LVN B that two residents had discharged , including CR #100, and when she walked the hall with the nurse both of them saw nobody in resident's room. LVN #1 said she never set her eyes on the resident and relied on LVN B's statement and discharged the resident in PCC, charting that he went home. Record review of CNA A's statement dated 5/23/23 revealed she last saw CR #100 around 6:50pm, as he was going towards the front of the building. When she asked where he was going, he said he was going to meet his wife. CNA A stated resident was acting normally. She saw him with a pullup in his hand. She told resident's nurse he was going to wait for his wife in the front lobby and she went to talk to him. Interview with CR #100's wife at 2/27/24 at 12:44pm, she said staff told her CR #100 informed them he was waiting for someone, but the wife told the staff she did not know anyone by the name CR #100 provided. She said she did not have transportation at the time so would not have been able to visit. She said CR #100's cognitive memory was 50% and he could not walk well. She said the police found CR #100 around a week and a half later sitting on his rollator, and that he was dirty and had lost his phone. The hospital informed resident's wife he had a diaper rash. She said the facility's told her their cameras face the front and did not capture him leaving. She said he never exhibited exit-seeking at his previous facilities. Interview with DON on 2/28/24 at 3:30pm, she last saw CR #100 sitting at the front entrance on 5/22/23 between 6-6:30pm. Resident #1 told her that his wife was coming to pick him up. DON said resident was pleasant and said he had eaten when asked. She didn't think nothing of it and trusted his nurse would sign him out on pass. When she came to work the following morning on 5/23/23, DON found out resident was marked as discharged in PCC. When she looked at his records, she did not locate any discharge paperwork. When she interviewed the nurse who worked the day shift of 5/22/23 , she said she thought the resident was leaving on pass. When she talked to the night nurse who took over the shift, she reported the day nurse told her the resident had been discharged . The night nurse marked the resident as discharged in the system. The DON said when she found out the resident was missing, she called a Code Pink, and the staff members did a full search of the facility and surrounding area by foot and car. The search was unsuccessful, so the Administrator notified the police for assistance. The DON also called CR #100's wife, who said resident is upset at her for not letting him come home and won't take her calls. The wife told the DON he has eloped multiple times before, but that she never told anyone at this facility. The DON then called resident's doctor who said resident is alert and oriented and therefore able to make the decision to discharge AMA. The DON called nearby shelters and hospitals. The facility conducted interviews of staff who worked with the resident on 5/22/23, including LVNs, CNAs, and housekeeping regarding resident's behavior. The DON said that LVN B was an agency nurse and did not return to the facility after 5/22/23 so she was unable to collect a witness statement. The facility reviewed cameras but was not able to see the resident exit the building. Based on the doctor's conclusion resident left AMA , the facility ended the search since he was able to leave on his own. When asked what should have been done, the DON said the nurses should have checked the sign-out binder, called the DON to confirm and reviewed PCC for discharge orders. During another interview with the DON on 2/29/24 at 9:50am, she stated the facility has not used agency staff since September 2023. She said the facility conducted in-services after the resident left, including rounding and census count during shift change, signing out residents, codes and elopement drills, anticipating elopement risk and identifying exit-seeking behaviors. She also said discharges are discussed during morning daily clinical meetings and that nurses receive resident discharge packets for the day so that staff are kept in the loop. She also said after the incident, nurses are required to provide a full 24-hour report both written and verbal. Interview with [NAME] County Police Department on 2/28/24 at 8:00am, the representative stated that a formal request for the police report on CR#100's missing persons case would need to be filled out and submitted to the legal department. The form has been submitted and is pending as of 03/12/2024. Attempted interview with RN B on 2/28/24 at 4:20pm and a voicemail was left. Attempted interview with LVN C on 2/28/24 at 1:01pm, LVN C was the one of the last staff to see resident at the facility. LVN C hung up after introduction. LVN C did not answer during the second attempt at 1:03pm; a voicemail was left. Interview with CR #100's physician on 2/29/24 at 11:44am, he stated that he had 4 visits with the resident between April and May 2023. He stated the resident was pretty stable, medically stable and that his visits were uneventful but that he left AMA (against medical advice). After the resident eloped, the DON called him regarding resident's right to leave. The physician said he told her he thought the resident could make his own decisions and therefore felt he was competent enough to leave on his own. When asked what his visits with the resident was like, the physician said he felt the resident was lucid and oriented every time he talked to the resident. He said during the last two visits with physician's NP, the resident could ambulate 150 ft (feet) with supervision. Physician did mention towards the end of his stay the resident was refusing physical therapy. Interview with the SW on 2/28/24 at 2:12pm, she said she conducts the BIMS score for residents. She said that CR #100 had a cognitive deficit, and she documents her assessments in PCC. She said that the resident never expressed wanting to leave the facility. She said she conducted initial social services assessments mainly with resident's wife. Interview with RN A on 2/28/24 at 9:19am, she said she did not know the resident. She said residents are assessed for elopement during admission and if they exhibit exit-seeking behaviors, such as saying I don't belong here or I don't belong here. If that happens, RN A will conduct an assessment and tell the DON who will conduct her own assessment for residents. She said she had elopement and Code Pink training in February. If residents are missing, staff will search each hall. If residents have a wanderguard it will sound an alarm. If residents aren't found after the search, staff will tell the Administrator and DON. Interview with LVN A on 2/28/24 at 1:12pm, they stated they did not know Resident #1 since they work on a different hall. They said they have in-services on elopement and abuse neglect twice a week. They said they round on residents every 30 minutes. When residents exhibit exit-seeking, they are placed on 1-to-1 monitoring and the DON was informed. An assessment would then conducted and if they determine a wanderguard is needed resident's representative will sign the form and resident will be placed with one. Wanderguards are checked for function every shift. When asked what they would do if they can't find a resident, they said they would check that the resident didn't go out on pass or an appointment and check all the rooms. If resident can't be located, they will notify staff to assist. If they still cannot locate resident, they will tell the DON, Administrator and the resident's physician. Interview with CNA B on 2/28/24 at 1:30pm, she stated that she did not know the resident and did not work on his floor. When asked what she would do if a resident said they want to go home, she would check to see if they have any appointments. If not, she would redirect the resident and inform her Charge Nurse or DON of resident's behavior. If a resident cannot be located, she would search the building; if unsuccessful she would go to the nurse's station and call a Code Pink. If that is unsuccessful, someone would call the DON. CNA B had an in-service on abuse and neglect two weeks ago. She said they have elopement in-services and drills every few months. Interview with Staff A on 2/29/23 at 10:00am, they stated that CR #100 had cognitive impairment. They said he had orientation, memory, reasoning, and safety awareness deficits. Resident was verbal and never mentioned wanting to leave. Interview with Staff B on 2/29/23 at 10:10am, they stated that CR #100 was very cooperative. He was in rehab for endurance and strengthening so he could achieve his goal of living alone. Staff B was surprised and never thought the resident would leave and he never had any discussion or complaints about leaving facility. Interview with Staff C on 3/1/24 at 9:30am, she stated that she did not know the resident. She said if a resident was missing, she would look in all the rooms on her hall. If unsuccessful, she would call a Code Pink and have all staff search the building. If resident is still missing, someone will let the Administrator and DON know. Since resident eloped, she has not heard of another elopement that she's aware of. Interview with the facility receptionist on 3/1/24 at 9:16am, she stated that when she sees residents walking towards the door, she makes sure they have signed the on-pass binder (on-pass was when the resident has received permission to leave the facility) at the nurse's station. She said if residents leave with family they are expected to electronically check in, then go to the nurse's station to sign the on-pass binder before residents can leave. Observation on 3/1/24 at 11:45am, a sign near guest check-in stated that guests should sign check-in binder at the nurse's station before leaving with residents. Record review of facility's Elopement policy dated January 2023 revealed the guideline on facility response to being unable to locate a resident as follows: 1.immediately initiate a search of the entire community both inside and outside premises 2. Search all rooms within the community . 3. Conduct a complete head count of all residents . 4. If the resident is not located .notify the Administrator/DNS immediately 5. Confirm all doors and windows are secured. Check all door locking systems, door alarms .exit seeking alarm devices . Further review of the facility's Elopement policy stated that the facility is supposed to review sign out logs and confirm with family, notify the MD (resident's physician), Administrator/DON, medical director and initiate an investigation and implement and develop a 4-step response plan. Additional steps are to assess current residents for elopement and provide services such as wanderguards (which are bracelets that activate an alarm when residents get close to any exit doors) and/or placing residents on Memory Unit if needed, and to refer residents to psychiatric/psychological services. Record review of facility's Resident's Rights policy dated October 2022 states that resident rights include: all care necessary for them to have the highest possible level of health .to discharge themselves from the community unless they have been adjudicated mentally incompetent. Record review of the facility's Admissions Packet dated 10/12/2020 states that residents may leave the facility for therapeutic home visits called out-on-pass, with permission of resident's attending physician and RP (responsible party). Administration will be notified of all passes in advance and the resident will be signed in and out at the nurse's office. The The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to state entrance, as evidenced below: Record review of facility's Discharge Assessment in-service acknowledgement dated 5/22/23 revealed charge nurses received training for how to discharge a resident in the online portal. Record review of the facility's daily staffing sheet for May 22, 2023, when CR #100 eloped from the facility revealed that LVN C was working on resident's hall on day shift and RN B was working on resident's hall on night shift. Record review of facility's Residents leaving AMA in-service acknowledgement dated 5/23/23 revealed nursing staff receiving training on the process for when a resident requests AMA. The steps included: notify the doctor, notify the DON, notify the responsible party, have the resident fill out the release form, and writing a process note stating the resident choosing to leave AMA, the time they left and how they left. Record review of facility's Discharge and Residents Leaving Facility in-service acknowledgement dated 5/23/23 revealed nursing staff receiving education on documenting resident leaving the facility, including how the resident left and where the resident was in route to, and a note after resident return, if applicable. The signature page included RN B the nurse who marked Resident #1 as discharged without verifying physician orders. Record review of facility's Shift Change Rounds/Resident Count in-service acknowledgement dated 5/23/23 revealed nursing staff receiving education on being expected to perform room to room rounds during shift change and checking the census for their hall. Residents who are not accounted or not discharged from PCC (Point Click Care, electronic medical record system) are treated as a missing person/elopement and that the DON and Administrator must be notified immediately. The signature page included LVN A, the nurse who marked CR #100 as discharged without verifying physician orders. Record review of facility's Calling a Code: Elopement/Missing Resident in-service acknowledgement dated 5/24/23 revealed facility staff receiving education what to do when a resident is unaccounted for at a facility. Record review of facility's Code Pink Drill in-service acknowledgement dated 5/24/23 revealed nursing staff receiving education on what to do when a resident was missing or eloped.

Based on observation, interview, and record review the facility failed to ensure residents who are incontinent of urine received appropriate treatment and services to prevent urinary tract infection for 2 out of 7 residents (Resident #30 and Resident #66) reviewed for Foley catheter care. -LVN T failed to secure Resident #66 foley catheter tubing to prevent pulling on tubing . CNA A did not separate Resident #30's labia to clean during incontinent, clean around the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care. This failure placed resident at risk for Foley catheter dislodgement, unwanted pain, and infections. Findings included: Record review of Resident #66's face sheet dated 07/03/2021 revealed an 76year old female admitted to the facility on [DATE] with the included diagnoses: dementia (a group of conditions characterized by my memory loss and judgement), acquired absence of left leg above the knee, peripheral disease (poor blood circulation), and retention of fluid (fluid buildup in the body tissues). Record review of Resident #66's MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition was severely impaired. Record review of Resident #66's Physician orders revealed the following order: -Dated 12/28/2023 Foley catheter 16 Fr dx: obstructive and reflux uropathy (when urine cannot drain through the urinary tract), check drainage each shift every day and night shift. Record review of Resident #66's care plan dated 02/02/2022 revealed that resident required an indwelling catheter 16 Fr/10 cc balloon with the following interventions: -Provide catheter secure band/tape as indicated. -Check tubing for kinks each shift and during each encounter. -Monitor for s/sx of discomfort and abnormalities report findings. Observation on 02/29/2024 at 11:42AM of staff CNA R and CNA S transferring Resident #66 from wheelchair to bed using a mechanical Hoyer lift. During transferred while staff was lifting resident out of the wheelchair with the mechanical Hoyer lift, resident began to complain of discomfort saying that she was experiencing pain in her vaginal area. The staff (CNA R and CNA S paused to see if resident Foley catheter tubing was pulling. At this time, it was observed that resident Foley catheter tubing was not secured to resident leg. The staff repositioned resident tubing to ensure that resident tubing was intact. When the staff transferred resident to her bed, further observation was made of resident bottom clothing with a wet spot. On the back of her pants. Further observation was made of resident brief soiled with pale yellow fluids and there was no urine observed in resident Foley catheter tubing or in Foley bag. CNA R and CNA S proceeded to provided resident Foley catheter care with no further concerns identified. Interview on 02/29/2024 at 12:10PM CNA R said she did not place resident in her wheelchair but another CNA did. CNA R said because Resident #66 had an indwelling Foley catheter, she should have had a stat loc on her leg to secure resident tubing to prevent the risk of the Foley catheter being pulled out. CNA R said it was the nurses that placed the stat locs on the residents to prevent the foley from being pulled out. CNA R said she would inform the nurse regarding resident Foley catheter tubing not draining properly as well as resident complaints of vaginal discomfort. Interview on 02/29/2024 at 12:15PM CNA S said she was just assisting CNA R with transferring Resident #66. CNA S said although she was a CNA and CMA , her role had changed to the staffing coordinator. Interview on 02/29/2024 at 12:20PM LVN T said after observing Resident #66's Foley catheter said she did not observe urine in resident tubing or bag, or a stat loc on resident leg to prevent Foley catheter being pulled out. LVN T said it was the nurses that were responsible for assessing the residents that had an indwelling Foley catheter ensuring that their Foley tubing was secured to leg. LVN T said she assessed Resident #66's Foley once a shift. LVN T said she did not recall assessing Resident #66 to see if her Foley catheter tubing was secured. After LVN T began to maneuver resident Foley tubing checking to see if the tube was in place, resident tubing began to flow with clear yellow fluids. Resident # 66 was no longer complaining of vaginal discomfort. LVN T went to get a stat loc to secure resident Foley tubing. Interview on 02/29/2024 at 1:00PM DON said it was the nurses that were responsible in assessing the residents with a Foley catheter to ensure that a stat loc was present to prevent the Foley catheter from being pulled out. The DON said the nurses should be assessing residents with Foley catheters at least once a shift and as needed. The DON was asked for the facility policy on Foley catheter. Record review of the facility policy on Incontinence and Catheterization revised January 2023 revealed in part: . Assessment and evaluation .Assessments also include consideration of the resident's overall condition, risk factors, and information about the resident's continence status, rationale for using a catheter, environmental factors related to continence programs, and the resident's responses to catheter/continence services . 16352 Record review of Resident # 30's face sheet dated 02/29/24 revealed a [AGE] year-old female admitted to the facility on [DATE] readmitted [DATE] with a diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory. Cerebrovascular disease ( stroke), paraplegia ( inability to voluntarily move the lower parts of the body), muscle wasting and atrophy, (aphasia) is a disorder that affects how you communicate [ Depressive disorder] is a mood disorder that causes a persistent feeling of sadness and loss of interest. Record review of Resident # 30's Quarterly MDS dated [DATE], revealed Resident #30 had a BIMS score of 01, which indicated severe cognitive Impairment. Resident #30 was indicated to always incontinent of bladder and bowel (inability of the body to control the evacuative functions of urination or defecation) and was dependent on assistance with her activities of daily living. Review of Resident # 30's care plan dated 01/09/2019, revealed a problem of Bladder Incontinence with interventions clean peri area with each incontinence episode. Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician. Observation on 02/29/24 at 9:32 AM. revealed that while providing incontinent care for Resident #30, CNA A using wet wipes. She did not open the labia to clean, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks with bowel movement, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #30. During an interview on 03/01/2024 at 3:25 PM CNA A revealed that she was nervous and forgot to open the labia to clean and cleaned the buttocks before applying the cleaned brief on Resident #30. CNA A said she had received incontinence care training within the last year, and she knew by not opening the labia to cleaned could cause urinary tract infection. Review of annual skills check for CNA A revealed CNA A passed competency for Perineal care/incontinent care on 07/18/2023. During an interview with the DON on 03/01/2024 at 3:25 PM., the DON stated that during the incontinent care of a female resident, Staff should wipe the peri area, then open the labia and clean downward. The DON said she was going to start incontinence care skills checks . The DON stated that if staff performed peri care deviating from policy, residents risked possible urinary infections. In an interview on 03/01/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection. Review of the facility's staff skills competencies on Perineal care (female Resident), dated 12/12/23, revealed: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . For a female resident: Wet washcloth and apply soap or skin cleansing agent. Wash perineal area, wiping from front to back. 1. Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) 2. Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. 3. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. 4. Gently dry perineum. 48923 Resident #30 Bladder and Bowel Incontinence

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities, which involved 2 of 5 residents (Resident #36, and #75) reviewed for medication errors. 1.- MA B did not administer Turmeric capsule (a medication that helps the inflammation, metabolic syndrome, arthritis, hyperlipidemia, kidney) to Resident #75. 2.- LVN A poured (26mls) wrong dosage of Potassium Chloride 10mg/ml and was about to administered via GTube ( Gastrostomy tube) to Resident #36 . These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: 1. Record review of Resident #75's face sheet revealed a [AGE] year-old female admitted on [DATE] and was readmitted on [DATE]. Her diagnosis included: hyperlipidemia (is an excess of lipids or fats in the body ), head of left femur fraction, (Alzheimer's disease) is a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), age -related physical debility and unsteady gait. Record review of Resident #75's quarterly MDS assessment dated [DATE] revealed a staff assessment for mental status was conducted. BIMS score was 09.The resident's cognitive skills for daily decision making was moderately impaired. She was totally dependent on one staff for dressing and eating; and two staff for transfers and toilet use. She required extensive assistance of one staff for personal hygiene and two staff for bed mobility. Record review of Resident #75's order summary report for 2/22/ 2024 revealed an order of Turmeric Curcumin Capsule 5-1000 mg ( black pepper -Tumeric) Give 3 capsule by mouth two times a day for supplement. Record review of Resident #75's medication administration record for February 2024 revealed Turmeric Curcumin Capsule 5-1000 mg 3 capsules (3000mg) was documented as administered on 02/27/22 at 8:35 AM by MA B. In an observation on 02/27/24 at 8:35 PM MA B prepared Resident #75's morning medications for administration. She prepared Turmeric Curcumin Capsule form 500 mg bottle ( 3 capsules (1500mg) was given to by mouth to Resident #75 with other medications). Instead of T Turmeric Curcumin Capsule 3000 mg being given. In an interview on 02/28/24 at 4:14 pm with DON regarding Turmeric Curcumin Capsule that MA A gave the wrong dose of 500 mg instead of 3000 mg. DON was shown the Turmeric Curcumin Capsule bottle 500 mg. DON said she was going to notify the doctor and she then ordered Turmeric Curcumin Capsule 1000 mg to correct the medication error. In an interview on 02/29/24 at 10:21 AM, the DON said nursing staff were trained to look at the blister pack, bottles and match the eMAR (electronic medication administration record)for dosage, route, frequency, and medication name. She said staff were expected to give medication as ordered by the physician and if they did not it was a medication error. In an interview with MA B on 03/01/2024 at 11:30 AM regarding Turmeric Curcumin Capsule 5-1000mg ( 500 mg 3capsules instead of 1000 mg 3 capsules to Resident #75), MA B said she was very sorry, and he had in-service from the DON and she had been working with the facility for over 5 years and she had training before on medication administration. She knew the 5 rights that included wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route, omitting a medication, and/or administering to the wrong resident. 2. Record review of Resident #36's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included: Gastrostomy status, ( G-Tube is a surgical procedure used to insert a tube, often referred to as a G-Tube for feeding), seizures ( sudden, uncontrolled electrical activity between brain cells( also called neurons or nerve cell causes temporary abnormalities in muscle tone or movements stiffness, twitching or limpness), cerebral infarction (stroke) and hemiplegia (paralysis of one side of the body. Record review of Resident #36's annual MDS assessment dated [DATE] revealed a BIMS score of 04 out of 15 which indicated severe cognitive impairment. She required extensive assistance of 2 staffs for bed mobility, dressing, and personal hygiene. She was totally dependent on 2 staffs for transfers and toilet use. Record review of Resident #36's care plan dated 02/18/24 revealed the resident had G-Tube. The intervention was to take diabetes medication as ordered by the doctor. Record review of Resident #36's order summary report for October 10, 2023, revealed an order for Potassium Chloride 20 milliequivalent (mEeq )/15millimiter(ml ) solution (10%) Give 20 mls via g-tube one time a day Record review of Resident #36's medication administration record for 2/2024 revealed Potassium Chloride 20meq/15mls solution (10%) Give 20 mls via g-tube one time a day was administered to Resident #36 by LVN A on 02/27/24 at the 8:55AM scheduled time. In an observation on 02/27/24 at 8:55 AM LVN A poured Potassium Chloride 26mls in a medication cup, LVN A checked Potassium Chloride solution and said it was 20 mls, and crushed other medications and was going to administer when the surveyor A called her attention and she wasted 6mls before administering through (via) g-tube. LVN A said she having problem reading the lines on the medication cups. LVN A said not giving medication as ordered was medication errors and she would be more careful. In an interview on 12/30/22 at 10:21 a.m. the DON said she expected staff to give Potassium Chloride 20meq/15ml solution (10%). Give 20 mls via g-tube one time a day as ordered by the physician She said nursing staff were not medical doctors and would not know what the outcome would be if not given as ordered. Record review of the facility's Pharmacy Services: Provision of Medications and Biologicals dated February 2017 read in part, .Medication errors: medication errors include, but are not limited to administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route, omitting a medication, and/or administering to the wrong resident .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that include procedures to ensure accurate acquiring, receiving, dispensing, administering of all drugs and disposingof expired medications for 2 of 4 medication carts residents (Nurse's cart for 100 and 200 hall) reviewed for medication storage. -The facility failed to ensure the nurse's cart for 100 hall,s did not have expired Lemon Glycerin swab sticks expired date 10/2023. -The facility failed to ensure the nurse's cart for 300 halls did not have expired lubricating jelly expired date 09/2023. These failures could place the residents in the facility at risk for not receiving needed medications to maintain optimum health, resulting in deterioration in their condition. Findings include: Observation on 02/28/24 at 4:48 p.m., of the nurse medication cart for 100 and 300 halls revealed the following: The medication listed below were in the original packet expired. -16 Lemon Glycerin swab sticks (Triple pack) expired date 10/2023. - 4 Sachet Lubricating jelly 3gm expired date 09/2023 Interview with LVN B on 02/28/24 at 4:48 PM, LVN B said she only worked as needed and she checked 100 hall medication cart whenever she worked. LVN B said she did not know the Lemon Glycerin swabs was expired until the surveyor A showed her. LVN B said she always checked the medication cart when she comes on duty for expired medication. Interview with RN A on 02/28/24 at 4:53 PM, RN A said she checked 300 hall medication cart whenever she works and lubricating jelly was only used for residents on as needed suppository. Interview with the DON on 02/29/24 at 3:00 PM, she said she just audited the medication carts and she missed those medications and lubricating jelly was not used. Interview with the DON on 03/01/2024 at 11:55 a.m. revealed whatever nurse was on shift and the medication aide checked the medication cart for expired medications. The DON said the nurse and medication aide monitored medications and the pharmacist comes to the facility on ce a month to document and checked for expired medications. The DON knew that giving residents expired medications could change chemical composition of the drugs over time which can render them unsafe or ineffective. Record review of facility policy on storage of medications, dated 2001 MED-PASS, Incorporated. (Revised April 2019) read . store all drugs and biologicals in a safe, secure and orderly manner .#5 .Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroy.

Based on observation, interview, and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 3 residents (Resident #13) reviewed for coordination of PASRR and assessments. The facility failed to request, submit and coordinate the PASRR assessment and screening in the Simple LTC portal to ensure therapeutic services (physical, speech and occupational) were completed for Resident #13 . This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs. Findings included: Resident #13 On [DATE] at 1:00 pm a telephone interview with an anonymous person revealed that the facility did not complete and submit PCSP forms to coordinate PT, OT, and ST services for Resident #13. During this interview, it was revealed that Resident #13 did not receive specialized PT, OT, or ST therapies due to this failure. On [DATE] at 8:20 am, an interview with the Director of Rehab, it was revealed that the therapy department fills out a request for specialized services then the MDS Coordinators complete the form, MDS Coordinator A usually submits the therapy documentation for long-term-care. She said that Resident #13 refused PT at one point, and she would try to find the dates for Resident #13's PASRR submissions. On [DATE] at 8:25 am an interview with MDS Coordinator A, it was revealed that PT,OT and ST fill out a request form for specialized services and she was not sure when they filled it out, but she had been in contact with the PASRR representative, and she was aware of the status. An interview on [DATE] at 12:24 pm with the Senior Director of Clinical Reimbursement, it was revealed that Resident #13 refused PT services and that Resident #13 received OT and ST services and never missed treatment even though the request for treatments were not in the portal . Interview on [DATE] at 4:27 pm with MDS Coordinator A, it was revealed that she could not confirm the habilitative services per Simple LTC portal, that the submitted request for PT was not approved and expired in January of 2023 and the OT and ST submitted request expired in [DATE]. On [DATE] at 1:37 pm with Physical Therapist A, it was revealed that PT, OT, and ST therapist were the ones responsible for completing the assessments, the assessments are then sent to MDS Coordinators, and the Director of Rehab does the rest of the process. It was revealed that the most recent request for PT was last year (date unknown) and they never received authorization and there were new requested submitted on [DATE] for all services (PT, OT and ST). Surveyor B requested to interview the Director of Rehab again to but was informed that she had already caught a flight and was not available. A specific policy and procedure for submitting the PT/OT and ST assessments and request was requested but not received. Record review of Resident # 13's facility admission record dated [DATE] revealed a [AGE] year-old female with an initial admitted [DATE] and admitted [DATE] with diagnoses that included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), deaf; nonspeaking (deaf people who cannot speak an oral language or have some degree of speaking ability) and Schizoaffective Disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations). Record review of Resident # 13's quarterly MDS dated [DATE] with an ARD of [DATE] revealed a BIMS score of 1, severe cognitive impairment. The MDS revealed Resident # 13 required 2-person assistance with bed mobility, transfers, and ADL's. Record review of Resident # 13's care plan, date initiated [DATE], revised on [DATE] revealed a care plan to address, narrate and document interventions for Resident #13's PASRR needs as follows: Resident was considered PASRR +:Initial Meeting held [DATE] with services of OT and ST recommended and will be initiated. PASRR quarterly meeting held [DATE]. Will continue current plan of care with no changes recommended. Translator was made available. Quarterly PASRR meeting held [DATE]. Continue POC. No changes to report . I will maintain my highest level of functional well-being with regards to my care and any PASRR special services that I may have in place throughout my next review date. Date Initiated: [DATE], Created on: [DATE], Revision on: [DATE] Target Date: [DATE] .Coordinate my plan of care with my Service Coordinator as indicated. Date Initiated: [DATE], created on: [DATE] . Invite my representative and/or responsible party to attend my care plan meeting as scheduled. Date Initiated: [DATE] Created on: [DATE]. Revision on: [DATE] Record review of the Texas Health and Human Services Pre-Admission Screening and Resident Review (PASRR) Evaluation Report, date of PASRR Evaluation [DATE], for Resident #13 revealed recommendations for Physical Therapy (PT) Specialized Assessment Speech Therapy (ST), Occupational Therapy (OT) Specialized Assessment Physical Therapy (PT) Speech Therapy (ST) and a Customized Manual Wheelchair (CMWC) in a Nursing Facility setting. Record review of the PASRR Evaluation dated [DATE] requested but the surveyor only received 2 pages which only revealed that Resident #13 was evaluated by a Qualified Intellectual Disability Professional (QIDP) Record review of the SimpleLTC documentation dated [DATE] revealed documentation IDD Specialized Comments read in part .Family/MPOA(Medical Power of Attorney) prefers for Resident #13 to be assessed for Habilitative OT/ST and is not interested in other NFSS, Resident #13 is in agreement. Record review of the NFSS Submissions page in the Simple LTC portal revealed that on [DATE] the assessments and submittal for OT, ST and PT rehab services were performed for Resident #13 and were pending state review. Record review of a screenshot of the NFSS Submissions page in the facility portal revealed that on [DATE] the assessments and submittal for OT, ST and PT rehab services were performed for Resident #13. Record Review of OT Treatment encounter notes dated [DATE] for Resident #13 read in part .patients reported no change in function and precautions are for safety, fall, deaf and mute. Record Review ST Treatment encounter notes dated [DATE] for Resident #13 read in part .patients reported no change in function and precautions are for communication, aspiration, confusion and PEG tube. Record Review of PT Evaluation/Plan of treatment and notes revealed a certification for [DATE] through [DATE] and a PT Discharge summary dated [DATE]. A PT Evaluation and Plan of treatment with a certification period of [DATE] to [DATE]. Observation on [DATE] at 9:52 am Resident #13 was observed to be lying in her bed and appeared to be asleep. Her face was covered with a blanket and a staff member explained that she preferred to sleep with her face covered. The call-light was attached to her bed and within reach. The room appeared to be clean, odorless and her specialized wheelchair was at the foot of her bed. Record review of the facility policy entitled Specialized Rehabilitative Services dated revised [DATE], read in part . Specialized services for MI or MR .for a resident with MI or MR, the community will ensure that the individual receives the services necessary to assist him or her in maintaining or achieving as much independence and self-determination as possible. The Preadmission Screening and Resident Review (PASRR) indicates specialized services required by the resident. The state is required to list those services in the report, as well as to provide or arrange for the provision of the services. Even if the state determines that the resident does not require specialized services, the community is still responsible for providing all services necessary to meet the resident's mental health or mental retardation needs. The community provides interventions that complement, reinforce, and are consistent with any specialized services (as defined by the resident's PASRR). The individual's plan of care specifies how the community integrates relevant activities to achieve consistency and enhancement of PASRR goals. Mental health rehabilitative services for MI and MR may include but are not limited to: consistent implementation during the resident's daily routine and across settings of systematic plans that are designed to change inappropriate behaviors .development, maintenance, and consistent implementation across settings of those programs designed to teach individuals the daily living skills they need to be more independent and self- determining, including but not limited to grooming, personal hygiene, mobility, nutrition, vocational skills, health, drug therapy, mental health education, money management, and maintenance of the living environment. Record review of the Texas Health and Human Services Guide for Completing the PASRR Evaluation (PE) dated [DATE], read in part . Documenting and Submitting an IDT Meeting into the LTC Portal For an individual with a positive PE portion of the interdisciplinary team (IDT) meeting is held within 14 days of an individual's admission or for a resident review, within 14 days after the LTC Online Portal generates a notification to the LA to complete a PE. The IDT is held to determine whether the individual is best served in a NF or community setting. The IDT is also used to identify which of the recommended specialized services the individual, or LAR on the individual's behalf, wants to receive. The IDT meeting is documented on the PASRR Comprehensive Service Plan (PCSP) Form and information from the PCSP is entered into the LTC Online Portal.

Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 2 residents (Resident #30) reviewed for infection control. 1.CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #30 by not changing gloves and washing hands . These failures could place residents at risk for transmission of diseases and organisms. The findings included: Record review of Resident # 30's face sheet dated 02/29/24 revealed a [AGE] year-old female admitted to the facility on [DATE] readmitted [DATE] with a diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory. Cerebrovascular disease ( stroke), paraplegia ( inability to voluntarily move the lower parts of the body), muscle wasting and atrophy, (aphasia) is a disorder that affects how you communicate [ Depressive disorder] is a mood disorder that causes a persistent feeling of sadness and loss of interest. Record review of Resident # 30's Quarterly MDS dated [DATE], revealed Resident #30 had a BIMS score of 01, which indicated severe cognitive Impairment. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder. Resident #30 was indicated to always incontinent of bladder and bowel and was dependent on assistance with her activities of daily living. Review of Resident # 30's care plan dated 01/09/2019, revealed a problem of Bladder Incontinence with interventions clean peri area with each incontinence episode. Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly, and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician. Observation on 02/29/24 at 9:32 AM. revealed that while providing incontinent care for Resident #30, CNA A using wet wipes. She did not open the labia to clean, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks with bowel movement, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #30. The resident was rolled to her back, and the brief was secured. CNA A pulled the blanket up to cover her legs. CNA A used the same gloves throughout while performing incontinent care, used the same gloves to open Resident #30's dresser and picked resident clean pants and top. During an interview on 03/01/2024 at 3:25 PM CNA A she said she was nervous and forgot to open the labia to clean and cleaned the buttocks before applying the cleaned brief on Resident #30. CNA A said she had received incontinence care training within the last year, and she knew by not opening the labia to cleaned and not changing gloves could cause urinary tract infection. In an interview with the DON on 02/29/24 at 3:53PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with for incontinent care. DON said not washing hands after changing gloves could cause urinary tract infections. DON said C.NA A knew she should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. Review of the facility's policy titled; Handwashing/Hand Hygiene revised on 04/12/2019. Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 4. Single-use disposable gloves should be used: 1. before aseptic procedures; 2. when anticipating contact with blood or body fluids; and 3. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 35822 48923

Based on observation, interview, and record review the facility failed to ensure resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 2 residents (Resident #1 and CR #2) reviewed for adequate supervision. 1. The facility failed to ensure the Hoyer lift being used to transfer Resident #1 was in good condition, the sling broke and Resident #1 fell on the floor, resulting in injuries while being transferred, Resident #1 sustained head and hip injuries and pain from the fall requiring transfer to hospital for further evaluation and higher level of care. 2. The facility failed to ensure CR #2 was assisted by 2 persons during incontinent care. CR #2 fell off the bed during incontinent care while being assisted by one staff and Sustained deep laceration and bleeding from her legs requiring transfer to hospital for higher level of care for the injuries and surgical intervention. The resident expired from complications post surgical treatment at the hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 9:52 AM. While the IJ was removed on [DATE] at 12:10 PM, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of harm, injury, and hospitalization . Findings include: Review of Resident #1's face sheet revealed a [AGE] year old woman admitted to the facility [DATE] with diagnoses of Hemiplegia and hemiparesis, Type 2 diabetes, muscle wasting, lack of coordination, Chronic obstructive pulmonary disease, heart failure, contusion of scalp, and hypertension. Review of Resident #1's Kardex record revealed, she currently required Hoyer lift for transfer from bed to chair and from chair to bed. Review of Resident #1's progress note documented by LVN C at [DATE] at 08:08am revealed Res noted on floor in room lying on back next to bed. Golf ball-sized hematoma noted to back of head on right side. CNAs were resent x 2. Incident happened while attempting to transfer from bed to w/c via Hoyer. Res c/o pain to back of head. MD notified. Order given to send to ER via911. RP informed of status. Res able to move left extremities and head without difficulty. In an interview on [DATE] at 12:50 p.m. with Resident #1, she stated she saw that the straps on the Hoyer lift sling were rotting, she stated she could tell the difference in the color of the straps of the sling, and she told them (the two CNAs who transferred her) it was rotten. Resident #1 stated when she was being lifted up with the Hoyer lift the slings broke loose, and she fell and hit her head on the floor. She stated 4 staff members helped her and she was sent to the hospital. She stated she had an injury on top of her head, and it had not gone away yet because the top of her head was still sore. Resident #1 stated her head hurt for 2 or 3 days and then her head was spinning. She stated her vision had been blurry since the incident. Resident #1 stated the doctor came by one day and he did examine her. He looked at her head. In an interview on [DATE] at 1:48 PM Resident #1 stated she was still having pain at her hip and head due to the fall. She said the nurse gave her pain medication. In an interview on [DATE] at 1:46 PM with CNA K on 100 hall, stated he had been working with the facility for three months; he started working in [DATE]. The Surveyor asked to know what training regarding a Hoyer lift he received during hiring. He stated they watched video. Further interview with CNA K revealed there was no hands on training, return demonstration on Hoyer lift operation, and safety check observation for him during hiring. Observation and interview on [DATE] at 2:03 PM revealed in room [ROOM NUMBER]A the Surveyor observed Resident #1 being transferred with Hoyer lift by two CNAs (CNA J and CNA L). Both CNAs failed to observe or inspect the Hoyer lift and the sling for safety, to make sure both the sling and the Hoyer lift were in a good working condition before they transferred Resident #1. In an interview with CNA J, she stated she had received in service training in the past week on how to use the Hoyer lift. CNA J did not state the reason why she did not perform a safety check on the Hoyer lift and the sling before they transferred Resident #1. In an interview with CNA L, she stated she was trained about using a Hoyer lift before she came to the facility. She also said she received training a few weeks ago around February 2023. In an interview on [DATE] at 2:55 PM with CNA P, working in the building as an agency staff, she stated it's been about eight months since she started coming to the building which she was off and on about 8 months ago. She said she just came back working at the building and today ([DATE]) was her first day coming back. She said she did not receive any training about how to use Hoyer lift in the building, she said I know how to use it because she had been using a Hoyer lift for a long time. She said, They know I know how to use it. The Surveyor asked how the facility knew that she could use a Hoyer lift, she said I told them I know how to use it. CNA P stated she did not go through any formal training on the use of Hoyer lifts and there was no return demonstration oh check off done for her before she started taking care of the residents in the building. In an interview on [DATE] at 3:08 PM with CNA A, she said she started working at the facility [DATE]. She said she had been working as a CNA for [AGE] years. She said CNA M was the primacy caregiver for Resident #1. She stated she was called to assist her, and they were transferring the resident as they usually did for all residents during a transfer. She also said she believed the Hoyer lift was okay before they used it because that was what they used all the time. However, she stated they hooked up Resident #1 on the sling but it split on us. She said the sling split at the top side of the sling. The Surveyor asked if she inspected the sling or noticed if the sling was ripping fore they did the transfer. She stated, Not the part that it split. She stated At the bottom part, the blue part looked like it was [NAME]. She said they only used the black part (the loop) at the bottom of the sling. She said the top part appeared okay but the top was the part that broke. She stated it never occurred to her that the sling could break because the part of the sling loop that broke was okay, however she did not take the time to inspect other parts of the sling altogether. She stated when the sling broke, the resident fell on the floor. She said the resident said she had no pain, but she had a little swelling on her head. She said the nurse came to assess the Resident #1 and was transferred to hospital for further check up. She said the same day the incident happened the Director of Clinical Education took her to another resident to observe how they did the transfer on Resident #1. CNA A did not state specifically if they performed safety checks/inspections on the sling before they used it. She stated there was no previous training observation and/or return demonstration on safety inspection of Hoyer lifts and slings at the time of her hiring at the facility. In an interview on [DATE] at 3:27 PM CNA M stated she started working with the facility on [DATE]. She stated Resident #1 fell when they (CNA A and CNA M) were transferring her from bed to wheelchair, because the sling broke. She stated she was trained on how to use Hoyer lift after the incident. She stated however, she did not have any return demonstration training or check off on Hoyer lift transfers and/or safety inspection of Hoyer lifts during her hiring process. CNA M stated the training she got at the facility was on video. She stated also that she had been using a Hoyer lift for up to 2 years before she became a CNA and she told them at the facility that she knew how to use it. In an interview on [DATE] at 4:02 PM with the DON, the Surveyor asked about their training for nursing staff for Hoyer lifts, and she stated they usually trained their staff during hiring with 15 minutes video. She said all their new staff watched the video before they let them take care of residents. The Surveyor asked if there was any checklist/observation of return demonstration from the staff using a Hoyer lift, and she stated they had a checklist and return demonstration which they used for in servicing their staff. She stated she was not sure if there was any before she got to the facility. However, further interview with the DON revealed that since she became the DON at the facility, there was no return demonstration observed for the nursing staff during the hiring process training and there was no checklist in place prior to the occurrence of the incident. She stated further that they had, since the incident occurred, been training every staff, and making sure they got the in service before they got to work with the residents. She stated the Director of Clinical Education was the one who always handled training with staff during the hiring process and the tool she used was the 15 minutes video. The DON stated further that when the incident happened, the company who made the Hoyer lift was called to come in and train them (facility staff). When asked about how often the company trained them, she stated she did not know the last time the company came to train the facility, and they never had any issue with the Hoyer lift before the incident happened. In an interview on [DATE] at 5:25 PM with Laundry Staff A, who had been working with the facility since [DATE], she stated she had been working as a laundry staff up to 7 years and she had been laundering the sling same way washing and drying in low heat. She stated no one ever told her not to dry the sling in the dryer. She said she followed the manufacturer's recommendation to dry on low heat. She stated since she had been working at the facility, she had been using the dryer on low heat to dry the sling and no one ever instructed her not to do so even including her supervisor. She said the same day the incident happened with Resident #1, she was written up after the incident occurred, and her supervisor told her never to use the dryer to dry the sling. She said the facility brought rack the next day and installed it on the wall at the back of the door for her to hang the slings on whenever she washed them. When asked Laundry Staff A stated she never used bleach to wash the sling since after COVID 19 protocol changed. She said during the outbreak of COVID 19 the guideline was to wash everything in the yellow bag twice with bleach and dry them twice. She said that was the only situation where she washed the sling with bleach, and it was the only the sling they used for residents in isolation for COVID 19, because she was trying to follow COVID 19 protocol. She said after the COVID 19 protocol changed she did not use bleach on the sling anymore. In an interview on [DATE] at 5:23 PM with Regional Director of Clinical Operation, she stated, as of the day that the Hoyer lift incident occurred, they did the 100% training for all staffs in the facility, and the training still continued. Review of CR #2's face sheet undated, revealed a [AGE] year old female, admitted into the facility on [DATE] with diagnoses of respiratory failure, heart disease, heart failure, kidney disease, morbid obesity, abnormalities of gait and mobility, and muscle wasting. Review of CR #2's care plan revealed she was a two person assist for bathing/shower, bed mobility, dressing/ grooming, hygiene, toileting/incontinent care, transfers, and turning/repositioning. s In an interview on [DATE] at 2:55 PM with CNA P, working in the building as an agency staff, the Surveyor asked how she would know if a resident required two person assist. She said she would hear from other CNAs because they would get report at the beginning of their shift. She said she did not know which record to review to see if any resident was a two person assist. She also stated she was not sure if it was documented in residents' profiles. CNA P stated the only way she knew if any resident was a two person assist was through the report from other CNAs. Review of hospital record for CR#2 revealed reason for visit was Laceration without foreign body left knee, initial encounter. and admit diagnosis was sepsis, unspecified organism Review of hospital record titled 'hospital course' dated [DATE] and electronically signed by MD at 10:06 a.m. revealed CR #2 has large laceration involving the deep subcutaneous tissue on both legs, right deeper than left. There is mild oozing on the right and a vein was ligated and the wound packed . The patient has difficulty talking due to shortness of breath . imaging was done without any fracture, but the wounds were extensive, so trauma surgery was consulted . 2 deep lacerations to the anterior aspect of both legs s/p fall . The right laceration was deep to the subcutaneous tissue approximately 16 centimeters in length and 5 6 centimeters deep. The left anterior lower leg laceration was superficial at 7.5 centimeter in length . postoperatively, patient had worsening shock and [NAME] (Acute Blood Loss Anemia) resulting in a AKI (Acute Kidney Injury) necessitating CRRT (Continuous Renal Replacement Therapy) and intubation for intensive mechanical ventilation. Patient ultimately made DNR (Do Not Resuscitate) comfort after being placed on three pressors and not tolerating CRRT. In an interview on [DATE] at 3:27 PM with CNA M, she stated resident CR #2 was a two person assist for all ADLs such as bed mobility, incontinent care, bathing/ shower, and transfer. In an interview on [DATE] at 5:10 PM with CNA B, who was providing incontinent care at the time CR #2 fell out of bed, he stated he assisted CR #2 reposition on her side, so he could clean her and change her diaper. He stated suddenly the patient fell from bed to the floor before he could intervene to hold her back in bed. He stated it was a surprise for him the night that the CR #2 fell . He stated he had been taking care (incontinent care) of the CR #2 all by himself in the past. He stated he knew the CR #2 very well and took care of the CR #2 often. He stated I was never really told that CR #2 required 2 people and had to be assisted by two people. He stated CR #2 sometimes would lay on her side to hold the side rail when turned, so he had taken care of CR #2 without any issues in the past. He stated his supervisors had always told him to call for help if he needed help, but no one had ever specifically instructed him to always use two person assist with the CR #2, neither was he trained or shown where to locate information in the resident's record. CNA B said he only used his initiative when taking care of all his residents including CR #2. He said he would call for help when trying to adjust resident's up in bed because the resident's was a big woman and he needed help to scoot her up. He said on the day when the CR #2 fell , he called on the nurse (LVN A) after which the CR #2 was transferred to hospital. In an interview on [DATE] at 4:47 PM with LVN A (the night nurse who assessed CR #2 after she fell out of bed), he stated he was called to the room after the resident fell out of bed. He said there was a CNA with the resident who was changing CR #2's brief. LVN A said he assessed the resident and observed a laceration on resident's lower extremities and bleeding. He said he tried to stop the bleeding by applying compression to the wound, and called 911 immediately, and he notified the DON, the resident's doctor, and family member. He stated he had to call 911 immediately because what he saw was a major thing. The Surveyor asked if CR #2 was usually a two person assist and the nurse stated the resident was usually assisted by 2 staff because CR #2 weighed more than 300 pounds. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 9:52 AM. The IJ template and the plan of removal was provided to the Administrator. The plan of removal was accepted on [DATE]. The plan of removal reflected the following: Immediate Jeopardy [DATE] 9:50 a.m.F689 Accidents and Supervision Imediate Response related to Accidents and Supervision 1. Resident # 1 Assessed immediately on [DATE] at 8:08 a.m. by LVN A resident alert, answers questions appropriately, gets up in w/c and propels self around and participates in activities back to baseline. 2. CR #2 discharged [DATE] at 8:30 a.m. to hospital via EMS. o All Team Members providing care to residents where re education/re training was provided regarding: o Transfers utilizing mechanical lifts and slings process and procedures by the DON/Designee. o Preventing Accidents/Fall Prevention/Promoting a Safe: identifying risk, reducing risks, and promoting an accident free environment and transferring as per indicated in the plan of care by DON/Designee. o Proper inspection of all mechanical lift devices and mechanical lift slings to validate that the equipment is in good repair and safe to use prior to patient use as per manufacturer's recommendation by Admin/DON/Designee. o Safe Lift and Transfer Program by the DON/Designee o Prevention of Abuse & Neglect as well as preventing, identifying, and reporting all suspicions or allegations of abuse by the DON/Designee o 1:1 skills observation DNS/Designee to validate competency on safe lift and transfers utilizing mechanical lift device to be completed prior to reassuming patient care. All staff to be educated prior to working the floor/shift by DON/Designee. o The DON/Designee provided immediate education on use of the Kardex (record that gives a brief overview of each patient care and is updated every shift). o The DON/Designee reviewed policy and procedure. No revisions were needed at this time. o Root cause analysis conducted for both incidents is: failure to thoroughly inspect the Hoyer pad and failure to review the Kardex prior to providing care to the resident. o Visual inspection of all Hoyer slings was conducted by the Administrator to determine if any slings were in use that should not be in use completed by the admin on [DATE]. o Community evaluated the process for cleaning and drying of slings and determine that the process the community is using is in accordance with the manufacturer specifications. The process was re evaluated on [DATE] and [DATE]. o Laundry staff and the Supervisor will be in serviced on washing and drying of the hoyer sling per manufacturer instructions: Sling is to be washed in warm water. Hoyer slings are to be dried utilizing the follow method: cool tumble dry, air dry or dry at a very low temperature. Date commenced: [DATE] Completion date: [DATE] Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Risk Response: Residents who currently reside in community, noted as a fall risk, assistance with transfers may potentially be affected by the alleged deficient practice. o DNS/IDT/Designee reviewed/assessed other residents who require assistance with transfers. All residents Kardex/plan of care to assure it is an accurate reflection of current patient needs and/or complete the care plan review and update as indicated. Direct care staff was educated on the use of Kardex, including how and where to access the Kardex. o Proper inspection of all mechanical lift devices and mechanical lift slings to validate that the equipment is in good repair and safe to use prior to patient use as per manufacturer's recommendation by Admin/DON/Designee. o Validating transfer assessment are complete and accurate by DON/Designee. Date commenced: [DATE] Date of completion: [DATE] Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in service/education prior team members working their assigned shift. Systemic Response: o All team members will receive re education on Prevention of Abuse & Neglect identifying and reporting all suspicions or allegations of abuse. All staff will receive the education on Abuse and Neglect prevention, identifying and reporting before assuming next shift. Effective as of [DATE]. o All direct care staff will receive additional training on the below topics and will not assume next shift until education has been received. o Proper inspection of all mechanical lift devices and mechanical lift slings to validate that the equipment is in good repair and safe to use prior to patient use as per manufacturer's recommendation. o Inspection of all mechanical lift slings to ensure that they are in good repair and safe to use as per manufacturer's recommendation. o Validating transfer assessment are completed and accurate on all residents. o Reviewing the Kardex/plan of care specifically regarding transfer status/needs, prior to transfer care being provided. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided. o Validate competencies of care givers regarding safe lift and transfers process for utilizing mechanical lift devices. o Education on review of the Kardex prior to providing care in response to CR #2 incident. o DON/Designee conducted a 100% audit onall residents transfer status on [DATE]. Date commenced by DON/Designee: [DATE] Date of completion: [DATE] Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in service/education prior team members working their assigned shift. Monitoring Response: The Administrator/ DNS/ designee will conduct weekly rounds to validate that transfer policies are followed to ensure the safety and wellbeing of our residents. Additional education will take place based on needs observed during this process. All findings will be reported to the QAPI committee during monthly meeting until there is 100% compliance observed during observations Adhoc QAPI was conducted on [DATE] with Medical Director All team members included in Resident #1 incident were educated with validation of mechanical lift device conducted on [DATE]. The team member involved with the incident for CR #2 was educated on [DATE] by phone and in person on [DATE] by the DON on providing care to residents per Kardex, what is the Kardex, How/where to access Kardex and when to access Kardex. Surveyor monitored IJ from [DATE] through [DATE]. IJ was removed on [DATE] at 12:10PM. In an interview on [DATE] at 4:02 PM with LVN B working at the facility since [DATE]th she said she received training yesterday [DATE]on how to use Hoyer lift, and she was also trained sometime in the past weeks. When asked, she stated further that the training involved inspecting the lift and the sling to make sure both were in good condition. In an interview on [DATE] at 4:39 PM with CNA C working 2 years at the facility, she said she was trained yesterday ([DATE]) about Hoyer lift transfer and to inspect it before they use it to make sure it is safe In an interview on [DATE] at 4:42PM with CMA A about a year, she stated she was trained to check the color, make sure they were 2 people when using Hoyer lift, inspect the sling and make sure they were okay. In an interview on [DATE] at 4:44 PM with CMA B started working February 1st 2023. She said she was trained this morning the correct way to put patient in the Hoyer lift, to check the lift and the sling and to make sure it is not torn, and they must be 2 people to use Hoyer lift on residents. In an interview on [DATE] at 4:46pm with CNA D working at the facility for the 1st day. She stated she was trained today ([DATE]) about how to use Hoyer lift correctly she stated she was trained to inspect the Hoyer lift, make sure the Hoyer lift worked properly and to make sure it has no rip. Record review of Hoyer lift competency assessment training revealed training had been provided to the two CNAs (CNA A and CNA M) involved with Resident #1 transfer. Record review of Hoyer lift competency assessment training revealed training had been provided to the CNA B who provided incontinent car for CR #2 In an interview on [DATE] at 8:50 AM interview with RN A, she said she had been working at the facility two years. she stated she received training on Hoyer lift transfer 2 days ago ([DATE]), she stated she was trained on how to transfer resident from the bed to chair and chair to bed, to make sure the lift and sling was working well and safe, and to also make sure they were two person assisting the resident during Hoyer lift transfer. She said they were taught to look in the PCC (point Click care) under Kardex tab to see patients' ADL needs for them to know if patient required two person assist and/or if the patient required Hoyer lift for transfer. In an interview on [DATE] at 9:03 AM interview with CNA E an agency staff who stated she had been working for the facility in and out for a while. She stated she was trained on how to use Hoyer lift couple of times in the past days. She said she was taught to make sure no holes, no rips, no tears, on both the sling and the Hoyer lift machine. She also said she was taught to check the computer in the PCC Kardex to know if a resident required two person assistance with ADLs. Record review of Transfer Audit tool included date of audit, resident number, compliance met or not, and intervention implemented if compliance was not met during the audit. In an observation on [DATE] at 9:18 AM Surveyor observed Hoyer lift transfer with CNA F and CNA G in room [ROOM NUMBER] B Resident #3. The two CNAs inspected the Hoyer lift and sling for safety before they hook the resident up on the Hoyer lift Transfer process was safe, and CNAs performed safety precaution. There was no concern. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 9:52 AM. While the IJ was removed on [DATE] at 12:10 PM, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures for 1 (CR#2) out of 2 residents reviewed for allegation of neglect. The facility failed to report to the State Survey Agency when on [DATE] CR #2 fell out of bed, sustained an injury, and was bleeding. CR#2 was transferred to hospital where she later died . This failure could place residents at risk for injuries, abuse, and/or neglect. Findings include Review of CR #2's face sheet revealed a [AGE] years old female, admitted into the facility on [DATE] with diagnoses of respiratory failure, heart disease, heart failure, kidney disease, morbid obesity, abnormalities of gait and mobility, and muscle wasting. Review of the incidents report reflected CR#2 fell on [DATE] at 11:00 PM. Review of progress note documented by LVN A dated and time stamped on [DATE] at 05:21 AM revealed called to resident room by the CNA that resident just had a fall. resident noted laying on left side on the floor with legs under her side table head to toe assessment done. bleeding laceration on both front leg. compression applied to both legs to stop bleeding. DON notified, [family member] called and voice mail was left. Family member called and notified 911 called vital sign taken, resident continue on 5 liters of O2, resident stated she was trying to turn on her side. In an interview on [DATE] at 5:10 PM with CNA B, who was providing incontinent care at the time CR #2 fell out of bed, he stated he assisted CR #2 reposition on her side, so he could clean her and change her diaper. He stated suddenly the patient fell from bed to the floor before he could intervene to hold her back in bed. He stated it was a surprise for him the night that the CR #2 fell , he stated he had been taking care of the CR #2 all by himself in the past, he stated he knew CR #2 very well and took care of her often and without any issues in the past. He said on the day when the CR #2 fell , he called on the nurse (LVN A) to assess CR#2, after which the CR #2 was transferred to hospital. In an interview on [DATE] at 4:47 PM with LVN A (the night nurse who assessed CR #2 after she fell out of bed). He stated he was called to the room after the patient fell out of bed, he said there was a CNA with the resident who was changing CR #2's diaper. LVN A said he assessed the resident and observed a laceration on residents lower extremities and bleeding. He said he tried to stop the bleeding by applying compression to the wound and called 911 immediately. He stated he notified the DON, patient's doctor, and family member. He stated he had to call 911 immediately because what he saw was a major thing. On [DATE] at 9:33AM, the DON stated the incident was not reported to the state agency because there was a witness to the fall. She stated further that the CNA was providing incontinent care for CR #2 when she fell out of bed. On [DATE] at 9:49AM in an interview with the Administrator and the DON, the Surveyor asked why a self report was not made to the state regarding the CR #2's fall in which she, sustained an injury, and was sent to the hospital. The Administrator did not give any response. When the Surveyor asked if the Administrator wanted to say anything or had any question, he stated no. Review of policy titled 'Accidents & Incidents Reporting/Investigation' dated [DATE] line (a) and (f) revealed An Accident will be reported to the department supervisor/Administrator/ designee as soon as such accident/incident is discovered or when information of such is learned .The community abuse coordinator should follow state and federal requirements in regards to what is state reportable and within the required timeframe.

47215 Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Residents #40 and #75) of 7 residents reviewed for quality of care. The facility failed to prevent Residents #40 and #75 from developing MASD (Moisture Associated Skin Damage) causing them pain and emotional distress. These failures placed residents at risk of a diminished quality of care which lead to residents having severe pressure ulcers and severe moisure associated skin damage. Findings included: Resident #40 Record review of resident #40's face sheet revealed a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Her diagnosis was morbid, severe obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), urinary tract infection, and retention of urine (a condition in which urine cannot empty from the bladder). Record review of Resident #40's Comprehensive MDS dated [DATE] revealed Resident #40 had a BIMs score of 04 indicating the resident was severely cognitively impaired. The Resident required one person assist with toileting. The MDS noted the resident was incontinent of bowl and had a Foley Catheter. The MDS Preferences for Customary Routine and Activities section noted it was very important to resident #40 to choose what clothes to wear and to choose between a tub bath, shower, bed bath, or sponge bath. Record review of Resident #40's Care Plan revised on 11/04/22 read in part . Resident #40 will remain free from catheter related trauma. Foley Catheter with perineal wipes and or soap and water. Q shift and PRN and activate task on POC every shift for pain. Bed mobility X1 person assistance as needed only. Hygiene 1 require 1 staff assistance for hygiene ADL's. Dressing and grooming X1 person assistance . Record review of Resident #40's skin assessment dated [DATE] read in part . Resident #40 has poor elasticity, normal temperature, dry skin, and very moist skin. Resident #40 is very limited to change or control body position. Resident #40 requires moderate to maximum assistance in moving, and she has MASD (moisture associated skin damage). Skin and wound evaluation: area 38.3 cm2, length 11.8 cm, width 6.7 cm, depth NA, undermining NA, turning NA . Observation and interview on 12/27/2022 at 11:05 a.m. with Resident #40, revealed her crying in her wheelchair while engaged in therapy. She said staff does not assist her in a timely manner. She said she had to wait 90 minutes for staff to respond to the call light. She said her bottom had changed from sitting in her feces and urine for too long. She said her bottom burned. She said the new administrator was doing what he could to change things at the facility. Observation and interview on 12/29/2022 at 10:00 a.m., with Resident #40, revealed her engaged in therapy. She said last night around 7:00 p.m., she pushed the call light button for assistance with care but fell asleep around 11:00 p.m. because no one came to assist her. She said she woke up wet the next morning. Resident #40 was not wet during interview and observation. In an interview on 12/30/2022 at 9:30 a.m. with DON, she said if residents had too much water or urine against their skin, then the skin would break down. She said she was not sure if Resident #40 and Resident #75 had seen the wound care doctor for the MASD. She said she had not seen the residents' skin areas recently. She said if residents were left wet for an extended period; they could develop MASD (moisture-associated skin damage). In an interview on 12/30/2022 at 10:50 a.m. with (MP), she said she does not see residents that has moisture-associated skin damage, (which is caused by prolonged exposure to various sources for moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents). She said leaking catheters, resident sweat, not being repositioned, and residents soiled in adult briefs with stool and urine can break down the skin in a matter of minutes. Observation and interview on 12/30/22 at 2:40 p.m., revealed the treatment nurse assisted by CNA T were providing wound care to Resident #40. CNA T placed the foley bag on the bed before the resident was turned to her side and it was left on the bed throughout her wound care. Resident #40 had a caked white substance on her sacrum, buttocks, and groin area, up to about one fourth of her upper thigh. The treatment nurse did not clean the caked area. The MASD had many tiny openings, red on the areas that did not have the caked-up barrier cream and were tender to the touch. The treatment nurse applied the barrier cream on top of the uncleaned caked area. The Foley bag was left on the bed for fourteen minutes. Resident #40 said the MASD was hurting badly. The Treatment nurse told Resident #40 that the cream she applied would stop the pain. The Treatment nurse measurements were: buttocks: 24 x 23 cm, inner left thigh to the groin measured 6 cm x 10 cm, and the right inner thigh measured the same. In an interview on 12/30/22 at 3:11 p.m. with CNA T, she said she placed the Foley bag on the bed because she did not want the bag to hit the floor. She said the urine flowed back into the bladder. She said she did not know what could happen to the residents when urine flowed back into the bladder. CNA T said she had been in-serviced on how to take care of a residents with Foley's. She said she no had told her not to place a Foley bag on the bed during in-service. She said she thought that was how she was supposed to clean the Foley from the vagina down. In an interview on 12/30/22 at 3:28 p.m., the Treatment nurse stated Resident #40's wound care order did not state to clean the area before applying barrier cream. The Treatment nurse stated she did not clarify the order with Resident #40's doctor. The Treatment nurse stated Resident #40 was cleaned when she was provided incontinent care before she came and applied the cream. The Treatment nurse stated to trust her because the arrier cream was not designed to be wiped off completely, and the incontinent wipes would not be able to cleanse the cream. The Treatment nurse stated the area would be washed clean during the shower because you have to use a towel and soapy water to clean the area for the barrier to come out. When she was asked why she did not use a towel and soapy water to wash the MASD area, she did not respond. The Treatment nurse and the surveyor read the instructions on the barrier cream, which read, wipe the area clean and allow to dry, then apply the cream. The Treatment nurse stated she should have washed the area before she applied the barrier cream. The Treatment nurse stated Resident #40 was admitted with Foley and was unsure if the Foley had leaked. The Treatment nurse stated Resident # 40 was on antibiotics, and she had diabetes, which could make her urine more concentrated, and Resident # 40 does sweat a lot, and which could cause a break in her skin. The Treatment nurse stated the staff should have changed Resident #40 more often to help prevent the MASD. Interview on 12/30/2022 at 3:57 p.m., the DON said she did not know how long Resident #40 developed MASD, but it has been there for a while. She said if the staff changed Resident #40 often and kept her dry, this may not have happened. She said she was not sure if the resident Foley had leaked because she had Foley upon admission. Interview and record review on 12/30/22 at 4:23 p.m., Resident #40's admission skin assessment with the DON, treatment nurse , and Corporate Nurse revealed Resident #40 was readmitted to the facility on [DATE] and there was no skin assessment until 11/07/22. The DON, treatment nurse, and Corporate Nurse stated the initial date of MASD was 11/11/22, and the previous wound care nurse put it in. In an Interview on 12/30/2022 at 4:54 p.m. with LVN K, revealed that the primary doctor gave her the standing order to apply Zinc for MASD. LVN K said MASD started because the Foley was leaking. She said she did not know how long the Foley had been leaking. She repeated she did not know how long it was leaking and it caused the MASD. She said if the aides providing care timely and stopped the leakage, the resident may not have had a skin issue. In an interview on 12/30/2022 at 5:02 p.m. with Corporate Nurse, she said if Resident #40 sweats and the Foley was leaking, then staff should continue to assess Resident #40 and change her. She said she did not have timely intervention in place but to change the resident. In an Interview with the MD on 12/30/2022 at 5:05 p.m., he said it has been long time since he gave the order for MASD and he cannot recall, he said during the Foley leakage he said, Resident #40 is wet all they can do is provide peri care and keep her dry to prevent the skin break down and the facility staff are doing that already. He said Resident #40 had so much to complain about whenever he sees her. He said whatever the order read and if the facility staff said he gave the order that means he did. Resident #75 Record review of Resident #75's face sheet revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, hypertension (persistently raised blood pressure), atrial fibrillation (irregular heartbeat, heart beats faster than normal) and need for assistance with personal care. Record review of Resident #75's admission MDS assessment, dated 10/31/22, revealed a BIMS of 11 indicating moderately impaired cognition. Resident #75 needs extensive assistance with ADL care with one staff assistance and the resident was incontinent of bowel and bladder. Record review of Resident #75's care plan dated 11/03/22 revealed Resident #75 had ADL (activity of daily living) self-care performance deficit related to pain in left hip. Intervention: resident needed extensive assist with two-person assistance with toilet use. It also revealed pressure ulcer or potential for pressure ulcer related to incontinent of bowel and bladder. MASD (moisture related skin damage) stared on 11/08/22, skin fragile and at risk for injury - new or worsening skin condition. Interventions: apply treatment s ordered, keep skin clean and dry and apply skin barrier cream as indicated. Record review of Resident #75's Braden scale dated:10/30/22, 11/06/22, 11/22/22, 11/26/22 read in part . Resident #75 score was 14 which indicated moderate risk for pressure sore risk . Record review of Resident #75's skin assessments dated, 10/24/22, 10/31/22, 11/16/22, 11/21/22, 12/05/22, 12/14/22 and 12/19/22 indicated the resident did not have new wounds. Record review of Resident #75's order summary report dated December 2022 revealed there was no order for MASD. Observation and interview on 12/30/22 at 2:36 p.m., revealed Resident #75 wound was treated by the treatment nurse . She said Resident #75's wound was almost gone. When she unfastened the incontinent brief, she said it looked worse than it did on yesterday, and now it was on his groin area, penis, and scrotum. She said we must go to another resident and come back to him later. She said he was bleeding from some of the open areas and there was fresh blood on Resident #75 incontinent brief. She said as of yesterday he was at the tail end of MASD. Observation on 12/30/22 at 2:58 p.m., revealed the treatment nurse was given to Resident #75 and treated by treatment nurse and was assisted by CNA T. CNA T grabbed gloves from her uniform pocket and donned it. She entered Resident #75's room and assisted the resident to his side. There was still fresh blood on the brief and some of the multiple open areas was still bleeding. The treatment nurse did not clean MASD areas before she applied the barrier cream. Resident #75 stated the MASD area was hurting, and the treatment nurse said the barrier cream would stop it from hurting. Observation on 12/30/2022 at 3:45 p.m., the treatment nurse said the area on Resident #75 was better on yesterday, but it was worse on today. She said that Resident #75 was using the urinal, but he was still incontinent, and they must monitor and make sure the aides are changing him in a timely manner and is kept dry. Resident #75's MASD on the buttocks measured 23 cm x 12 cm. The right thigh was 9 cm x 11.5 cm and the left thigh 9 cm x 10 cm. The groin area was red and MASD. Interview on 12/30/22 at 4:03 p.m., the DON stated Resident #75 used a urinal and the aides emptied the urinal and Resident #75 was incontinent he had to be checked and changed often, or Resident #75 skin could be damaged more. Interview on 12/30/2022 at 4:46 p.m., with Resident #75, said he was admitted on [DATE]. He said he uses a diaper and a urinal to release himself. He said there are times he has waited a long time for staff to assist him with care. He said he has waited 3 to 4 hours for assistance and that has happened twice since he has been at the facility. Resident #75 said he has a sore near his groin area that has been there for 10 days or two weeks. He said staff is treating his sore by changing his diaper and applying some type of cream. Record review of the facility's policy titled Quality of Care revised on (no revision date) read in part . Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on the comprehensive assessment of a resident, the community will ensure that resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The community will ensure a resident who enters the community without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that reduction in range of motion is unavoidable. The community will ensure a resident who is continent of bladder and bowl on admission receives services and assistance to maintain continence unless his or her clinical condition is or become such that continence is not possible to maintain. For a resident with urinary incontinence, based on the resident's comprehensive assessment, the community will ensure that, a resident who enters the community without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates catheterization was necessary .

Based on observation, interview, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 18 residents (CR #1) reviewed for pressure ulcers. 1. The facility failed to adequately assess and treat CR #1's pressure wounds when he admitted to the facility on [DATE] until 4/20/2022, which resulted in hospitalization with bilateral lower extremity [CONDITION(S)] (a common and potentially serious bacterial skin infection), [CONDITION(S)] (inflammation of bone caused by infection, generally in the legs, arm, or spine), and right trans metatarsal amputation. 2. LVN A failed to identify, accurately document, and communicate CR #1's skin breakdown to Treatment LVN B, the DON, and his primary physician and resulted in no assessment/treatment by the wound physician and a delay in treatments orders and daily wound care. 3. Treatment LVN B failed to assess and treat CR #1's skin breakdown/wounds when he admitted to the facility on [DATE] until 4/20/2022. An Immediate Jeopardy (IJ) situation was identified on 05/05/2022 at 3:02 p.m. While the IJ was removed on 5/10/2022, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents with skin breakdown at risk of pain, worsening of wounds, infection, and emotional distress. Findings include: Record review of CR #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with post COVID-19, diabetes, [CONDITION(S)], [CONDITION(S)] (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic obstructive pulmonary disease, [CONDITION(S)], end-stage renal disease, obesity, and muscle wasting and atrophy (no wounds were documented under diagnosis). Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 15 (cognitively intact); he required extensive physical assistance from at least two staff members for bed mobility and toilet use, total assistance from at least two staff for transfers, and extensive assistance from one staff for locomotion via wheelchair; he was always incontinent of bowel and bladder; he occasionally experienced pain; and he was at risk for developing pressure ulcers/injuries (no pressure ulcers/injuries, deep tissue injuries, or venous/arterial ulcers were documented). Record review of CR #1's care plan, updated 3/22/2022 revealed he was on anticoagulant therapy due to [CONDITION(S)] process and was at risk for abnormal bleeding, bruising and skin injury (created by RN A) (Interventions/Tasks included: monitor for abnormal bleeding and monitor skin for excess bruising as indicated); his skin was fragile and at risk for skin injury (created by RN A)(Interventions/Tasks included: Apply treatment as ordered, keep clean and dry and apply skin barrier cream as indicated, pressure relieving cushion device in wheelchair as indicated, therapeutic pressure reducing mattress, turn and reposition regularly during rounds and more often as needed, handle fragile skin with caution and report to nurse if any skin concerns arise); and he had diabetes and was at risk for diabetic wounds (created by RN A) (Interventions/Tasks included: check skin during showers and care [check between toes], report any changes such as redness, open areas, blisters, unusual discolorations and report those findings to nurses/MD/resident/RP). Further review of the record revealed no documentation of actual pressure/arterial ulcers. Record review of CR #1's clinical records from his previous placement revealed he was admitted to a rehabilitation hospital on 3/1/ and was discharged to the facility on [DATE]. Further review of the clinical records revealed CR #1's pressure and arterial wounds were treated by a wound care specialty physician on 3/4/2022, 3/8/2022, 3/11/2022, and 3/15/2022. Record review of CR #1's, Wound Care Specialty Physician Wound Evaluation and Management Summary, dated 3/15/2022 revealed: Focused Wound Exam (Site 1) Unstageable DTI of the Left Heel Partial Thickness. Etiology . Pressure. Duration . more than 10 days. Wound Size . 2x1x not measurable cm. Objective . Healing. Exudate . None. Dressing Treatment Plan . Skin prep apply every two days for 19 days . Recommendations . Float heels in bed; Off-load wound. Focused Wound Exam (Site 2) Unstageable (Due to Necrosis) of the Right Heel Full Thickness. Etiology . Pressure. Duration . more than 10 days. Wound Size . 3.1x4.2x not measurable cm. Objective . Control infection, Manage Exudate. Exudate . None. Thick adherent black necrotic tissue (eschar) . 100%. Dressing Treatment Plan . [MEDICATION(S)]- apply once daily for 19 days: [MEDICATION(S)]-soaked gauze, gauze island with border dressing- apply once daily for 19 days. Reason for no Debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) . Non-infected heel necrosis. Goal of treatment is healing evidenced by a 7.5% decrease in surface area within the wound bed. Focused Wound Exam (Site 3) Arterial Wound of the Left, Lateral Calf Partial Thickness. Etiology . Arterial. Duration . more than 10 days. Wound Size . 9.1x8.4x not measurable cm. Objective . Control Infection, Manage Exudate. Exudate . Light Serous. Scab . Dried fibrinous exudate (scab). Wound Progress . Deteriorated . Additional Wound Detail . wound is draining now and no longer stable eschar. Ultrasound showed moderate peripheral artery disease (narrowing or blockage of the vessels that carry blood from the heart to the legs) but no stenosis, so debridement done superficially. Dressing Treatment Plan . Iodosorb gel- apply once daily for 30 days; Alginate calcium- apply once daily for 30 days, gauze island with border dressing- apply once daily for 19 days. Recommendations . Recommend vascular surgery consult after discharge. Focused Wound Exam (Site 4) Stage 3 Pressure Wound of the Right Buttock Full Thickness. Etiology . Pressure. Duration . more than 7 days. Wound Size . 0.7x1x0.1 cm. Objective . Healing. Exudate . Moderate Serous. Granulation tissue . 100%. Dressing Treatment Plan . Alginate calcium- apply once daily for 23 days, gauze island with border dressing- apply once daily for 23 days. Recommendations . Reposition per facility protocol; Off-load wound; Turn side to side and front to back in bed every 1-2 hours if able. Focused Wound Exam (Site 5) Unstageable (Due to Necrosis) of the Left Buttock Full Thickness. Etiology . Pressure. Duration . More than 7 days. Wound Size: 0.7x1.7x not measurable cm. Objective . Healing. Exudate . Moderate Serous. Slough . 100%. This wound is in an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of a biofilm (a microbial colony encased in a matrix which can become attached to a wound surface). Dressing Treatment Plan . Alginate calcium- apply once daily for 23 days, gauze island with border dressing- apply once daily for 23 days. Site 5 Surgical Excisional Debridement Procedure (done on 03/15/2022) . Remove necrotic tissue and establish the margins of viable tissue . Goal of treatment is healing evidenced by a 12.5% decrease in surface area within the wound bed. Follow-Up . Evaluation by wound care specialist within 7 days with further interventions as indicated. Record review of CR #1's discharge summary, dated 3/18/2022 revealed he was provided with wound care at 11:40 a.m. (before he discharged to the facility): Right heel pressure injury- wound dressing changed: Gauze dressing, other [MEDICATION(S)]-soaked gauze. Left heel pressure injury- Unstageable due to deep tissue injury: open to air. Right buttock pressure injury- wound dressing changed. Left buttock pressure injury- wound dressing changed: Gauze dressing. Left lower leg arterial ulcer- wound dressing changed: Gauze dressing, Iodosorb applied. Record review of CR #1's Hospital Report Sheet, dated 3/18/2022 revealed RN A received CR #1's clinical report from his previous placement on 3/18/2022 at 1:36 p.m. The document read in part, . Pressure ulcers: Skin Bottom - Dressing - Unstageable right heel, left lower limb arterial ulcer . Record review of CR #1's admission, Head-to-Toe Skin Assessment, dated 03/18/2022 revealed RN A wrote, . 4. Open/Significant Skin Issue - Other Open Wound/Issue: Complete Skin and Wound Module . 2b. Comments on items for general skin conditions . Right heel unstageable, Left lower leg arterial ulcer, sacrum unstageable with dressing . Record review of CR #1's electronic clinical records revealed no documentation of any weekly skin assessments. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's TAR for March 2022 revealed no documentation of wound care/treatment. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Order Date: 4/9/2022. Left Lateral Leg unstageable wound - cleanse area with normal saline, pat dry, apply [MEDICATION(S)] moist 4x4 sterile gauze and cover with dry dressing daily and as needed until resolved. Order Date: 4/20/2022. Right medial heel: Cleanse with wound cleanser, pat dry, paint with [MEDICATION(S)] moist gauze and leave open to air Tuesday, Thursday, Saturday and as needed. Order Date: 4/23/2022. Right medial heel: Cleanse with wound cleanser, pat dry, apply [MEDICATION(S)] moist gauze wrap with Kerlix and secure with tape every Tuesday, Thursday, Saturday and as needed. Record review of CR #1's TAR for April 2022 revealed: Complete the Skin and Wound- Total Body Skin Assessment every day shift every Friday for Skin Integrity. Start Date 3/25/2022. There were no entries for 4/1/2022, 4/8/2022, and 4/15/2022. Left Lateral Leg unstageable wound - cleanse area with normal saline, pat dry, apply [MEDICATION(S)] moist 4x4 sterile gauze and cover with dry dressing daily and as needed until resolved. Start Date 4/10/2022. There were no entries for 4/11-13/2022, 4/15-17/2022, and 4/25/2022. Right medial heel: Cleanse with wound cleanser, pat dry, paint with [MEDICATION(S)] moist gauze and leave open to air Tuesday, Thursday, Saturday and as needed. Start Date 4/20/2022, Discontinued 4/23/2022. There were no entries for 4/20/2022 and 4/22-23/2022. Right medial heel: Cleanse with wound cleanser, pat dry, apply [MEDICATION(S)] moist gauze wrap with Kerlix and secure with tape every Tuesday, Thursday, Saturday and as needed. Start Date 4/23/2022. There were no entries for 4/23-26/2022 (CR #1 discharged from the facility on 4/26/2022). Record review of CR #1's physician's progress notes revealed: - Primary Physician: 3/21/2022, . Chief Complaint/Nature of Presenting Problems: Evaluation of patient with generalized weakness and debility, end-stage renal disease, lower extremity weakness . Review of Systems . Skin/Breast: No rashes or skin breakdown . Physical Exam . No [CONDITION(S)] or varicosities (dilated vein that primarily occurs in the lower limbs particularly in the legs) . Skin: Inspection: No rashes or ulcers . - NP: 3/22/2022, . Physical Exam . No peripheral [CONDITION(S)] (swelling caused by the retention of fluid in legs, ankles, and feet) . - Primary Physician: 3/23/2022, . Review of Systems . Skin/Breast: No rashes or skin breakdown . Physical Exam . Trace lower extremity [CONDITION(S)] bilaterally . Skin: Inspection: No rashes or ulcers . - Primary Physician: 3/28/2022, . Review of Systems . Skin/Breast: No rashes or skin breakdown . Physical Exam . Trace lower extremity [CONDITION(S)] bilaterally . Skin: Inspection: No rashes or ulcers . - NP: 3/31/2022, . Physical Exam . No peripheral [CONDITION(S)] . - Primary Physician: 4/4/2022, . Review of Systems . Skin/Breast: No rashes or skin breakdown . Physical Exam . Trace lower extremity [CONDITION(S)] bilaterally . Skin: Inspection: No rashes or ulcers . - NP: 4/7/2022, . Physical Exam . No peripheral [CONDITION(S)] . - Primary Physician: 4/11/2022, . Review of Systems . Skin/Breast: No rashes or skin breakdown . Physical Exam . Trace lower extremity [CONDITION(S)] bilaterally . Skin: Inspection: No rashes or ulcers . - NP: 4/12/2022, . Chief Complaint/Nature of Presenting Problem: Evaluation of debility, DM2, left lateral leg wound, [CONDITION(S)] . His only acute concern today is he is waiting to see wound care to dress the wound to his left lateral leg, he denies any pain to area . Physical Exam . Trace pitting BLE [CONDITION(S)] . Skin: Wound to left lateral leg, covered with dressing today which is clean dry and intact . - Primary Physician: 4/18/2022, . Chief Complaint/Nature of Presenting Problem: Evaluation of patient with increased lower extremity [CONDITION(S)], lower extremity wounds . Patient has been concerned about lower extremity wounds. Patient has noticed more lower extremity [CONDITION(S)] despite [CONDITION(S)]. Patient's wounds are also very cool/cold to touch . Skin/Breast: No rashes or skin breakdown . Trace lower extremity [CONDITION(S)] bilaterally . Skin: Wound to left lateral leg, covered with dressing today which is clean dry and intact. lateral lower extremities cool/cold to touch . Record review of, Nursing Progress Note, dated 4/22/2022, at 6:15 p.m. revealed Treatment LVN C wrote, Patient wound care done as ordered, patient tolerated well. Patient has excess swelling with weeping legs, also skin starting to break due to excess fluid. Notified Primary Physician and NP at the same time this morning about patient's excess fluid build-up and how it is starting to break patient's skin on BLE (bilateral lower extremities) and also asked if we could see about getting him an extra day of [CONDITION(S)] to help get rid of some of the excess fluid. Primary Physician instructed NP to follow up on that and she did so patient is now scheduled for an extra session of [CONDITION(S)] tomorrow, Saturday 4/23/2022 and patient is pleased about that. I also educated patient on making sure toes and feet are dry after any shower or bed bath to help eliminate some of the moisture to his feet so we can try and prevent any more skin breakdown. Patient verbalized understanding. Record review of, Nursing Progress Note, dated 4/26/2022, at 6:38 p.m. revealed Treatment LVN C wrote, Treatment to BLE was done as ordered but BLE [CONDITION(S)] is 4+ weeping through skin also breaking skin. Patient noted with necrotic right 1st toe and skin breaking between toes of RLE (right lower extremity) LLE (left lower extremity) also weeping and skin breaking because of [CONDITION(S)]. I asked patient could I take picture of his leg and foot to send to the doctor because I did not like how it looked, he said yes, and family member was in the room at the time as well. This nurse contacted NP to notify her of how patient BLE was looking because I was very concerned and sent pictures, she said she would let the Primary Physician know about it but he should be in the facility tomorrow (4/27/2022) and I said ok I will make sure I get with him while he is in the facility so he can look at the patient's legs. Record review of Nursing Progress Note, dated 4/26/2022, at 8:24 p.m. revealed LVN H wrote, EMS picking up resident at this time in stable condition alert and oriented x3-4 can make needs known and move all extremities . Record review of CR #1's hospital records, dated 4/26/2022 thru 4/29/2022 revealed he was admitted to the hospital from theER on [DATE] at 9:53 p.m. The record read in part, . Physical Exam . Dermatology: Right foot: There are several ulcerations at all toes and also the web spaces covered by dry scar tissues, the midfoot and distal foot shows signs of ischemic changes. With dorsal skin ulcerations deep to dermis and cold on palpation, toes are discolored, no ascending [CONDITION(S)], no crepitus or abscess formation. - Right distal leg with large self-rupture blisters at the anterior lateral aspect of the lower leg deep to dermis, skin is atrophic, fragile and edematous. Ischemic changes. - Right heel with a pressure ulcer, measuring about 3x2 cm covered with a black eschar tissue. - Left foot: There is an ulceration at the dorsal medial aspect of the left great toe deep to dermis associated with skin discoloration, also discolored left second toe on the dorsal aspect with his current tissue formation. - Left posterior leg: There is an ulceration measuring about the same time 5 cm. The ulcer base is dry covered by eschar and fibrotic tissue . X-ray Foot 3+ views Left . Findings: 3 views left foot are obtained . Impression: 1. Periarticular lucencies with cortical erosion at the interphalangeal joint of the left great toe suspicious for [CONDITION(S)] (bone infection) . Imaging: Ultrasound duplex arterial lower extremity, Result Date: 04/27/2022 . Impression: No evidence of hemodynamically significant stenosis in either lower extremity . Assessment and Plan: 1. Bilateral lower extremity [CONDITION(S)]/[CONDITION(S)] - IV antibiotics. Await blood culture reports. Podiatry has been consulted. May need infectious disease consultation as a suspect the patient may need prolonged antibiotics following multiple debridement surgeries . Observation and interview with CR #1 in his room at a local hospital on 5/9/22 at 8:15 a.m. revealed he was alert and oriented. CR #1 stated when he was admitted to the facility, he was placed on the quarantine hall for a few days (CR #1 was moved from the warm/quarantine [300] hall to a regular room on the 100 Hall on 3/29/2022). He said the first nurse who admitted him (RN A) threw him in the bed and left him there. He said RN A did not look at his body when he was admitted , and nobody looked at his wounds or provided care the entire time he was in his first room. He said he asked the aides to put cream on his backside wound when they changed him, but other than that, nobody changed the dressings at all for the entire time he was at the facility for his back-side wound. He said all of his wounds caused him pain and he kept asking the nurses for the wound care doctor because the wound people his previous facility told him to make sure the wound care doctor at his new facility watched his wounds. He said the nurses at the facility acted like they did not know who the wound doctor was or said she was not there. He said his previous placement had him wear heel protectors, but he only wore them at the facility for about one week until his heels looked bloody. He said after that, the nurse stopped putting the heel protectors on. He said he kept the same wound dressings from his previous placement on until the facility hired Treatment LVN C (Treatment LVN C was hired on 4/12/2022). He said Treatment LVN C was concerned when she saw his wounds and she started changing the leg/foot wound dressings daily. He said after Treatment LVN C started providing daily wound care, he could feel his legs swelling and he asked for extra [CONDITION(S)]. He said Treatment LVN C told him his wounds were getting worse. He said LVN C got very concerned and sent pictures to his doctor, who sent him to the hospital on 4/26/2022. He said the hospital staff were providing wound care every other day, including the wound on his backside. He said his right foot was infected and the hospital doctor decided to amputate the top of his right foot the next day (5/10/2022). He said his wounds started at his previous placement, but they were not in bad condition when he initially went to facility. He said he only saw his Primary Physician in the hallways or in the physical therapy room. CR #1 said his Primary Physician never looked at his legs/feet at all and only told him everything was going to be ok and keep up the good work. He said the only time his Primary Physician went to room was when he told CR #1 his family member's FMLA paperwork was ready. He said he never had a chance to talk to his Primary Physician about the wounds because the physician would leave so fast. Observation of both of CR #1's legs on 5/9/2022 at 8:30 a.m. revealed both his feet and legs were completely wrapped to just beneath the knees. At that time, a hospital nurse entered hid room and stated CR #1 had more than just bilateral [CONDITION(S)] because his legs/feet looked really bad with drainage and odor. She said she had taken wound cultures of both legs/feet wounds on Saturday, 05/07/2022, when the hospital physician provided wound care. She said the laboratory results had not come back yet. At that time, the hospital nurse received a call on her phone device. When she answered the call on speaker phone, it was the hospital's laboratory with CR #1's wound culture results for his left foot. The person from the laboratory said CR #1's left foot was positive for [CONDITION(S)] and ESBL (plasmid-mediated enzymes that confer resistance to antibiotics. ESBL's are most commonly detected in [CONDITION(S)] pneumoniae, which is an opportunistic pathogen associated with severe infection). The laboratory person said CR #1's cultures were not in yet for his right foot. The hospital nurse said CR #1 was currently on antibiotics and was scheduled to have a right trans metatarsal amputation (a surgery to remove part of the foot that includes the metatarsals which is used to treat a severely infected foot or a foot with lack of oxygen supply) for 5/10/2022. In an interview with LVN F on 4/28/2022 at 9:45 a.m., she stated she cared for CR #1 after he was moved to the 100 Hall from the 300 Hall (warm/quarantine unit). She said CR #1 had wounds to his lower extremities that were doing well when he was first admitted . She said CR #1's wounds started getting worse because wound care was probably not done as consistently as it should have been. She said the previous treatment nurse (Treatment LVN B) was consistent with wound care. She said there was no rhyme or reason to care and Treatment LVN B would hit and miss with her treatments. She said Treatment LVN B would cover night shifts (12-hour shifts, from 6:00 p.m. until 6:00 a.m.) when nurses called out. She said Treatment LVN B would stay over the next day after covering a night shift and leave after the morning meetings. She said there were many days when Treatment LVN B did not complete residents' wound care. She said she once observed CR #1 with an undated dressing (she could not recall the date this happened). She said when she asked Treatment LVN B about the dressing, she said she was going to go and do the treatment. She said CR #1 was alert and oriented and frequently asked about getting wound care. LVN F said she provided CR #1 with wound care a hand-full of times (she said this happened maybe four times) after CR #1 said he had not received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said it got quite hectic sometimes and things slipped through the cracks. She said the weekend supervisors provided residents' wound care on the weekends. She said CR #1's wounds started getting a little larger (she did not measure or stage the wounds) but they did not look infected. LVN B said she never reached out to the wound doctor or CR #1's doctor. She said she and the other nurses did know to residents' wound care if the treatment nurse was not there, but sometimes, they thought Treatment LVN B was there when she was not, so no wound care was done. In an interview with Treatment LVN C on 4/28/2022 at 10:15 a.m., she stated she was hired by the facility two weeks prior (4/12/2022) and from her understanding, the treatment nurse before her did not provide treatments daily. She said she had to set up weekly visits with the wound care physician and 4/28/2022 was the wound care physician's first day back in the facility after a month. She said by the time she saw CR #1, he already had treatment orders for his left leg, and she thought he was admitted with order because of how bad it was. She said she did a skin sweep on everyone in the building and found CR #1 had the right leg wound, so she requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said when she initially assessed CR #1, there was a date on his wound dressing, but she could not say what the date was or if it was old. She said CR #1 was in bad shape by the time she saw him and that was why he was going to be on wound list for the wound care doctor. She said when she called the wound doctor to set up weekly rounds, she mentioned CR #1, but he was already sent out to the hospital by the time the doctor came. She said when she initially started treating CR #1, he had a wound to lateral left lower extremity and right heel, but she started to notice bilateral fluid retention. She said the fluid eventually started to break CR #1's skin with little cracks where the fluid seeped out. She said she brought the [CONDITION(S)] to CR #1's Primary Physician to get an extra session of [CONDITION(S)]. She said the extra [CONDITION(S)] helped, but CR #1's legs were still massive with [CONDITION(S)]. She said when she did CR #1's treatment on Tuesday, 4/26/2022, she noticed the tip of his right first toe (not the great toe) was necrotic and there was a lot of moisture between and under the toes. She said she sent pictures of CR #1's feet to the NP and she sent them to the Primary Physician. She said after she left the facility that evening, the Primary Physician ordered to send the resident out. In an interview with the Wound Care Physician on 4/28/2022 at 11:10 a.m., she said she was a physician's assistant. She said she had been seeing residents at the facility once per week, but she stopped visiting on 3/28/2022 because the facility had two previous treatment nurses who were not consistent with rounds. She said she would show up and the treatment nurses were not there. She said she did not typically round with anybody other than a treatment nurse because they were familiar with each resident's wounds. She said she started to visit off and on but her last visit before that day (4/28/2022) was 3/28/2022. She said no other wound physician from her company had visited the facility since that time. She said she just stopped going to the facility and never reached out to the DON about the treatment nurses' behaviors. She said she was never asked to assess or treat CR #1. In an interview with the DON on 4/28/2022 at 11:30 a.m., she said CR #1 did not have wounds when he admitted to the facility on [DATE], so he did not receive any wound care. She said CR #1 did not have skin breakdown until approximately 4/9/2022 or 4/19/2022 as a result of his co-morbidities, such as, renal disease, obesity, swelling, and non-compliance with elevating his feet while in his wheelchair all day. She said CR #1 was not off- loading either heel and his right heel went acute (present or experienced to a severe or intense degree) within one week. She said CR #1's wounds were acute and necrosis developed within that week or less when they sent him to the hospital on 04/26/2022. She said she and Treatment LVN C were trying to re-build the wound care program. She said she could only provide about one week of wound care tracking because Treatment LVN B stole the measuring device and lap top computer they used to document and track the facility's wounds. She said Treatment LVN B just stopped showing up for work and did not answer calls or comply with requests to return the facility's equipment (Treatment LVN B was hired on 02/14/2022 and her last day in the facility based on time clock documentation was 04/01/2022). The DON provided a one-page document and stated she did not know the date of the information listed on the document. She said she could not provide any weekly skin assessments for CR #1 because none were documented other than his initial admission assessment. Record review of a document provided by the DON titled, Wounds revealed it was not dated. The document had 19 residents' names, including CR #1. CR #1's wounds included: Left Lateral Leg (in-house) and Right Medial Heel (in-house). CR #1's wounds were not staged, and no measurements were listed. The Orders in Place column was not checked for CR #1 (which indicated no orders were in place). In an interview with CR #1's Primary Physician on 4/28/2022 at 12:15 p.m., he stated he was also the facility's medical director. He stated he started seeing CR #1 when he admitted to the facility and his condition was good for the first 3-4 weeks. He said he did not recall CR #1 having a wound on his heels. He said CR #1 may have had a DTI, but generally, his skin was intact. He said about two weeks ago, the facility nurses said CR #1 was retaining fluid in his legs, so he gave him additional diuretics and eventually an extra session of [CONDITION(S)] on 04/23/2022. He said CR #1's legs looked slightly better on 04/18/2022 but on 04/21/2022, the nurses asked him to look at the legs and they were swollen, but he did not see any open areas. He said as of Monday, 04/25/2022, CR #1 had no necrotic areas but by Tuesday, 04/26/2022, he had skin changes with necrotic areas. He said they were acute changes in less than 24-hours. He said on his physical examination of CR #1, he did not have any wounds for the first three weeks. He said he did not appreciate (he did not see any wounds)any wounds when first came and the wounds came two weeks ago. He said he did not appreciate any skin issues until two weeks ago. In an interview with the DON on 4/29/2022 at 9:50 a.m., she said she did not know when the wound care doctor stopped visiting the facility because the wound doctor and Treatment LVN B never informed her. She said she could not say when she found out the wound care doctor was not visiting the facility. She said ultimately, it was her responsibility as the DON to oversee the treatment nurse and the wound care program, but she was doing best she could. She said there were holes in their wound care processes and things were being missed. She said she knew Treatment LVN B worked night shifts at the facility, but she thought she slept a few hours and came back to do wounds. Interview attempts were made but unsuccessful for Treatment LVN B on 4/29/2022, at 12:36 p.m. and 5/6/2022, at 12:05 p.m. Voicemail messages were left but were not returned. In an interview with RN A on 4/29/2022 at 1:15 p.m., she stated CR #1 admitted on her shift (3/18/2022) and she did his head-to-toe assessment. She said she assessed CR #1's heels and they were unstageable. She said the heel (she did not say which heel) was a DTI, boggy looking, it was not open, and he had [CONDITION(S)]. She said there was nothing on CR #1's leg. She said she assessed CR #1 while EMS placed him in bed. RN A then recalled CR #1's left lateral leg wound was pink with a pond (depression) in the middle, but she said it was not deep at all at about an inch and half. She said CR #1's leg was covered with a dressing, but the heel was not. She said CR #1 had socks on, not heel protectors. She said she reconciled CR #1's mediations with his receiving physician (Primary Physician) but there were no orders for wound care from his previous placement. She said she could not recall if she mentioned CR #1's left lateral leg or heel wound when she reconciled his medications. She said she did not recall telling the doctor that CR #1 did not admit with orders for wound care but normally, if the resident did not admit with orders, the receiving nurse would get orders from the doctor. She said [TRUNCATED]

Based on observations, interviews, records reviews, and facility policy and procedures review, the facility failed to provide one of nine sampled residents (Resident (R)13) adequate supervision, including a secured door to prevent R13 from wandering out of the facility. As a result, R13, who was not assessed to be at risk for wandering, or exit seeking, exited the facility twice on 03/24/21 at 5:25 PM and at 5:45 PM. This failure placed the resident at risk for serious injury, serious harm, serious impairment, and or death. Findings included: Resident R13 Record review of R13's undated Face Sheet, located in the electronic medical record (EMR) indicated R13 was admitted on [DATE], readmitted on [DATE] and discharged to a higher level of care on 04/02/21. R13 had diagnoses which included Alzheimer's without behavioral disturbances, hypertension, lack of coordination and muscle weakness. R13 had a Brief Interview for Mental Status (BIMS) of three of 15, which indicated R13 was severely cognitively impaired. According to the Minimum Data Set (MDS) assessment dated [DATE], R13 required supervision with ambulation and was able to ambulate with a one person assist. The resident was not coded as exhibiting behaviors of wandering. Observation on 07/20/21 at 3:00 PM, during a facility tour, revealed eight entry/exit doors throughout the facility. At no time during the survey period from 07/20/21 through 07/23/21, did any resident exhibit wandering or exit seeking behaviors. Record review of R13's nursing Progress Notes, dated 03/24/21, located in the EMR, indicated R13 eloped from the facility, unaccompanied by facility staff on 03/24/21 at 5:20 PM and a second time at 5:45 PM. Record review of R13's nursing Progress Notes, dated 03/24/21 at 5:20 PM, indicated . resident was observed (sic) wandering outside parking lot at 5:25 PM, nurse Licensed Vocational Nurse (LVN 2) found pt [patient], and was safely returned to the unit, escorted by two CNA [Certified Nursing Assistant] back to her room safely, assessment done, pt was confused and un-able to express self, denies pain and no injury noted and at 5:45 PM pt was observed lying outside at (sic) the parking lot, upon assessment pt was unable to respond with confusion, unable to explain self, complain of serve (sic) pain on her lower extremities, provider notified, order given to send resident to ER [emergency room ] for further eval [Evaluation]. responsible party and supervisor was notified, transported to hospital . Record review of R13's nursing Progress Notes dated 03/31/21 at 1:30 PM indicated . Report hospital. Patient was admitted on [DATE] for elopement from facility and fell x2 [times two]. Patient had right shoulder dislocation and right shoulder reduction with brace in place. History of stroke and, dementia. Patient is to continue physical therapy (PT) and occupational therapy (OT) upon return to facility. Patient walks with gait belt, remains very active, and requires constant redirection and a bed alarm. Patient has abrasions to bilateral knees, bruises to right hip, right shoulder, and bilateral knees. CXR [chest X-Ray} showed right shoulder dislocation . Record review of R13's care plan revealed no specific care plan was implemented at the time of readmission on 03/31/21, to address the elopement risk. R13 did have a care plan in place at the time of the elopements on 03/24/21 for Cognitive loss/Dementia related to Alzheimer's which included interventions such as . cue, reorient, supervise as needed; and supervise and assist with decision making . During an interview with the Director of Nursing (DON) on 07/21/21 at 12:50 PM, the DON stated the elopement was not reported to the state survey agency (SSA) on 03/24/21 . because she didn't leave the property . and . I've never reported elopements in the state if the resident is found on the property . The DON also stated the injury was not reported to the SSA due to . it was a dislocation and not a fracture . and additional guidance from the corporate office. During the same interview with the DON on 07/21/21 at 2:15 PM, the DON stated . the resident went out the OT door . The OT door opens directly into the main parking lot/front of the building, which is located on busy two-way street with an embankment down to the main road on the outside edge of the parking lot. The DON also stated R13 had not made any exit seeking, or elopement, attempts prior to 03/24/21. The DON stated they placed R13 on immediate 1 to1 supervision, however a emergent situation came up with another resident on the same hall which required the attention of all staff which is the DON'S best guest as to how R13 eloped the second time. The DON further stated no investigation into the elopement attempts was completed and was unable to provide a rationale why. During an interview with LVN1 on 07/21/21 at 2:45 PM, LVN1 stated R13 had not attempted to exit the facility prior to this incident and R13 did not have a wander guard bracelet on at the time. LVN1 stated she was not the staff who found R13, LVN2 found her outside and brought R13 back into the building the first time, at 5:20 PM. LVN1 does not recall who found R13 on the second occurrence at 5:45 PM or where R13 was found. LVN1 was only able to recall that R13 had eloped the second time on 03/24/21 at 5:45 PM and the staff were reporting R13 had injuries. During an interview with LVN2 on 07/21/21 at 3:20 PM, LVN2 stated she observed R13 in the . side parking lot outside the OT exit door, just walking . LVN2 stated R13 was on the sidewalk, did not appear to have any injuries and LVN2 was able to walk with R13 to the 300 hall exit door and escorted R13 back in. LVN2 does not know who found R13 the second time. During an interview on 07/21/21 at 3:00 PM with the Administrator, he stated the front/main door was the only door in the facility connected to the wander guard monitoring system. The Administrator was unable to state the rationale for that. The Administrator further stated the remaining exit doors were alarmed with the . 15 second push bar alarm in case of an emergency . The Administrator stated the alarm company did a facility wide check on all the exit doors on 03/26/21 and the report showed . all locks were functioning properly at the time of the inspection . During an interview on 07/21/21 at 3:15 PM, with the Maintenance Director, he stated all exit doors are checked daily for functioning and there have been no reported malfunctions. The Maintenance Director also confirmed the front door was the only door connected to the wander guard system. The Maintenance Director further stated the daily door alarm checks were not documented; he completes them as part of his daily morning routine. During an interview on 07/21/21 at 6:15 PM with the Director of Rehab (DOR), the DOR stated she was in the physical therapy (PT) room at the time of the elopement, and not the OT room. The DOR stated she heard the alarm go off and staff calling for assistance but did not witness R13 go out the OT door. The DOR also stated the OT door, which can be accessed by residents from the front living room area will be locked by the DOR around 6:00 PM most nights. During an interview on 07/21/21 at 6:40 PM with the Assistant Director of Nursing (ADON), the ADON stated the facility has Wander Guard book which is usually kept at the nurse's station and receptionist desk. The Wander Guard book contained eight residents the facility had identified as . at risk for elopement . During an interview on 07/21/21 at 6:30 PM with LVN3, LVN3 stated there was a book located at the nurse's station that identified residents at risk for elopement. During an interview on 07/22/21 at 8:30 AM with Certified Nursing Assistant (CNA) 1, CNA1 stated there was a book located at the nurse's station that identified residents at risk for elopement. During an interview on 07/22/21 at 9:00 AM with Certified Nursing Assistant (CNA) 2, CNA2 stated there was a book located at the nurse's station that identified residents at risk for elopement. During an interview on 07/22/21 at 9:30 AM with Housekeeper 1, Housekeeper1 stated there was a book located at the nurse's station that identified residents at risk for elopement During an interview with the receptionist on 07/21/21 at 11:30 AM, the receptionist stated, she sits at the main entrance to check staff temperatures as they report to work and assist any residents that would like to go outside and sit. The receptionist also stated there was a book on the desk which contained information on residents who were at risk of eloping. The receptionist was able to verbally state who the eight residents were. Record review of the facility's policy titled, Exit Seeking Policy, last revised 08/08/16, indicated . head to toe assessment of resident will be completed to include vital signs; place on 15 minute checks for 24 hours (or longer as needed); assess the need to move the resident closer to the nurses station; if the community is equipped with a Wander Guard system, assess the residents need for a wander guard; immediately notify the DON and physician; an incident report will be completed; at each nurses station a notebook will be placed identifying those residents at risk for exit seeking; re-admits will be assessed for behavior and/or history of exit seeking; careplan will be updated as needed .

Based on observation, interview and record review the facility failed to provide the necessary treatments and services to prevent the development, promote healing for 3 (Residents #78, #[AGE], and #32) of 4 residents reviewed for pressure ulcers. in that: -Resident #78 was admitted without any pressure ulcers and developed a Stage 3 ulcer to his buttocks and sacral area measuring 4.5 cm x 4.5 cm x 0.1 cm. -Resident #[AGE] was admitted without any pressure ulcers and developed a Stage 2 pressure ulcer to the left and right sacrum measuring 6 cm x 5 cm x 0.1 cm. -Resident #32 was admitted without any pressure ulcers and developed a pressure wound to the sacrum measuring 1 cm x 1.5 cm. -The facility failed to maintain skin assessment sheets for Residents #78 and #32. These failures could affect all residents at risk for development of skin ulcers and placed them at risk of new pressure ulcers or worsening of existing pressure ulcers. Findings include: Resident #78 Record review of Resident #78's face sheet revealed he was a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #78's Order Summary Report dated Feb. 27, 2020 read in part . Right buttock wound - cleanse with wound cleanser, pat dry, apply [MED] and cover with clean dressing QD. Every day shift for Wound Healing . order date 2/24/20 . [MEDICATION NAME] [MED] Tablet 50 mg give 1 tablet by mouth every 8 hours as needed for Pain . order date [DATE] . [MED] Tablet 325 mg ([MEDICATION NAME]) Give 2 tablet by mouth every 4 hours as needed for Pain . order date [DATE] . Record review of Resident #78's MAR for February 2020 printed on Feb. 27, 2020, revealed no administration of [MEDICATION NAME] [MED] Tablet 50 mg or [MED] Tablet 325 mg. Record review of Resident #78's Quarterly MDS dated [DATE] revealed a BI[CONDITION] score of 14 indicating cognitively intact. He needed extensive help of two staff for bed mobility and was totally dependent on two staff for transfers. He had no pressure ulcers identified on this assessment but was considered at risk to develop pressure ulcers and was using a pressure reducing device for the bed. Record review of Resident #78's progress note dated 2/5/20 at 12:00 p.m. by LVN E read in part . noted a large red area to right buttock. Skin intact. Informed treatment nurse. Record review of a delivery ticket for a low air loss mattress for Resident #78. ordered on [DATE] at 4:41 p.m. and received on 2/10/20. Record review of Resident #78's progress note/quality of life review note dated 2/11/20 at 11:14 a.m. completed by PT. IDT met during QOL to review residents stage 2 sacral wound care needs. Replaced air mattress and assessing for wound healing to determine if this will facilitate wound healing vs changing to regular mattress due to the resident's preferred positioning in the bed which right lower extremity flexed, externally rotated, abducted and knee flexed. Lab work for CBC, pre-[MEDICATION NAME] and CMP is being recommended and vitamin C and multivitamin is being ordered. Record review of Resident #78's wound care consult dated 2/11/20 read in part . Patient is known to our service for past pressure injuries to the buttock and sacral areas that has since closed .Patient has new breakdown in the right buttocks . right ischial pressure injury, stage 2. Wound has pink tissue present. There is moderate maceration noted . No overt infection is noted . [ENTITY]t calcium alginate, to be done daily and as needed. Low air loss mattress with repositioning every 2 hours to offload. Monitor for change . Signed by Wound Care PA. Record review of Resident #78's skin: pressure, right buttocks assessment completed as a late entry 2/14/20 by the wound care nurse identified Resident #78 developed an in-house stage 2 acquired pressure ulcer on 2/6/20. Skin assessment date of 2/14/20; measurements were 4.5 cm x 4.5 cm x 0.1 cm. She identified the . wound Bed has [MEDICATION NAME] tissue, exudate is serosanguineous (slightly bloody drainage), wound has no odor, there is a moderate amount of exudate in the wound. Surrounding skin color is pink and the surrounding tissue and wound edges are macerated. There has been a deterioration in the resident response to treatment. Care plan is currently in place for this wound. Comments: Right ischial pressure injury, stage 2. Wound has pink tissue present. There is moderate maceration noted. Wound has no peri wound [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. No overt infection is noted. Drainage is moderate serous that has no malodor. [ENTITY]t calcium alginate, to be done daily and as needed. Low air loss mattress with repositioning every 2 hours to offload. Monitor for change. Once maceration is resolved and drainage reduced, plan to change to [MEDICATION NAME] therapy, to be changed Q[AGE]h and as needed . Record review of Resident #78's wound care consult dated 2/18/20 read in part . Right ischial pressure injury, unstageable. Wound is stable . Change calcium alginate to [MED], to be done daily and as needed. Low air loss mattress . Nurse reported resident is noncompliant with offloading . Measurement: 4.0 x 5.0 cm . Signed by Wound Care PA. Record review of Resident #78's progress note dated 2/18/20 at 4:00 p.m. by the wound care nurse read in part . during wound care, wound bed noted with yellow slough. Resident continue to lay in bed for maximum days at a time. Only allowing a pillow to be placed under right buttock. Resident continues to be educated on proper offloading and the risk vs benefits of offloading for wound healing. Wound edges continue with maceration . Record review of Resident #78's skin: pressure, right buttocks assessment completed on [DATE] by the wound care nurse identified Resident #78 developed an in house acquired pressure ulcer on 2/6/20 of a stage 3. On [DATE] wound measurements were 4x4x0.1, identified as a stage 3. The wound bed had slough, with a small amount of serosanguineous exudate, and surrounding tissue was normal skin. Resident response to treatment was identified as improved. Signed off on 2/24/20 by the wound care nurse. Record review of Resident #78's progress note dated 2/25/20 at 5:26 p.m. by the wound care nurse read in part . Resident wound care performed this a.m. Wound stable. Slough present. Little drainage noted. Record review of Resident #78's physician order [REDACTED]. -May consult with wound care specialist order date of 2/11/20. -May use pressure reducing mattress order date of [DATE]. -Monitor proper functioning of air mattress every shift order date of 2/4/20. -Right buttock wound- cleanse with wound cleanser, pat dry, apply [MED] and cover with clean dressing QD, order date of 2/24/20. -Weekly skin review; Wednesday for skin integrity documentation. Record review of Resident #78's undated Care Plan read in part . a pressure wound to right buttocks . Interventions: apply treatment as ordered, complete weekly wound assessments - notify MD of any signs or symptoms of infection or worsening condition, educate on offloading due to history of refusal, and specialty air mattress . The resident has an ADL self-care performance deficit due to resident is dependent for ADL care, contractures of right and left knee and autonomic dysreflexia related to spinal cord injury and [MEDICAL CONDITION] . Interventions: The resident requires x 2 staff to turn and reposition in bed and as necessary, he has contractures of the right and left knees, provide skin care on rounds to keep clean and prevent skin breakdown, requires assistance by 1 staff for toileting, foley cath care and incontinent care, and requires assistance by 2 staff to move between surfaces with use of slide board as necessary . Resident #78 has potential for further skin impairment related to immobility, decreased sensation, mobility deficits, contractures of knees, muscle spasms, urinary catheter, fecal incontinence, inadequate nutritional intake, co-morbidity complications . Interventions: Educate the resident/ family/ caregivers of causative factors and measures to prevent skin injury, keep skin clean and dry, monitor/ document location, size and treatment of [REDACTED]. Obtain blood work. Resident #78 needs an air mattress, pillows, etc to protect skin. Use a draw sheet or lifting device to move resident. Weekly treatment documentation to include measurement of each area of skin breakdown width, length, depth, type of tissue and exudate and other notable changes or observations . Record review of Resident #78's MAR indicated [REDACTED] -Monitor proper functioning of air mattress every shift. Signed off by staff on MAR indicated [REDACTED]. -Right buttock wound cleanse with wound cleanser, pat dry, apply calcium alginate and cover with clean dressing QD for wound healing. [ENTITY]t date of 2/8/20 and discontinued on 2/23/20. Treatment not signed off on [DATE]. -Right buttock wound- cleanse with wound cleanser, pat dry, apply [MED] and cover with clean dressing every day for wound healing start date of 2/24/20. - Weekly skin review; use the following code: (11) no new skin concern, (12) new skin concern, (13) existing skin concern, (14) current skin concern & No New concerns, and new skin concern every Wednesday start date of 7/17/19. On 2/5/20 the wound care nurse documented a 12. On 2/12/20 the wound care nurse documented a 14. On [DATE], no skin assessment documentation. On 2/26/20, the wound care nurse documented 13. Observation and Interview on 2/24/20 at 9:18 a.m. with Resident #78 who was sitting in bed in a semi-upright position interacting with a computer on a bedside table. He said he was fully aware of his situation, had a [DIAGNOSES REDACTED]. He said he was capable of repositioning himself in bed because he had full ROM in his upper arms, but had a loss of a feeling in part of both arms and hands. Resident #78 was able to lower the head of his bed, reposition himself by wiggling himself to the top of the bed with the use of the hand rails, and then raised the head of bed. He said when he was in his bed his left leg draws upward onto the right leg/thigh area. He said he had a history of [REDACTED]. He said he has had the same air mattress for a few years. He said a few weeks ago he noticed that he was sinking in the mattress when he was in an upright position. He said he had told a CNA (whom no longer was employed) that he didn't feel his air mattress was working properly. He said the CNAs identified a skin concern a couple days before the wound care nurse assessed the area. He said the Wound Care Nurse came and assessed the wound and applied a dressing. He said he told the wound care nurse about the air mattress on a Thursday and received a new one on the following Monday. He said from the Thursday to Monday the area on his buttocks opened and was identified as a stage 2 wound to his right buttocks. Interview on 2/25/20 at 2:20 p.m. with the Wound Care Nurse. She said Resident #78 had a history of [REDACTED]. She said the resident had knee contractures and his left leg draws upward putting pressure on the right leg and buttocks. The Wound Care Nurse said she notified the doctor, an air mattress was ordered, and received the next day. She said she had trained the CNAs to make sure Resident #78 had a pillow under his buttocks to prevent pressure. She said the resident would spend days in his bed and if he did get out of bed he would spend hours out of the facility in his electric wheelchair. Observation on 2/26/20 at 10:40 a.m. of Resident #78's wound to right buttocks and part of the wound care treatment by the Wound Care Nurse. The wound was nickel sized to the mid right buttocks with no signs of infection and pink tissue around the edges. The Wound Care Nurse said the wound as an improving, stage 3 wound to right buttocks with no signs or symptoms of infection. Interview on 2/26/20 at 10:40 a.m. with Wound Care Nurse, she said Resident #78's wound had improved with the new air mattress. She said the resident was at risk for pressure sores due to the contractures of his legs and knees. She said usually a malfunctioning air mattress would not hold air or made a noise. She said she could not remember when or who told her of the Resident #78's wound. She said she immediately assessed the wound and it was a stage 1, and no dressing or treatment was needed because his skin was still closed. She said the CNAs were instructed to place a pillow under his buttocks, but his right buttock wound worsened to a stage 3 by the following Monday even with the use of pillows for pressure relief. She said she had notified the DON and the NP of the resident's status and what she found about the air mattress on that 2/6/20. She said she completed a skin assessment, change of status, measured the wound and documented it in the progress notes on 2/6/20. She said there was another wound care nurse who worked at the facility on the weekends - Friday, Saturday and Sunday. She said she assessed Resident #78's wound on 2/10/20 after the weekend and identified it as a stage 3. She said she notified medical supplies tech and the air mattress was delivered and set up within a couple days. She said on the following Monday the wound was determined at a stage 3. She said the wound care NP saw Resident #78's wound once since the development of the pressure ulcer. She said she had no formal wound care training, but received informal training by the DON, corporate nurse and the wound care NP who made rounds on a weekly basis with her. She said she was responsible for updating a resident's care plan related to new or change in wounds and the interventions. She said if a resident was discovered with a new or changed wound she would discuss it with her IDT in the weekday morning meetings or QOL quality of life meetings which reviewed wounds bimonthly. She said she communicated with the floor nurses and unit managers if a resident had a change in skin and would ensure the interventions were implemented. She said she had not done training with the CNA's related to skin conditions, repositioning or monitoring of air mattresses. She said she was not sure who was responsible to make sure resident air mattresses are functioning correctly. She said the floor nurses were responsible for weekly skin checks on all residents. She said that Residents #32, #78, and #[AGE] wounds were all avoidable wounds. She said if the nurses identified a concern, then the nurse would notify the wound care nurse. The Wound Care Nurse would initiate documentation of a resident's skin assessment on the on the MAR indicated [REDACTED] Interview on 2/26/20 at 5:02 p.m. with Medical Supplies Tech, she said medical equipment can be ordered and delivered the same day, even on the weekends. She said she can order the equipment or management knows how to order medical equipment. She said she ordered Resident #78's mattress the same day she received the request. She said she was unsure of the date or time but could provide the receipt for the transaction. Resident #[AGE] Record review of Resident #[AGE]'s face sheet revealed he was a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #[AGE]'s admission assessment completed on 2/6/20 at 7:49 p.m. by LVN P identified his Braden score as an 11 high risk for development of pressure ulcers. LVN P completed a skin assessment and the resident had no skin concerns. Record review of Resident #[AGE]'s Comprehensive MDS dated [DATE] revealed a BI[CONDITION] score of 99, cognitive skills was identified as moderately impaired. He needed extensive assistance of two staff for bed mobility and was totally dependent on two staff for transfers. His nutritional needs were met through a feeding tube and was at risk of developing pressure ulcers. He had no pressure ulcers identified on the assessment and had a pressure reducing device for the bed. The CAA included ADL functional, urinary incontinence, nutritional status, feeding tube, and pressure sore. Record review of Resident #[AGE]'s physician progress notes [REDACTED]. transfers. Record review of Resident #[AGE]'s non-pressure assessment on [DATE] at 8:35 a.m.; late entry time of [DATE] at 8:38 a.m. revealed an onset of an open area to the sacrum; description was left sacrum 5x 1.5 right sacrum 2.5x 1.5. Physician and family notified. The assessment identified a treatment was initiated. Record review of Resident #[AGE]'s weekly skin progress note date [DATE] at 11:09 a.m., entered as a late entry. The assessment revealed Resident #[AGE] had a stage 2 pressure ulcer that developed on [DATE] to the sacrum with measurements of 6 x 5 x 0.1. The assessment identified there had been a deterioration in the resident response to treatment. Record review of Resident #[AGE]'s Care Plan dated 2/24/20 read in part . Focus area: actual pressure injury/ skin issue. Related to mobility, incontinence problems, malnutrition/ poor nutritional state . Interventions: Administer treatments as ordered and observe for effectiveness (if no improvement within 2 weeks) notify M.D. for change of orders . Assess nutritional status . assess wound healing weekly . follow facility policies/ protocols for the prevention/ treatment of [REDACTED]. Focus area: Self care deficit related to weakness and lack of coordination . Interventions: Bed mobility x 2 person assistance, transfers x 2 person assistance . Record review of Resident #[AGE]'s progress notes revealed a note dated 2/25/20 at 3:12 p.m. by Wound Care Nurse which read in part . new orders received from MD to change sacrum treatment to cleanse with wound cleanser, pat dry, apply nickel thick layer of [MED] ointment, cover with calcium alginate, cover with clean dressing QD and prn soiled. Record review of Resident #[AGE]'s MAR/ TAR for February revealed the following orders: -[MEDICATION NAME] [MED] Tablet 50 mg Give 50 mg via PE[DEVICE] every 6 hours as needed for Pain - Severe, start date 2/25/20 - no medication documented indicating given for dates 2/1/20 through 2/24/20 -[MED] Tablet 325 mg ([MEDICATION NAME]) Give 2 tablet via PE[DEVICE] every 6 hours as needed for pain, start date 2/6/20 - no medication documented indicating given for dates 1/2/20 through 2/5/20, 2/25/20 Pain level 3 - dose given and initialed. -[MEDICATION NAME] Acid Tablet daily for supplement, start date of 2/18/20. -Multivitamin Liquid daily for supplement, start date of 2/18/20. -Pro-Stat for wound healing for 30 days, start date on 2/18/20. -Ensure dressing to left and right buttocks clean, dry and intact every shift. Apply PRN treatment order every shift for wound healing, start date [DATE]. -[MEDICATION NAME] 1.5 at 45 cc/hour x 22 hours, start date of [DATE] and [DATE] feeding increased to 55 cc/hour. On [DATE] increased to [AGE] cc/hour x 22 hours. -Right and left buttock shearing - cleanse with wound cleanser, pat dry, apply mixture of collagen powder and [MED] cream to open wounds and cover with clean dressing daily and as needed for soiled.start date of [DATE] and d/c on 2/24/20. -Sacrum wound cleanse with wound cleanser, pat dry, apply manuka sheet to wound bed, cover with clean dressing daily and as needed for wound healing . start date on 2/24/20 and discontinued on 2/25/20. -Sacrum wound cleanse with wound cleanser, pat dry, apply nickel thick layer of [MED] oint to slough, cover with calcium alginate, cover wound with clean dressing daily and as needed for wound healing . start date of 2/26/20. -Weekly skin review; use the following code: (11) no new skin concern; (12) new skin concern or (13) existing skin concern and new skin concern every Wednesday start date of 2/12/20 and signed off by the Wound Care Nurse as an 11. On [DATE], no skin assessment documentation. On 2/26/20, the Wound Care Nurse documented (14) current skin concern and no new concerns. Interview on 2/24/20 at 10:27 a.m. with LVN B, she said Resident #[AGE] had a stage 2 wound to his coccyx. She said the wound developed at the facility, was unsure of the date, but the etiology was shearing. Observation on 2/25/20 at 1:26 p.m. of Resident #[AGE]'s wound care treatment completed by Wound Care Nurse with assistance from CNA GG. Resident was on a pressure relieving mattress, he had a pillow to float his heels, a pillow to his left side to tilt him to the right and a pillow under his head for support. The Wound Care Nurse and CNA used a draw sheet to assist with repositioning the resident from his back to his right side, they first pulled the resident to the right side causing the fitted sheet to bunch under the left side of the resident. CNA GG was asked what causes and she said it was when the residents skin rubs tight up against the linens, sometimes causing it to bunch up. She said it was very difficult to lift Resident #[AGE] up off the bed when he needed to be repositioned because he was heavy. She said it would take about 3 CNA's to reposition him to prevent any kind of shearing. She said she repositions him every 2 hours or more often because he tends to urinate often. He had a wound on his sacrum approximately the size of a baseball and in the middle of the wound was a deep purple area wound care nurse measured the area and said it was 2.3 x 1cm in the middle of the wound. She said it appeared to be a deep tissue injury. Interview on 2/25/20 at 1:50 p.m. with the Wound Care Nurse, she said the first time she seen Resident #[AGE]'s sacrum wound on [DATE]; it appeared to be a stage 2 shear wound. She said the first time she saw the wound it looked red and agitated like it had been rubbed up against something. She said this was in house acquired and the wound. She said over the weekend his wound had worsened. She said she notified the MD. She said Resident #[AGE] was reviewed by the dietitian because he had poor nutrition intake. His feeding was increased because he was on a low rate for feeding. She said the dietitian recommended the resident start a multivitamin, zinc, and prostate to improve wound healing. She said Resident #[AGE]'s wound had worsened from the day before when she did the treatment. She said on 2/24/20 the resident did not have a deep purple bruising under the wound bed, she said it looked like a deep tissue injury and had some slough inside the wound bed. She said she would notify the physician and also the DON about difficulty repositioning the resident. She said she was unsure if the physician saw the resident's wound and there was no referral for the wound care physician. Observation on 2/26/20 at 8:30 a.m. of Resident #[AGE] who was in a semi-upright position with a pillow under his right side, he was tilting to the left side. He appeared to be sleeping. Observation on 2/26/20 at 10:40 a.m. of Resident #[AGE] who was in the same position as 8:30 a.m. Observation on 2/26/20 at 12:46 p.m. of Resident #[AGE] who appeared to be in the same position. Record review of Resident #[AGE]'s progress note dated 2/26/20 at 12:54 p.m. by the Wound Care Nurse indicating a low air loss mattress with bolster was ordered related to pressure wound to sacrum. Observation on 2/26/20 at 2:30 p.m. of Resident #[AGE] whose position had changed to the left side with pillows to support him on the right side. Observation on 2/26/20 at 4:46 p.m. of Resident #[AGE] was in the same position as 2:30 p.m. Resident #32 Record review of Resident #32's face sheet revealed he was a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #32's nursing admission assessment dated [DATE] revealed he had no pressure ulcers. Record review of Resident #32 's weekly Braden scale dated 4/3/2019 revealed he had total score of 13, which indicated he was at moderate risk for pressure ulcer development. Record review of Resident #32's Admission MDS dated [DATE] revealed a BI[CONDITION] of 12 indicating moderate cognitive impairment and he did not have a pressure ulcer documented. Record review of Resident #32's Quarterly MDS dated [DATE] revealed a BI[CONDITION] score of 13 indicating cognitively intact. He needed extensive assistance with bed mobility. Record review of resident #32's Nurse's note dated 11/12/19 12:05 p.m. written by ADON B read in part . IDT met for new pressure wound to the sacrum, II Foam dressing QOD . this a new area noted on 11/7/19 . Record review of quality of life notes dated 1[DATE] read in part . area to sacrum pink, padded 2 x 2 x .02 cm II. On multivitamin with mineral needs vitamin C 500 mg. Zinc 220 x 14 days, needs [MEDICATION NAME]. There were no further notes in the quality of life documentation . Record review of facility weekly pressure ulcer log dated 1/20/2020 - [DATE] revealed Resident #32 was not listed on the log. Record review of Resident #32's care plan dated 1/22/20 read in part . Resident #32 had a potential impairment/breakdown/injury to skin integrity related to impaired mobility to bilateral upper body/lower body deficiency to [MEDICAL CONDITION] . and required staff assistance for ADL care . Interventions . Resident needed pressure relieving/reducing mattress, pillows to protect the skin while in bed . Weekly treatment documentation . and any other notable changes or observations . created 10/29/2019 . revised 12/23/2019 . Record review of Resident 32's TAR for 2/2020 revealed on [DATE] there was a code of 11 which indicated clear skin no new skin concern. Record review of Resident #32's Order Summary Report dated Feb. 27, 2020 read in part . Sacrum wound - cleanse with wound cleanser, pat dry, apply triple antibiotic and cover with clean dressing QD and prn. Every day shift for Wound Healing . order date 2/26/20 . Interview on 2/26/20 at 1:15 p.m. with LVN M said Resident #32's wound will re-occur, and he has [MEDICAL CONDITION] which affects his movement. She said it depends on how much he sits in his wheelchair on how frequent the wound opened. She said one prevention is the cushion in his wheelchair. She said LVN I was doing the skin assessments but recently gave the task to the assigned hall nurse to complete. She said she relies on the cna's to tell her and the resident will tell you if he has a wound issue. She said the resident can turn himself. She said he should be turned every two hours by cna's if he can't do it himself. Interview on 2/26/20 at 3:40 p.m. with DON said staff should document in nurses notes and notify the wound care nurse of any skin changes. He said LVN I usually does the skin assessment. He said he was not aware that the assigned hall nurses took over and did the skin the assessments. He said cna's should tell the nurse about skin breakdown and then the nurse would tell the wound care nurse. He said he was not aware of Resident #32's new wound. Observation on 2/27/20 at 12:00 p.m. of Resident #32 wound care treatment completed by the wound care nurse. Resident #32 had a prominent boney sacral area with an open area on bilateral sides of sacrum/ buttocks. The right upper buttocks had an open area approximately 1 cm x 1.5 cm and left upper buttocks had an open area pea size width with white tissue around the edges of the wound. Record review of the facility undated Quality of Life read in part . Purpose: A weekly interdisciplinary review of all residents whose life in our community encompasses the following care components: a. Falls, b. unplanned weight variances, c. pressure areas, d. restraints, e. psychoactive medications . Record review of facility policy on Skin Care Management dated 5/2015 revealed in part . Objective: Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible. Each resident shall be evaluated to determine his or her risk for skin compromise or the presence of wounds and/or pressure ulcers. A plan of care shall be developed and implemented based on this evaluation with ongoing review. If skin compromise occurs, evaluation shall be conducted by the interdisciplinary team to ensure appropriate measures are in place to minimize further compromise and aid in healing to extent possible . Fundamental Information . The Director of Nursing, or designee, is responsible for coordination of an interdisciplinary approach to managing the process for prediction, assessment treatment, management, and tracking of community-acquired pressure ulcers . Risk Factors . Diagnoses/Conditions . Impaired/decreased mobility and decreased functional ability, Co-morbid conditions, Drugs . that may affect healing, Impaired diffuse or localized blood flow . Cognitive impairment, Exposure of skin to urinary or fecal incontinence, Under nutrition, malnutrition, and hydration deficits, A healed ulcer . 3. Resident shall be checked from head to toe weekly by a licensed nurse to identify any new pressure ulcers or other types of skin concerns. The licensed nurse shall document the results of weekly skin checks in the resident's medical record. 4. When a pressure ulcer is identified, the licensed nurse shall document as appropriate. 5. The licensed nurse shall communicate all identified pressure ulcers and non-pressure skin concerns to the attending physician and resident's family or responsible party. The licensed nurse shall document notifications and orders/changes to treatment in the resident's medical record and the care plan. 6. Residents with newly identified or known pressure ulcers shall be reviewed by the IDT upon notification and weekly thereafter, and a care plan shall be developed, implemented, evaluated, and re-evaluated to treat actual pressure ulcers and reduce further pressure ulcers. This will include but not be limited to review of lab results, risk factors, positioning, etc. 7. The DON or designee shall conduct weekly rounds to evaluate new/existing pressure ulcers, monitor measurements . Wound Care Policy/Procedure was requested from the Administrator on 2/26/20 and 2/27/20 from the DON and Administrator and was not provided at exit.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 (CR #2) resident of the seven reviewed for accidents and hazards. -The facility failed to ensure there were adequate staff to provide bed mobility for CR #2, which resulted in the resident falling to the floor and being sent to the hospital. This failure affected 1 resident and placed him at risk of injury due to inadequate staff to meet his bed mobility needs. Findings Included: CR #2 Record review of CR #2 face sheet revealed a [AGE] year-old male who was admitted on [DATE] and discharged to a local hospital on [DATE] with a weight of 164.2 lbs. His [DIAGNOSES REDACTED]. Record review of CR #2's care plan dated 11/6/19 read in part . The resident has an ADL Self Care Performance Deficit r/t Activity Intolerance, Disease Process, limited Mobility, Incontinence, and Impaired Cognition. Dated Initiated 8/13/19 . Interventions . Bed Mobility: Requires x2 staff assistance to reposition and turn in bed . Physical exam in the record listed a left hip unstageable ulcer and contracted extremities. Record review of CR #2 discharge MDS dated [DATE] revealed a BIMS score of 2, indicating severely impaired cognition. He needed extensive assistance of 2 staff with bed mobility and had a pressure reducing mattress due to a pressure ulcer on his coccyx. Record review of CR #2's incident report dated 11/29/19 read in part . CNA D was standing near the wall to reposition (CR #2) in his bed. Resident is on an air mattress. During the repositioning (CR #2) fell out of his bed on the opposite side of the bed. CNA D called the floor nurse for assistance, who was standing outside of the room preparing medication for (CR #2). LVN B entered the room and assessed the resident and called the emergency services to transport the resident to hospital. No injuries were identified or noted on the nursing assessment . Record review of CR #2's hospital admission documents dated 11/29/19 revealed history of chronic [MEDICAL CONDITION], dementia, gout, metabolic [MEDICAL CONDITION],dysphagia, [MEDICAL CONDITION], peg tube placement (4/2019), falls, aortic aneurysms, multiple pressure ulcer wounds, and generalized weakness. Physical exam in the record listed a left hip unstageable ulcer and contracted extremities. PT presented to the ED via EMS on 11/29/2019 after fall onto ground from from bed after nursing home staff dropped pt onto the ground while changing him. PT fell on his right side. Chest X-ray 11/29/2019 left PICC line tip at the brachiocephalic level. The heart is enlarged. Small right pleural effusion is increased. No confluent consolidation, No pneumothorax. X-ray right shoulder 11/29/2019 no fracture or dislocation involving the right shoulder. X-ray right elbow 11/29/2019. Patient positioning limits visualization. No definite fractures visualized . 2. Generalized bone demineralization. X-ray of right humerus 11/29/2019. No acute fracture or dislocation. X-ray of right hip 11/29/2019 suboptimal positioning. No definite fractures visualized. X-ray right wrist 11/29/2019. No acute fracture or dislocation. X-ray right hand 11/29/2019. No acute fracture or dislocation. X-ray of cervial spine 11/29/2019. Limited study C5-C7 are not visualized. C2-C4 do not demonstrate any fracture od subluxation. [MEDICAL CONDITION] changes are present. CT Head 11/29/2019 no acute intracranial abnomality identified. Pt has had 10 hospitalization s in the last 12 mos. Record review on 12/18/19 at 2:39 of CR#2 in local hospital, revealed he was a [AGE] year-old male African American. Patient history was limited due to no family present and he has dementia. Physical exam in record report a left hip unstageable ulcer along with contracted extremities. Observation on 12/18/19 at 2:50 p.m. of CR #2 in a local hospital resting in bed with no signs of acute distress. CR #2 was awake, lying on his right hip. He did make eye contact but was unable to verbalize. Interview on 12/05/19 at 9:14 a.m. with DON, he said that CR #2 was currently in the hospital after his fall on 12/29/19. The DON also said the resident was on an air mattress in the facility. Interview on 12/05/19 at 10:00 a.m. with CNA B, she said CR #2 was a two-person total assist with transfers and bed mobility. Interview on 12/05/19 at 10:45 a.m. with CNA D she said CR #2 needed extensive assistance with ADL's and she said she was working with CR#2 the day he fell out off the bed. She said she found CR #2 on the edge of the bed, went to the other side of his bed, and pulled on the draw sheet to move him away from the edge. She said since CR#2 was on an air mattress when she pulled the draw sheet the resident flipped out of the bed onto the floor. CNA D stated she normally did bed mobility by herself' for the CR #2. She said when CR #2 fell , LVN B immediately came into the room to assess the resident as she was just outside his room door. CNA D said CR #2 was sent to the ER about 10 minutes after his fall. She said that two CNA's were supposed to reposition the residents on air mattresses. Interview on 12/05/19 at 12:54 p.m. with DON, he said that CR #2 was sent to the hospital immediately after his fall. He said that it took 2 people to assist CR #2. He said that he was unsure of what the care plan or the MDS recommendations were for CR #2's bed mobility. Interview with Administrator on 12/05/19 at 1:12 p.m. She said that CR #2 had no injuries from his fall and the incident had not been called into the state because he had not been injured in a fall. The facility policy and procedure on transfers and bed mobility was requested on 12/05/19 at the 12:54 p.m. interview with the DON. The policy was not provided prior to exit. Interview on 12/16/19 at 11:00 a.m. with LVN C, she said the nursing Kardex had the care requirements for the residents and the information was in the P[NAME]. All residents on air mattress, required two staff assist. If she would see the staff doing something different, she would stop them, and tell them to get someone to help them. Interview on 12/16/19 at 11:05 a.m. with LVN D, she said all residents on air mattresses required two people assist. She said sheets were not to be on the mattress, just a draw sheet for a pad. She said she watched CNA's randomly to see what they are doing. She said if she saw them doing something they should not be doing, she would stop them, and tell them to get someone to help them. Interview on 12/16/19 at 11:10 a.m. with LVN E, she said all residents on an air mattress required two people assist. She said the air mattress required a fitted sheet with a draw sheet over it. She said if she saw them doing something they should not be doing, she would stop them, and tell them to get someone to help them. Interview on 12/16/19 at 11:15 a.m. with LVN F, she said the nursing Kardex has the requirements for the residents' care. All residents on an air mattress required two people assist. She said if she saw them doing something they should not be doing, she would stop them, and tell them to get someone to help them. Observation on 12/16/19 at 11:20 a.m. with CNA [NAME] and CNA C to reposition Resident # 2 that was on a air mattress. CNA [NAME] interviewed about where she finds information on bed mobility. She would look in the Kardex for that information. Record Review 12/16/19 at 11:40 a.m. of Resident # 2 found his Kardex was listed as bed mobility of team member support X 1 and bed mobility resident requires 1-2 staff participants to reposition and turn in bed Interview on 12/16/19 at 2:00 with the MDS Dir, she said the information gets moved to the Kardex through the computer. She said it was pulled from the care plans by the system and can be edited by authorized staff to make changes or updates. Interview on 12/16/19 at 3:00 with DON, he said as a nursing intervention for a resident with stage 3 or 4 pressure wounds, an air mattress was indicated. He said that was to protect the resident from further wound development. He said, if a resident had an air mattress, that makes them a 2 person assist or lift. Record review of facility policy Skin Management dated (MONTH) (YEAR) read in part . Pressure Reduction 4. Multiple Stage II pressure injuries: Consider special pressure relieving mattress . Pressure Relief 1. Pressure Relief mattress such as a low-air-loss surfaces are to be utilized if wound is located on the trunk area .

Based on interview and record review the facility failed to ensure that a resident receives care to prevent pressure ulcers and does not develop pressure ulcers and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (CR#1) of 4 residents reviewed for pressure ulcers. --CR#1 developed pressure ulcers on the left posterior and anterior thigh, right upper back, and left heel while in the facility. --The facility failed to identify CR#1's new pressure ulcers. --The physician was not consulted and treatments were not provided. These failures affected 1 closed record and placed 9 residents receiving pressure ulcer care at risk for developing new pressure ulcers and worsening of current pressure ulcers. Findings include: Record review of CR#1's face sheet revealed she was an [AGE] years old who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of CR#1's Nursing: Admit/Re-admit pressure ulcer assessment dated [DATE] revealed an entry of 2 for pressure ulcer which meant that CR#1 had no pressure ulcer on admission. Record review of CR#1's skin pressure assessment dated [DATE] revealed a deep tissue injury on the right heel and right inner foot. Record failed to note the wounds to the left posterior and anterior thigh, upper back, and left heel. Record review of CR#1's treatment administration record dated March 2017 revealed that two skin assessments done 03/05/17 and 03/12/17 also failed to mention the wounds to the left posterior and anterior thigh, upper back, and left heel. Further review of the record revealed that the skin assessment for 03/19/17 was not completed. Record review of CR#1's medical record revealed no documentation that the physician had been notified or consulted regarding the wounds to the left posterior and anterior thigh, upper back, and left heel. Record review of CR#1's care plan dated 02/24/17 did not mention any wound or deep tissue injury on the left heel, right upper back, blisters on both posterior and anterior, or sacral wound. Record review of CR#1's MDS dated [DATE] revealed that resident's BIMS was 07. It also revealed that the resident is marked for needing extensive assistance for personal hygiene and shower, while dressing was marked as limited assistance. Upon further review of the MDS, it revealed that CR#1 was frequently incontinent of urine and always incontinent of bowel. The record did not mention pressure ulcers on admission. Record review of CR#1's medical record revealed that she was discharged to the local hospital for a change of condition on 03/20/17. Record review of CR#1's wound care documentation, from a local hospital, dated 03/20/17 revealed that CR#1's had wounds on the following areas: --Left posterior thigh measured 8.00cm x1.5cm (blister) some of the blister was still intact. --Anterior thigh measured 14 cm x 2 cm (blister) that opened up. --Right upper back wound, measured 2.5 cm x 2.00 cm. --Left heel deep tissue injury, measured 1.5 cm x 1.00 cm. During an interview on 04/13/17 at 9:58 a.m., the DON revealed that the CR#1 had a wound on her sacral area but it was healed on admission and that was why it was not documented. She did not have any explanation for why the wound on the right upper back was not documented. She stated the blister on both posterior and anterior left thigh were noted the night before the resident went to the hospital by CNA A and he reported to LVN A, who applied [MEDICATION NAME] powder to the blistered area. The DON provided the phone number for both LVN A and CNA A and the surveyor tried to contact them but was not able to reach them. LVN A's phone was busy, while CNA A's phone went straight to voicemail. Then the DON stated CNA A had traveled to Africa and would return in maybe a week or two. During the same interview, the DON revealed that upon admission the charge nurse is responsible for completing the initial head to toe skin assessment on newly admitted residents, and documents any skin issues. She also writes the residents name on the wound care note for the wound care nurse to follow up on any skin issues. She stated they use an electronic assessment tool to document the skin issues such as pressure sores and deep tissue injuries. Interview on 04/13/17 at 11:16 a.m., LVN B stated that she did not notice the deep tissue injury on the left heel, the wound on the right upper back, blisters on the posterior and anterior of the left thigh and the sacral wound on Friday, 3/17/17. On 04/13/17, the surveyor requested the facility's policies on initial head to toe assessments and weekly skin assessments from the DON but none were provided prior to exit. The facility 672 dated 04/13/17 revealed a census of 78 residents, 9 of which received pressure ulcer care.