Every finding on record at The Rehabilitation Center of Albuquerque

Based on record review, observation, and interviews, the facility failed to ensure a resident had the right to reasonable access to a working telephone for 1 (R #13) of 1 (R #13) resident, when R #13's telephone did not function for several weeks and R #13's family was unable to speak with R #13 by telephone. This deficient practice is likely to cause residents to feel alone and isolated if their family is unable to contact them by telephone. The findings are: A. Record review of R #13's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/27/26, revealed an admission date of 07/21/26 with diagnoses of a left femur fracture, chronic obstructive pulmonary disease (COPD; lung disease), rheumatoid arthritis (RA; chronic joint disease causing pain and swelling), and vascular dementia (a form of dementia caused by reduced or blocked blood flow to the brain, which causes memory, thinking, and behavior issues). B. On 08/07/26 at 11:10 am, during an observation, R #13's room contained a white telephone on the nightstand with a cord. The telephone cord was plugged into the telephone plug (the connector at the end of a telephone line that inserts into a jack, which is the fixed socket in a wall or device, enabling the telephone to connect to the telephone network) that was hanging out of the wall with exposed electrical wiring, and the telephone did not work. C. On 08/07/26 at 11:30 am during an interview, the Maintenance Director (MD) stated not all facility staff were aware of how to enter a maintenance work order, and sometimes issues were not entered into the system for correction. He stated a work order was placed on 07/27/26 to fix R #13's room telephone because R #13's family was unable to speak with R #13 by telephone. The MD stated the Maintenance Assistant (MA) replaced the telephone but did not replace the telephone plug. D. On 08/07/26 at 1:18 pm, during an interview, the MD stated when the MA replaced R #13's telephone for the work order placed on 07/27/26, the MA noticed R #13's telephone was still not working. The MD stated R #13's telephone was replaced twice, but after each replacement, the telephone still did not function appropriately. The MD stated the communication regarding whether R #13's telephone was working did not meet his expectations. E. On 08/07/26 at 3:50 pm during an interview, the Director of Nursing (DON) stated she was notified today of R #13's telephone not working. She stated her expectation was for R #13's telephone to be fixed right away and not two weeks after the work order was placed. F. On 08/19/26 at 1:53 pm, during an interview, R #13's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) stated R #13's roommate pulled the telephone cord out of the wall. He stated he did not know why R #13's roommate did this, but he was unable to call R #13 after the incident. R #13's POA stated he reported the broken phone to the facility, but the repair took too long. He stated he was upset because he could not speak with R #13 by telephone.

Based on record review and interviews, the facility failed to ensure residents received the necessary treatment and services to promote healing of a wound for 1 (R #3) of 1 (R #3) resident reviewed, when facility staff failed to:Provide consistent wound care per physician orders for R #3.Follow up with the hospital and/or the facility Wound Nurse Practitioner (WNP) to clarify confusing wound care orders.These deficient practices led to R #3 having maggots (a soft bodied, legless larva of a fly or other insect, found in decaying matter) present in a wound on R #3's right foot. If wound care is not provided as ordered by a physician, residents are likely at risk for wound deterioration, infection, delayed healing, and other complications.The findings are: A. Record review of the facility's treatment policy, revised 06/01/21, revealed the following:Licensed nurses or medical technicians, in accordance with state regulations, are responsible for performing ordered treatments, and staff are required to perform treatments as ordered.If a resident refuses treatment, staff are required to attempt the treatment again at a later time and notify the physician or advanced practice provider (APP) if the resident refuses the treatment after a second attempt.Facility staff are required to evaluate the resident for comfort during treatment and notify the physician or APP of significant changes in the treatment area.Facility staff are required to document treatment administration on the Treatment Administration Record (TAR), the resident's response, treatment refusals, and physician or APP notification, as applicable. B. Record review of the facility's skin Integrity and wound management policy, dated 09/15/25, revealed the following: Comprehensive skin and wound assessments are completed upon admission, weekly, with significant changes in condition, and as clinically indicated. Staff are to evaluate, document, and perform skin inspections and wound evaluations for newly identified or existing skin and wound impairments.Facility staff are to complete daily monitoring and documentation of wounds and dressings, including assessment of dressing integrity, surrounding tissue changes, wound associated pain, and signs of wound deterioration or complications.Facility staff are to implement physician ordered wound care treatments, notify the physician or advanced practice provider of changes in wound condition, and communicate significant changes to the interdisciplinary team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident). Staff are to revise the resident's care plan to reflect findings from the comprehensive skin and wound assessment and changes in the resident's condition. C. Record review of R #3's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/24/26, revealed an admission date of 06/18/26 with diagnoses of type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin), peripheral vascular disease (PVD; poor circulation), venous insufficiency (can lead to leg ulcers and sores including pain and swelling), and cellulitis (deep inflammation of the tissues just under the skin; caused by infection) of right and left lower limbs (legs). D. Record review of R #3's care plan, dated 06/18/26, revealed a focus on skin breakdown related to multiple co morbidities (the simultaneous presence of two or more diseases or medical conditions in a patient) and refusals of wound evaluations and dressing changes. E. Record review of R #3's physician orders, dated 06/24/26, revealed an order for wound care to R #3's right foot. Nursing staff were to cleanse R #3's right foot with wound cleanser and pat it dry, apply betadine soaked gauze (gauze soaked in antiseptic to help prevent infection), apply an ABD pad (large wound dressing), wrap the area in rolled gauze, and secure it with tape every day shift. This order was discontinued on 07/07/26. F. Record review of R #3's TAR, dated 06/24/26 to 07/07/26, revealed the following for R #3's right foot wound care:Dated 06/24/26, 06/29/26, 06/30/26, 07/01/26, and 07/04/26 the TAR stated to see nursing notes. Dated 06/25/26, R #3 refused treatment. Dated 06/26/26, 06/28/26, 07/02/26, 07/03/26, 07/05/26, and 07/07/26 the TAR indicated R #3's wound care was completed as ordered. Dated 06/27/26 and 07/06/26 the TAR was left blank, indicating the wound care treatment was not completed. G. Record review of R #3's nursing progress notes, dated 06/24/26 to 07/07/26, revealed the following:Dated 06/24/26, R #3 stated the dressing was okay and declined wound care.Dated 06/29/26, R #3 stated the nurse should not complete the wound care because he preferred the wound care nurse to do it.Dated 06/30/26, R #3 stated he wanted the wound care completed by the wound care nurse.Dated 07/01/26, R #3 stated he had other things to get done first and refused wound care.Dated 07/04/26, R #3 stated the night shift nurse would complete wound care.Dated 07/06/26, R #3 stated he would wait for the night shift nurse to complete wound care. H. Record review of R #3's physician orders, dated 07/08/26, revealed an order for wound care to R #3's right foot. Nursing staff were to cleanse R #3's right foot with wound cleanser and pat it dry, apply betadine soaked gauze, apply an ABD pad, wrap the area in rolled gauze, secure it with tape, wrap it in a bandage, and secure it with tape every day shift. This order was discontinued on 07/15/26. I. Record review of R #3's TAR, dated 07/08/26 to 07/15/26, revealed the following for R #3's right foot wound care:Dated 07/09/26, 07/10/26, 07/11/26, and 07/12/26 the TAR indicated R #3's wound care was completed as ordered.Dated 07/14/26 and 07/15/26 the TAR indicated R #3 was at the hospital. J. Record review of R #3's nursing progress notes, dated 07/09/26, revealed during wound care to R #3's right foot, staff removed old wound dressings and found several small white maggots between R #3's toes. Staff cleaned R #3's toes, removed the maggots, and applied a new dressing. The Director of Nursing (DON), the Nurse Practitioner (NP), and the wound care nurse were notified. K. Record review of R #3's change in condition (CIC; any noticeable shift in a resident's health, behavior, or functional status that deviates from their established baseline), dated 07/13/26, revealed R #3 had a right foot wound infection and was sent to the hospital. L. Record review of R #3's hospital notes, dated 07/14/26, revealed R #3 had a worsening right foot wound infection with maggot infestation. R #3's right foot wound displayed necrosis (dead tissue) with concern for a recurrent soft tissue infection. Hospital staff administered antibiotics, and the wound was debrided (removal of dead, damaged, or infected tissue) without a sharp surgical debridement. Non viable tissue, slough (dead tissue in the wound), and hyperkeratosis (thickening of the skin's outer layer) were identified and removed during debridement of R #3's right foot. R #3 was discharged back to the facility on [DATE]. M. Record review of R #3's physician orders, dated 07/18/26, revealed an order for wound care to R #3's right lower leg and foot. Nursing staff were to cleanse R #3's wound with wound cleanser and pat it dry, apply xeroform (a sterile, non adherent gauze dressing used to protect wounds and promote healing) to R #3's foot and toes, apply ABD pads, wrap the area in rolled gauze, secure it with tape, and wrap it in bandages every day shift. This order was discontinued on 07/22/26. N. Record review of R #3's TAR, dated 07/18/26 to 07/22/26, revealed the following for R #3's right foot wound care: Dated 07/18/26 and 07/19/26, R #3 refused wound care treatment.Dated 07/20/26, 07/21/26, and 07/22/26 the TAR was left blank, indicating the wound care treatment was not completed. O. Record review of R #3's nursing progress notes, dated 07/18/26 to 07/22/26, revealed the following:Dated 07/19/26, R #3 requested wound care treatment at 4:00 am each morning. The Unit Manager (UM) was aware and would assist with adjusting R #3's wound care treatment times.Dated 07/22/26, R #3 was discharged to the hospital. P. Record review of R #3's transfer note, dated 07/21/26 at 3:00 am, revealed R #3 was experiencing significant right foot pain, which he described as throbbing. During assessment, staff observed maggots between R #3's right toes. The provider ordered pain medication, directed R #3 to be seen by the wound care team, and referred R #3 to the hospital. Q. Record review of R #3's hospital documentation, dated 07/21/26, revealed R #3 had continued pain in his right foot. R #3's right foot displayed extensive purulent drainage (a thick, pus like fluid from a wound indicating infection and requiring prompt medical attention) and Myiasis (larvae of certain flies infesting and feeding on the tissues of living humans or animals). Surgery was consulted and recommended debridement of R #3's right foot wound, which was completed on 07/24/26. R #3 was administered antibiotics. R #3 was discharged to the facility on [DATE] with updated wound care instructions directing facility staff to apply two layers of xeroform to R #3's open wound on his right foot, multiple ABD pads, and a sterile dressing to R #3's right lower leg. R #3's hospital documentation did not indicate facility nursing staff should refrain from providing wound care for multiple days once R #3 returned to the facility. R. Record review of R #3's nursing progress notes, dated 07/31/26, revealed a note was present on R #3's wound care dressing stating not to remove the wound care dressing for 5 to 7 days (on 07/29/26). The nurse spoke with R #3, and the wound care dressing would be removed on Tuesday (08/04/26) with the wound care provider. S. Record review of R #3's physician orders, dated 07/30/26 to 08/05/26, revealed the following: Dated 07/31/26, an order directed staff to monitor R #3's right lower leg dressing and notify the provider if it became compromised every day and night shift. This order was discontinued on 08/04/26.Dated 08/04/26, an order for right foot wound care directed staff to cleanse R #3's right foot wound with wound cleanser and pat it dry, apply calcium alginate rope (a highly absorbent dressing for managing deep wounds and maintaining a moist environment) between the toes, apply Therahoney (clears away necrotic tissue) to the wound bed on top of the foot, apply a calcium alginate sheet, apply an ABD pad, wrap in rolled gauze, and secure with tape every night shift. Nursing staff were directed to document wound care refusals.A physician order was not available for nursing staff to provide wound care to R #3's right foot until 08/04/26, several days after R #3 returned to the facility from the hospital. T. Record review of R #3's TAR, dated 07/30/26 to 08/05/26, revealed staff did not complete any type of wound care treatment for R #3's right foot during this timeframe. U. On 08/05/26 at 8:26 am, during an interview, the emergency room Director ([NAME]) stated that on 07/14/26 he was notified of R #3's foot wounds with a maggot infestation on the right foot, located between R #3's toes. The [NAME] stated he does not typically see patients from skilled nursing facilities with maggots in a wound. He stated R #3 returned to the emergency room (ER) on 07/21/26 with the same wound infection, and the maggots had again appeared between R #3's right toes. The [NAME] stated R #3 experienced a significant amount of pain while in the ER. V. On 08/05/26 at 12:25 pm, during an interview, R #3 stated he had been to the hospital a couple of times because of his right foot. He stated the wounds on his foot had an infection, so he was receiving treatment for it. R #3 stated when the facility wound care nurse changed the bandages on 08/04/26, his feet were a mess and he had blisters everywhere. He stated the wound care caused him a lot of pain. R #3 stated he had no idea where the maggot infestation came from and the maggots just appeared, but they were gone now. R #3 stated there was a lot of pain associated with the maggots on his right foot. W. On 08/06/26 at 9:45 am, during an interview, the Wound Care Nurse (WCN) stated R #3's edema (swelling caused by excess fluid) creates many of the issues with his wounds, and since he remains in his wheelchair all day, the edema builds up and causes blisters. She stated when wound care was completed on 08/04/26, R #3 had blisters around the bandage edge. The WCN stated R #3's wounds require daily wound care. She stated the facility is now trying to complete R #3's wound care at night because that was his preference. The WCN stated she has concerns about completing R #3's wound care at night because if something was wrong, she would not be present to address it immediately. The WCN stated when R #3 returned to the facility from the hospital on [DATE], a written note on his bandage stated not to change the dressing for 5 to 7 days, but she did not know who wrote the note. She stated the facility did not receive wound care orders from the hospital, and the hospital orders dated 07/29/26 did not specify how often to change R #3's dressing. She stated after R #3 returned to the facility on [DATE], she trained nursing staff to clean, dry, and place gauze between R #3's toes, but she did not add this to R #3's wound care treatment orders because she assumed nursing staff would wash and clean between his toes. The WCN stated it was not acceptable for a wound to become infested with maggots while in the facility. X. On 08/06/26 at 10:30 am, during an interview, the Unit Manager (UM) #1 stated the first-time maggots appeared on R #3's right foot wound was on 07/09/26. She stated the provider saw R #3 and directed staff to clean the area and the wound, removing all maggots. UM #1 stated the maggots returned on 07/13/26, and the provider ordered R #3 to be sent to the hospital for debridement and antibiotics. She stated R #3 was always in his wheelchair and enjoyed being outside. UM #1 stated the wound care dressing did not cover R #3's toes, and he did not usually wear socks. Y. On 08/06/26 at 11:30 am, during an interview, the WNP stated she saw R #3 when he was first admitted on [DATE], on 07/07/26, and again on 08/04/26 after he returned from the hospital the second time. She stated when she saw R #3 on 07/07/26, an infection with bright green drainage was present, and she ordered antibiotics. She stated the maggots returned on 07/13/26, and R #3 was sent to the hospital. The WNP stated she was not made aware of the note on R #3's wound dressing indicating staff were not to change the dressing for 5 to 7 days. She stated when she saw R #3's wound on 08/04/26, the wound was macerated (softening and breakdown of tissue caused by prolonged exposure to moisture) again. She stated the instruction on R #3's dressing to avoid changing it for 5 to 7 days was not an acceptable hospital order, and she should have been notified of that note. The WNP stated R #3 needed daily wound care, and the surgeon recommended daily wound care. She stated if she had been contacted, she would have recommended daily wound care based on the surgeon's note. She stated R #3's wound dressing went too long without being changed, and facility nursing staff should have contacted the hospital for clarification regarding R #3's wound care. Z. On 08/06/26 at 2:30 pm, during an interview, the Director of Nursing (DON) stated R #3 was not compliant with wound care, and she felt the hospital performed only minimal debridement. The DON stated she was not aware of the note written on R #3's wound care dressing indicating staff should not change the dressing for 5 to 7 days. AA. On 08/06/26 on 2:48 pm, during an interview, the Nurse Practitioner (NP) #1 stated she was aware of R #3 refusing wound care, but she was unsure if the refusals contributed to the maggot infestation on R #3's wound. NP #1 stated daily wound care would have been helpful for R #3. BB. On 08/06/26 at 2:56 pm, during an interview, the Medical Director (MD) stated when maggots first appeared on R #3's right foot, they were probably not completely removed since they returned, and R #3 was discharged to the hospital on [DATE]. The MD stated when R #3 returned to the facility on [DATE] with a note on the wound dressing instructing staff not to change the dressing for 5 to 7 days, she would expect facility nursing staff to contact the WNP for clarification. CC. On 08/07/26 at 3:43 pm, during an interview, the WCN stated when she saw the piece of tape on R #3's right lower leg wound dressing with a note instructing staff not to change the dressing for 5 to 7 days, she informed NP #1 and NP #1 told her R #3 would not allow her to assess it. The WCN stated this was why she entered an order for nursing staff to monitor the wound dressing in case it became compromised. She stated if physician orders are not provided when a resident returns from the hospital, she enters basic orders and then refers back to the providers for guidance if any changes are needed.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) for 4 (R #'s 5, 6, 7, and 8) of 4 (R #'s 5, 6, 7, and 8) residents reviewed for ADL care provided to dependent residents, when staff failed to: Provide baths/showers per the facility bathing schedule. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #5: A. Record review of R #5's face sheet revealed an admission date of 04/01/25 and included the following diagnoses:Need for assistance with personal care. Muscle weakness. History of falling. B. Record review of the facility's shower schedule revealed R #5's scheduled shower days are Tuesday and Friday. C. Record review of R #5's care plan, dated 02/11/26, revealed R #5 required staff assistance with ADL care due to R #5 experiencing pain and repeated falls. D. Record review of R #5's documentation survey report (ADL tracking form), dated 03/01/26 through 03/31/26, revealed R #5 was offered or provided 6 baths/showers out of 9 opportunities. E. Record review of R #5's shower sheets, dated 03/01/26 through 03/31/26, revealed R #5 was offered or provided 6 baths/showers out of 9 opportunities. F. Record review of R #5's documentation survey report, dated 04/01/26 through 04/30/26, revealed R #5 was offered or provided 4 baths/showers out of 8 opportunities. G. Record review of R #5's shower sheets, dated 04/01/26 through 04/30/26, revealed R #5 was offered or provided 3 baths/showers out of 8 opportunities. H. Record review of R #5's documentation survey report, dated 05/01/26 through 05/15/26, revealed R #5 was offered or provided 3 baths/showers out of 5 opportunities. I. Record review of R #5's shower sheets, dated 05/01/26 through 05/15/26, revealed R #5 was offered or provided 3 baths/showers out of 5 opportunities. J. On 05/13/26 at 4:56 pm, during an interview, R #5 stated he does not get offered baths or showers per the shower schedule. R #5 stated he is supposed to get at least two baths/showers per week, but he will often only get one. R #5 stated he does not feel good when he is not offered at least two showers per week. K. On 05/14/26 at 2:41 pm, during an interview, Certified Nursing Assistant (CNA) #1 stated R #5 likes to be bathed on his scheduled days. CNA #1 stated baths/showers are documented in the electronic health record and/or the shower sheets, and R #5 should be offered a bath/shower at least twice per week. R #6: L. Record review of R #6's face sheet revealed an admission date of 07/04/25 and included the following diagnoses:Need for assistance with personal care. Muscle weakness. Acquired absence of right leg below knee. M. Record review of the facility's shower schedule revealed R #6's scheduled shower days are Monday and Saturday. N. Record review of R #6's care plan, dated 01/12/26, revealed R #6 required staff assistance with mobility due to R #6 having a right leg below knee amputation. O. Record review of R #6's documentation survey report, dated 03/01/26 through 03/31/26, revealed R #6 was offered or provided 1 bath/shower out of 9 opportunities. P. Record review of R #6's shower sheets, dated 03/01/26 through 03/31/26, revealed R #6 was offered or provided 5 baths/showers out of 9 opportunities. Q. Record review of R #6's documentation survey report, dated 04/01/26 through 04/30/26, revealed R #6 was offered or provided 4 baths/showers out of 8 opportunities. R. Record review of R #6's shower sheets, dated 04/01/26 through 04/30/26, revealed R #6 was offered or provided 4 baths/showers out of 8 opportunities. S. Record review of R #6's documentation survey report, dated 05/01/26 through 05/15/26, revealed R #6 was offered or provided 1 bath/shower out of 4 opportunities. T. Record review of R #6's shower sheets, dated 05/01/26 through 05/15/26, revealed R #6 was offered or provided 3 baths/showers out of 4 opportunities. U. On 05/13/26 at 5:12 pm, during an interview, R #6 stated he is supposed to be offered a bath/shower on Monday's and Saturday's, but the shower schedule is not followed, and he will only be offered one bath/shower during the week. R #6 stated he needs the facility nursing staff's assistance with bathing, and he does not feel good when he is not offered a bath/shower per the facility shower schedule. V. On 05/14/26 at 2:43 pm, during an interview, CNA #1 stated R #6 likes at least two baths/showers per week, and staff is aware of R #6's preference. W. On 05/14/26 at 5:30 pm, during an interview, CNA #2 stated R #6 has told her that he is not offered a bath/shower per the facility shower schedule. CNA #2 stated R #6 should be offered at least two baths/showers per week. R #7: X. Record review of R #7's face sheet revealed an admission date of 03/17/26 and included the following diagnoses:Need for assistance with personal care. Reduced mobility. Muscle weakness. Y. Record review of the facility's shower schedule revealed R #7's scheduled shower days are Wednesday and Sunday. Z. Record review of R #7's care plan, dated 03/18/26, revealed R #7 required staff assistance with ADL care related to limited mobility. AA. Record review of R #7's documentation survey report, dated 03/17/26 through 03/31/26, revealed R #7's baths/showers were not documented. BB. Record review of R #7's shower sheets, dated 03/17/26 through 03/31/26, revealed R #7 was offered or provided 2 baths/showers out of 4 opportunities. CC. Record review of R #7's documentation survey report, dated 04/01/26 through 04/30/26, revealed R #7 was offered or provided 0 baths/showers out of 9 opportunities. DD. Record review of R #7's shower sheets, dated 04/01/26 through 04/30/26, revealed R #7 was offered or provided 4 baths/showers out of 9 opportunities. EE. Record review of R #7's documentation survey report, dated 05/01/26 through 05/15/26, revealed R #7 was offered or provided 3 baths/showers out of 4 opportunities. FF. Record review of R #7's shower sheets, dated 05/01/26 through 05/15/26, revealed R #7 was offered or provided 3 baths/showers out of 4 opportunities. GG. On 05/14/26 at 3:26 pm, during an interview, Nursing Assistant (NA) stated R #7 enjoys baths/showers and R #7 should be offered at least two baths/showers per week as scheduled. HH. On 05/18/26 at 4:24 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated R #7 does not refuse baths/showers and R #7 should be offered at least two baths/showers per week as scheduled. II. On 05/18/26 at 4:34 pm, during an interview, R #7 stated she has missed showers often and it makes her feel like shit when she is not offered or given baths/showers per the facility shower schedule. R #8: JJ. Record review of R #8's face sheet revealed an admission date of 06/05/25 and included the following diagnoses:Thoracic spinal cord injury (damage occurring to the spinal cord in the chest region, specifically between the vertebrae T1 and T12). Need for assistance with personal care. Reduced mobility. Muscle weakness. KK. Record review of the facility's shower schedule revealed R #8's scheduled shower days are Monday and Friday. LL. Record review of R #8's care plan, dated 03/12/26, revealed R #8 required staff assistance with ADL care related to paralysis (the loss of the ability to move, and sometimes to feel anything, in part or most of the body) and weakness. MM. Record review of R #8's documentation survey report, dated 03/01/26 through 03/31/26, revealed R #8 was offered or provided 5 baths/showers out of 9 opportunities. NN. Record review of R #8's shower sheets, dated 03/01/26 through 03/31/26, revealed R #8 was offered or provided 5 baths/showers out of 9 opportunities. OO. Record review of R #8's documentation survey report, dated 04/01/26 through 04/30/26, revealed R #8 was offered or provided 6 baths/showers out of 8 opportunities. PP. Record review of R #8's shower sheets, dated 04/01/26 through 04/30/26, revealed R #8 was offered or provided 5 baths/showers out of 8 opportunities. QQ. Record review of R #8's documentation survey report, dated 05/01/26 through 05/15/26, revealed R #8 was offered or provided 3 baths/showers out of 5 opportunities. RR. Record review of R #8's shower sheets, dated 05/01/26 through 05/15/26, revealed R #8 was offered or provided 4 baths/showers out of 5 opportunities. SS. On 05/14/26 at 2:35 pm, during an interview, CNA #1 stated R #8 wants two to three baths/showers per week and does not refuse baths/showers often. TT. On 05/14/26 at 3:55 pm, during an interview, R #8 stated she received a shower yesterday (05/13/26) for the first time in almost a week. R #8 stated she needs help with baths/showers and when she is not offered baths/showers per the facility shower schedule, she does not feel like herself and she does not want to be around others. UU. On 05/14/26 at 5:29 pm, during an interview, CNA #2 stated R #8's baths/showers are often missed or forgotten. CNA #2 stated she has seen R #8 cry after missing baths/showers while stating nobody wants to help her. VV. On 05/18/26 at 5:22 pm, during an interview, the Director of Nursing (DON) stated all residents in the facility should be offered a bath/shower per the facility shower schedule. The DON stated R #5, #6, #7, and #8 were not offered enough baths/showers per the facility shower schedule and her expectations but should have been.

Based on record review, observation, and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 89 residents residing in the facility, when:The facility failed to offer baths or showers to residents as scheduled. The facility staff used R #4's family member to assist with a transfer using a Hoyer lift (equipment used to move residents who have limited mobility) when staff were not available. These deficient practices are likely to negatively impact resident safety, comfort, and impede processes such as timely showers and appropriate assistance with care. The findings are:Baths/Showers: A. Refer to F0677 for related findings. B. On 05/13/26 at 4:56 pm, during an interview, R #5 stated the facility is so short staffed that staff often do not offer or provide him with at least two baths or showers per week. R #5 stated nursing staff tell him they do not have enough staff to complete his showers consistently. C. On 05/13/26 at 5:12 pm, during an interview, R #6 stated Certified Nursing Assistants (CNAs) often tell him they do not have enough help, and as a result, he regularly misses a bath or shower. D. On 05/14/26 at 2:42 pm, during an interview, CNA #1 stated she ensures her residents receive their scheduled baths or showers, but she knows other residents miss their baths or showers due to low staffing. CNA #1 stated resident baths and showers can take between 15 and 45 minutes, which affects staffing on the unit floors. E. On 05/14/26 at 3:55 pm, during an interview, R #8 stated there are often times when the facility does not have enough CNAs, and as a result, her baths or showers are missed. F. On 05/14/26 at 5:27 pm, during an interview, CNA #2 stated the facility does not have enough staff, and when the facility is short staffed, residents' baths and showers are often missed. CNA #2 stated residents do not receive the help they need when there is not enough staff, which occurs often. G. On 05/18/26 at 4:34 pm, during an interview, R #7 stated that on several occasions the facility nursing staff has told her they did not have enough staff to bathe her according to the facility's schedule. R #7 stated she often misses showers on the weekends. H. On 05/18/26 at 4:44 pm, during an interview, Licensed Practical Nurse (LPN) #2 stated the facility is short staffed with both CNAs and nurses. LPN #2 stated residents should be offered at least two baths or showers per week, but this does not occur because there is not enough nursing staff available. I. On 05/18/26 at 4:56 pm, during an interview, LPN #3 stated the facility consistently has staffing issues, which affects the care residents receive. LPN #3 stated residents' baths and showers are often missed due to the lack of nursing staff. J. On 05/18/26 at 5:19 pm, during an interview, the Director of Nursing (DON) stated it is her expectation that nursing staff offer baths and showers according to the facility's shower schedule. Hoyer Lift: K. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] with the following diagnoses: Morbid (severe) obesity due to excess calories. Muscle weakness. Need for assistance with personal care. Traumatic brain injury (TBI). L. Record review of R #4's physical therapy treatment encounter note, dated 11/19/25, revealed R #4's mother was instructed on the proper use of the Hoyer lift for safe transfers. They were reminded that the Hoyer lift requires two persons during all transfers to ensure safety and reduce risk of injury. M. Record review of R #4's care plan, dated 05/06/26, reveled the following: R #4 is a long-term care resident and does not have current plans to discharge. R #4 is at risk for falls related to impaired mobility and a TBI. R #4 requires assistance from two staff for Hoyer lift transfers. R #4's care plan did not indicate that R #4's family could assist with transfers instead of facility nursing staff. N. On 05/13/26 at 4:39 pm, during an observation, CNA #4 brought a Hoyer lift into R #4's room alone. R #4 was seated in a wheelchair next to her bed with family present. CNA #4 closed the door after entering. O. On 05/13/26 at 4:48 pm, during an observation and interview, CNA #4 was observed leaving R #4's room, and R #4 was lying in bed. CNA #4 stated she did not usually work on the unit where R #4 resides, but she had been asked to assist R #4. CNA #4 stated R #4 requires a two person assist for transfers, but there was not any other staff available to help her, so she asked R #4's mother to assist. CNA #4 stated she only asked R #4's mother to help because there was not any other staff available. P. On 05/13/26 at 4:52 pm, during an interview, R #4 stated there is not enough staff to transfer her when needed. R #4 stated she has to wait extended periods of time to be transferred due to the facility's staffing issues. Q. On 05/14/26 at 2:37 pm, during an interview, CNA #1 stated she was not aware of any family member in the facility who was trained to assist with resident transfers. CNA #1 stated she had been informed that only two trained staff members should transfer a resident using a Hoyer lift. R. On 05/14/26 at 3:01 pm, during an interview, the Registered Nurse Supervisor (RNS) stated she was not aware of any family member in the facility who was trained to assist with resident transfers, and that Hoyer lift transfers should only be performed by two trained staff members. S. On 05/14/26 at 3:26 pm, during an interview, Nursing Assistant (NA) #1 stated she was taught that only two trained staff members are permitted to transfer a resident using a Hoyer lift. NA #1 stated facility staff should not ask family members to assist with resident transfers. T. On 05/14/26 at 5:31 pm, during an interview, CNA #2 stated that even though the facility experiences short staffing, only trained staff members should transfer a resident, not family members. U. On 05/15/26 at 10:34 am, during an interview, the Director of Rehab (DOR) stated R #4 is always with her mother or grandmother. The DOR stated R #4's mother was educated on the Hoyer lift because R #4 was expected to be discharged home with Hoyer lift use, but the discharge did not occur. The DOR stated the training provided to R #4's mother on 11/19/25, but it was not intended to replace staff assistance while R #4 remained in the facility. V. On 05/15/26 at 10:43 am, during an interview, Physical Therapy Assistant (PTA) stated R #4 was expected to discharge home, and the training was completed with R #4's mother so she could assist a paid caregiver at home. The PTA stated the training provided to R #4's mother was basic and not as in depth as the training facility staff receive. W. On 05/18/26 at 4:24 pm, during an interview, LPN #1 stated that even when staff are not available, a resident's family member should not assist with Hoyer lift transfers. X. On 05/18/26 at 5:25 pm, during an interview, the DON stated nursing staff should be available to assist residents, but she was okay with family members assisting with Hoyer lift transfers only if the family members were properly trained.

Based on record review and interviews, the facility failed to ensure resident property was protected from misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) for 1 (R #3) of 1 (R #3) resident reviewed for misappropriation of resident funds and belongings, when: R #3's purse, wallet, and reading glasses went missing in an area where a facility housekeeper was working, and only R #3's purse was eventually returned to her.If the facility fails to ensure resident property is protected from misappropriation, then residents are at risk for unauthorized use of personal funds, financial exploitation, and potential financial loss. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's follow-up incident report, dated 04/29/26, revealed that on 04/27/26, R #3 reported her pink purse missing, and staff later found it in the trash bin of the housekeeper's cart. R #3 reported her red wallet containing $20 (dollars) and her reading glasses were still missing, and the Administrator assisted her in searching her room. During the facility's review, staff learned the housekeeper had unauthorized individuals accompanying her during her shift, and she was placed on administrative leave. The housekeeper stated she accidentally discarded the purse and denied taking the missing items, although she admitted bringing unauthorized individuals into the facility. C. On 05/13/26 at 1:24 pm, during an interview, R #3 stated she always kept her purse on her nightstand, but it went missing the only time she saw the housekeeper near it. R #3 stated she had $20, business cards, and reading glasses in the purse. R #3 stated the facility found her purse, but her wallet was never located. D. On 05/14/26 at 3:01 pm, during an interview, the Registered Nurse Supervisor (RNS) stated that R #3 reported the missing belongings and money to an activities assistant, who then brought the concern to her for investigation. E. On 05/15/26 at 10:24 am, during an interview, the Medical Records (MR) stated the facility staff found R #3's purse and belongings in the housekeeper's trash bin. The MR stated the housekeeper returned the purse back to R #3, but the purse did not contain R #3's reading glasses or $20. The MR stated the facility refunded the $20 to R #3, but she was unsure about the status of R #3's wallet and reading glasses. F. On 05/18/26 at 5:38 pm, during an interview, the Activities Assistant (AA) stated she was helping in the hallway after completing meal tray service when R #3 activated her call light. R #3 reported she could not find her purse and described it as a smaller purse. Staff searched under the bed and between the sheets. R #3 reported that housekeeping had been organizing her belongings. The housekeeper stated she had cleaned R #3's room and had R #3's purse on her cart, but she had not recognized it. R #3 asked why her purse had been found in the trash can, and staff told her they were not sure. The AA stated after the housekeeper left, R #3 began looking for her wallet and located two wallets that did not belong to her, but both were empty. The AA stated R #3 could not find her red wallet or her reading glasses, and the housekeeper was accompanied by two other staff members, who were cleaning with her. The AA stated R #3 appeared panicked when her wallet and glasses were not found, so she reported this to her manager and assisted R #3 with filing a grievance. G. On 05/18/26 at 6:07 pm, during an interview, the Administrator stated that the incident involving R #3 began as a missing items grievance and the housekeeper returned R #3's purse to her. The Administrator stated that R #3's purse had been found in the trash, which she described as unusual. The Administrator stated that while staff were searching for R #3's missing belongings, the housekeeper left R #3's room and later returned with only R #3's purse. The Administrator stated that the housekeeper was terminated.

Based on record review and interviews, the facility failed to ensure staff revised the care plan for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed, when staff failed to: Conduct a quarterly care plan meeting as required for R #1 in accordance with their admission date and Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff).This deficient practice is likely to result in residents' care and needs not being addressed if care plan meetings are not completed as required. The findings are:A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] and was discharged to the hospital on [DATE]. B. Record review of R #1's MDS page located in the electronic health record (EHR), revealed the following MDS completion dates: Dated 10/15/25, comprehensive MDS completed and submitted. Dated 01/08/26, quarterly MDS completed and submitted. Dated 04/07/26, discharge MDS completed and submitted. C. Record review of R #1's care plan meeting progress notes revealed R #1's most recent care plan meeting occurred on 11/07/25. A care plan meeting for R #1 was not documented as occurring after 11/07/25. D. On 05/13/26 at 1:50 pm, during an interview, R #1's daughter stated she had multiple care concerns regarding R #1 while she was in the facility. She reported she was unable to address these concerns with the facility because the facility did not hold care plan meetings as frequently as required. E. On 05/15/26 at 3:47 pm, during an interview, the Social Services Director (SSD) stated the facility is required to hold care plan meetings every three months. The SSD stated R #1 should have had a care plan meeting in February 2026, but the facility did not conduct one. The SSD explained that care plan meetings are important because they allow staff to meet with residents and their families to address any care concerns. F. On 05/18/26 at 6:02 pm, during an interview, the Administrator stated her expectation is for care plan meetings to occur quarterly as required by regulation. She stated R #1's care plan meetings were not conducted as required and should have been.

Cross-Reference with F0602. Based on record review and interviews, it was determined the facility was not administered in a manner that ensured the effective and efficient use of resources to attain or maintain each resident's highest practicable physical, mental, and psychosocial well being, when:The facility administration failed to prevent unauthorized individuals, who were not contracted or directly hired by the facility, from working in the facility near residents.This deficient practice is likely to affect the 89 residents listed on the facility census provided by the Administrator on 05/13/26. If the facility is unaware of an individuals' status when they enter the facility and are near residents, residents' safety and well being are placed at risk. The finds are: A. Record review of R #3's facility follow-up incident report, dated 04/29/26, revealed when the facility was reviewing R #3's missing item grievance, the night nurse manager reported that the housekeeper in question had two men accompanying her, which the nurse manager found unusual. The nurse manager stated that all three individuals were wearing uniforms, and the housekeeper told her that she was training the two men. The Administrator contacted the housekeeping supervisor and learned that this was not true; the men accompanying the housekeeper were not employees and were not authorized to be in the facility. The housekeeper was placed on administrative leave, and the unidentified individuals were directed to leave the facility. The housekeeper admitted that she had allowed unauthorized individuals to accompany her during her shift. She reported that her boyfriend and brother in law had been helping her but claimed they had never been alone and always remained with her. She stated that neither man took R #3's wallet. The housekeeper also admitted she dressed the two men in work uniforms and told others she was training them because she did not want them to get in trouble for being in the facility. Interviews with other residents confirmed no additional concerns related to the housekeeping staff or the security of personal belongings, and no pattern of grievances related to missing valuables was identified. B. On 05/14/26 at 3:07 pm, during an interview, the Registered Nurse Supervisor (RNS) stated that during the facility's investigation of R #3's missing items grievance, staff discovered the two men accompanying the housekeeper were not hired or contracted facility staff. The RNS stated the housekeeper claimed she was training them, but this was not accurate, and the individuals should not have been in the facility impersonating facility staff. The RNS stated they were unaware this was occurring and did not know how long the two individuals had been accompanying the housekeeper into the facility. C. On 05/18/26 at 5:22 pm, during an interview, the Director of Nursing (DON) stated the facility staff located the two individuals who had been accompanying the housekeeper and escorted them out of the facility. The DON stated the housekeeper reported she had dressed her boyfriend and brother in law as housekeeping staff to help her, even though they were not hired or contracted by the facility. The DON stated she was unaware this was occurring and unauthorized individuals should not be in the facility near residents. D. On 05/18/26 at 6:10 pm, during an interview, the Administrator stated she immediately reached out to the housekeeping supervisor who informed her that they had not recently hired new staff members. The Administrator stated she interviewed the housekeeper, and the housekeeper admitted that she had dressed her boyfriend and brother-in-law in housekeeping attire to help her, but those two individuals were not hired or contracted by the facility. The Administrator stated the housekeeper was terminated and unauthorized individuals should not be in the facility near residents.

Based on observation, record review, and interview, the facility failed to notify resident Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care)/emergency contacts and facility providers (Physicians and Nurse Practitioners) of when a resident had a change in condition (a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) for 2 (R #15 and R #25) of 4 (R #15, #16, #17 and #25) residents reviewed, when staff failed to: Notify R #15's emergency contacts regarding illness, falls, and abnormal vital signs (body temperature, pulse rate, rate of breathing, oxygen saturation, and blood pressure).Notify a provider regarding R #25's unresponsive state. These deficient practices likely resulted in R #15 not receiving necessary assistance and contributed to the deterioration of R #25's condition and cardiac arrest. The findings are:R #15: A. Record review of R #15's face sheet revealed an admission date of [DATE] and included the following:Diagnoses:Traumatic hemorrhage of right cerebrum (a type of stroke),Aneurysm of carotid artery (a bulge or ballooning in the wall of a blood vessel and can rupture),Convulsions (sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles), Cognitive communication deficit (deficits result in difficulty with thinking and how someone used language).Emergency Contacts:Family Member (FM) #1: Spouse, emergency contact #1, and POA.Family Member #2: Son, emergency contact #2, and secondary POA. Family Member #3: Emergency contact #3.Resident Representative (RR): Daughter-in-law. B. Record review of R #15's POA document, dated [DATE], revealed R #15's husband was POA. Further review revealed emergency contact #2 would step in as a POA if the husband was unable to make decisions on behalf of R #15, C. Record review of R #15's Situation, Background, Appearance, Review and Notify (SBAR) forms (tool used to communicate critical information) revealed the following: Dated [DATE] at 1:30 pm: R #15 had abnormal vitals and was unresponsive. The facility notified R #15's daughter-in-law (Resident Representative; RR), who was at bedside. The facility did not notify any other family member. Dated [DATE] at 11:15 am: R #15 had a change in condition (CIC; a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains). Staff identified a new swallowing issues during medication pass. Staff notified the RR in person. The facility did not notify any other family member. Dated [DATE] at 1:00 pm: R #15 had a CIC. The resident tested positive for COVID (respiratory illness). Staff notified the RR. The facility did not notify any other family member. Dated [DATE] at 3:10 pm: R #15 had a CIC. The resident had swallowing difficulties. Staff notified the RR. The facility did not notify any other family member. Dated [DATE] at 6:23 pm: R #15 had a CIC. The resident fell and hit her head. Staff notified the RR. The facility did not notify any other family member. Dated [DATE] at 4:45 pm: R #15 had a CIC. The resident had an altercation with another resident. Staff notified the RR. The facility did not notify any other family member. Dated [DATE] at 9:00 am: R #15 had a CIC. The resident had a seizure. Staff notified the RR. The facility did not notify any other family member. Dated [DATE] at 1:30 pm: R #15 had a CIC. The resident fell. Staff notified the RR. The facility did not notify any other family member. D. Record review of R #15's social services note, dated [DATE], revealed the Social Services Director spoke with R #15 regarding her decision-making. R #15 stated if she was ever unable to make decisions for herself, then her husband was fully capable of making decisions on her behalf. The resident stated her husband would act in her best interests. E. Record review of R #15's nursing progress note, dated [DATE], revealed R #15 was at an increased risk for falls with injury due to on-going seizures with intermittent altered mental status. R #15 stated she wanted her husband to be the first one notified of any changes. She stated her son would be second person to notify. F. On [DATE] at 9:50 am, during an interview, R #15's son stated the facility did not notify him after any of R #15's change in condition incidents. R #15's son stated the facility knew to notify him for any of R #15's changes. R #15's son stated the Resident Representative notified him of R #15's changes in conditions. G. On [DATE] at 10:23 am, during an interview, R #15's husband stated he did not recall if the facility notified him regarding any of R #15's change in condition incidents. He stated he did not know who the facility contacted regarding R #15's changes in conditions. H. On [DATE] at 10:25 am, during an interview, R #15's RR stated she would visit R #15 at the facility often. R #15's RR stated sometimes R #15's husband/POA and son would not answer the phone when the facility called them, so the facility would notify her regarding R #15. R #15's RR stated the facility began contacting her instead of R #15's husband and son, and that bothered R #15's son. I. On [DATE] at 12:00 pm, during an interview, the Unit Manager (UM) #1 stated facility nursing staff were required to call the POA and the emergency contact regarding any resident CIC. She stated nursing staff reviewed each resident's record to see who to notify, and they always tried to call the POA or the emergency contact. The UM stated if a family member was onsite when a CIC occurred, then they will notify the family member who was currently onsite. UM #1 stated if the family member onsite was not the POA, then they would notify the POA as well. The UM #1 stated nursing staff should have contacted R #15's husband or son regarding R #15's changes in conditions, even if R #15's RR was in the facility. R #25: J. Record review of the facility Notification of Change in Condition policy, dated [DATE], revealed the facility must immediately inform the resident, consult with the residents' physician, notify a resident representative when:An accident involving the resident which resulted in injury and has the potential for requiring physician intervention, A significant change in the resident's physical, mental, or psychosocial status (a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications), A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences, A decision to transfer or discharge the resident from the facility. K. Record review of R #25's face sheet revealed an admission date of [DATE] and included the following diagnoses: Dementia with behavioral disturbance (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life),Chronic respiratory failure with hypoxia (when your respiratory system is unable to remove enough carbon dioxide from your blood, causing it to build up in your body),Chronic congestive heart failure (CHF; impaired heart function),Hypoglycemia (low blood sugar). L. Record review of R #25's advance directive (a person's wishes if they would like to be resuscitated during an emergency), dated [DATE], revealed R #25 was a full code with all interventions (indicating all life saving measures should be implemented). M. Record review of R #25's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) revealed the following: Annual MDS, dated [DATE]: Staff did not document an overall decline. Quarterly MDS, dated [DATE]: Staff did not document an overall decline.Quarterly MDS, dated [DATE]: Staff did not document an overall decline.The record did not contain any other MDS after [DATE]. N. Record review of R #25's Electronic Health Record (EHR), dated [DATE], revealed R #25's EHR did not contain any documentation related to an overall health decline or the need for palliative care (specialized medical care for people living with a serious or chronic illness) interventions. O. On [DATE] at 9:45 am, during an observation, a code blue (a person who was not breathing and requires intervention) was announced over the facility loudspeaker. P. Record review of R #25's nursing progress notes revealed the following: Dated [DATE] at 4:59 am, staff observed R #25 mouth breathing with gurgling to inner/deep throat. The resident was non-productive when coughing. Oxygen saturation (the amount of oxygen in the blood) measured 92 percent (%; normal range is 95 to 100%) on 3 liters of oxygen. R #25 uneasily aroused via tactile/verbal stimuli (physical touch/or verbal stimuli using words) during early morning medication pass. Lung sounds bi-lateral upper lobe rhonchi (low-pitched, rattling sounds in the lungs that indicate airway obstruction or mucus buildup). Bi-lateral lower lobe diminished as pulmonary hypertension (high blood pressure in the arteries of the lungs). Primary care physician made aware via in-house communication (a logbook used to communicate non-emergent resident requests to the provider) for further evaluation and treatment. Oncoming nurse to be made aware for continuity of care.Dated [DATE] at 10:54 am, the Nurse was called to R #25's room and found the resident unresponsive. Resuscitation started (the action of reviving someone from unconsciousness or apparent death), code blue (medical emergency that requires resuscitation) performed by 911 Emergency Medical Services personnel. Resident pronounced dead at 10:12 am. Dated [DATE] at 11:00 am, cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation) began at 9:30 am by a nurse after R #25 was unresponsive, and Emergency Medical Services (EMS) was contacted via 911. Q. On [DATE] at 2:40 pm, during an interview, Nurse Practitioner (NP) stated Registered Nurse (RN) #8 (who was R #25's nurse on [DATE]), wrote a note in her non-emergent provider logbook that indicated R #25 was experiencing decreased oral intake, was unaroused via verbal stimulation or a sternum rub, and experienced gurgling sounds when breathing. The NP stated staff should use the non-emergent logbook for anything that did not require her to immediately assess and/or treat a resident. She stated what staff wrote in the non-emergent logbook for R #25 was inappropriate. The NP stated staff should have called a facility provider and 911 immediately regarding R #25's status, but staff did not make the calls. The NP also stated she believed R #25 was experiencing an overall health decline, but she was unable to describe the type of decline experienced by R #25. R. On [DATE] at 2:35 pm, during an interview, Certified Nursing Assistant (CNA) #7 stated R #25 was not responding and opening her eyes when she arrived at the facility on [DATE]. She stated R #25 was coughing and producing gurgling sounds. CNA #7 stated that was not R #25's normal state. She stated R #25 was a little bit like that on [DATE]. The CNA stated the resident did not eat much, but she would take her drinks. CNA #7 stated she went to check on R #25, and she noticed she was very pale. She checked R #25's pulse, and she did not get a reading. CNA #7 stated she asked CNA #9 to come check the resident's pulse, and CNA #9 was also not able to get a reading. CNA #7 stated they called the nurse down to R #15's room, and they started the Code Blue. S. On [DATE] at 3:19 pm and [DATE] at 11:30 am, during an interview, the Director of Nursing (DON) stated the first time she was made aware of the situation with R #25 was when staff called the Code Blue. The DON stated staff should have called the provider and implemented immediate interventions when R #25 was outside of her normal baseline status. The DON stated she reviewed RN #8's logbook note and R #25's electronic health record. The DON stated RN #8 should have called the on-call provider on [DATE]. The DON stated they had the on-call provider review their log for any calls from the facility, and there were not any on [DATE] or [DATE] for R #25. The DON stated the facility nursing staff are required to notify a provider for any change in condition (CIC). The DON stated staff did not notify a facility provider on [DATE] or [DATE] regarding R #25's unresponsiveness. The DON stated she believed R #25 was experiencing an overall health decline which might have required palliative care, but she was unable to describe the type of decline experienced by R #25. The DON stated palliative care was not ordered for R #25. T. On [DATE] at 1:50 pm, during an interview, Registered Nurse (RN) #8 stated she obtained R #25's vitals on the morning of [DATE], but she did not document the vital signs. She stated she remembered R #25's oxygen level was at 88% on 2 liters of oxygen. RN #8 stated she turned the oxygen up to 3 liters and R #25's oxygen saturation went up to 92%. RN #8 stated R #25 would cough when she moved, but she could not expel the mucous from her lungs. RN #8 stated she worked with R #25 several times, and she felt like R #25 was at her baseline with her responsiveness level and lung sounds. She stated she did not call the on-call provider, but she wrote a note in the non-emergent logbook. She stated she did not think R #25 was experiencing an emergency. RN #8 stated she believed R #25's presentation on the morning of [DATE] was normal and did not require her to contact a provider, but she informed the day shift nurse. U. On [DATE] at 1:49 pm during an interview, RN #10 stated RN #8 informed her R #25 was not feeling well when she started her shift on [DATE]. RN #10 stated she did not receive R #25's vital signs from RN #8 when her shift started. She was told by RN #8 that R #25 was not awake nor alert enough to give her the morning medications, so RN #10 did not attempt to give R #25 her morning medications. RN #10 stated she did not see R #25 until the CNA came to get her and reported R #25 was not breathing. RN #10 stated if a sternal rub (a medical technique used to assess an individual's level of consciousness by applying firm pressure with the knuckles to the sternum to elicit a pain response) was necessary to use on a resident, then the nurse who conducted the sternal rub should have called the provider. Based on observations, interviews, and record review, an Immediate Jeopardy (IJ) was identified. The facility ADM was notified in person on [DATE] at 5:30 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The POR was approved on [DATE] at 1:14 pm. Corrective Action/Identification: Current residents have the ability to be affected by this deficient practice.Change in condition education was initiated with Licensed Practical Nurse (LPN) and RN staff. The education defined what a change in condition is, appropriate mode of communication to providers, nursing responsibilities on follow-up and documentation, consequences of delayed intervention, and the importance of timely notification. Education stressed early recognition and intervention to prevent negative outcomes for our residents and reinforced numerous times appropriate communication practices. Nurse education regarding early recognition and proper provider notification allows for all medical interventions to be initiated in accordance with resident wishes. The DON/designee ensured that all nurses on duty since time of the event have received this education and understand their responsibility.On [DATE], an initial review of the non-emergent provider communication log process was conducted. The provider and administration team discussed appropriate acuity of notifications for the log. The team agreed that changes of condition need to be reported directly to the provider. Log is only for non-emergent patient requests or medication refills. Log form updated to reflect this change. The agency nurse who documented the progress note on [DATE] was placed on administrative leave pending a review of care. Two nurse managers met in-person with this nurse regarding the substandard care. She was educated one-on-one, with documentation review. Her agency was notified of the event and investigation. Following the event on [DATE], nurse staff assessed vital signs on every resident in the facility within 24 hours. These vitals included temperature, pulse, respirations, blood pressure, and oxygen saturation. Nurse managers walked room to room to conduct visual inspection of proof of life and patient stability. No patients were found in acute distress during the audit. Quality Assurance and Monitoring: The center will review documented changes of condition in clinical meetings. Review includes change of condition assessments and progress notes. Items of review include ,but are not limited to, change in level of consciousness (confusion, lethargy, unresponsiveness), new or worsening pain, abnormal vital signs, shortness of breath or respiratory distress, chest pain, fever or other signs of infection, falls or injuries, change in skin condition (new wounds, worsening wounds), decreased intake/output, and behavioral or mental status changes. For these events, the team will ensure that proper provider notification has occurred. The DON/designee will conduct a questionnaire with nursing staff to screen for any documented or undocumented changes in condition or notable decline. This questionnaire will allow the center to identify changes of condition that have not been documented or previously identified. Any significant changes will prompt escalation and intervention following the facility protocol. This process will occur daily for 2 weeks, then weekly for 2 weeks, then monthly for 2 months. Any identified deficiencies will be addressed immediately by the DON/designee with the nurse or staff member responsible. The DON/designee will report the outcome measures of this monitoring to the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months or until full compliance is noted. Implementation of the POR was verified onsite on [DATE], and the IJ was removed on [DATE] at 4:00 pm. The scope and severity were reduced from a J to an H. Implementation of the POR was verified by the following:Record review of the facility-wide vital signs audits, dated [DATE] through [DATE], indicated every resident's vital signs were obtained and documented to identify any abnormalities. Record review of the facility Change in Condition Identification and Notification Education, dated [DATE] through [DATE], revealed 100% of the facility staff were educated on identifying a CIC, obtaining vital signs, nurses' responsibility, notifying a provider, and outcomes for a delay in treating and notification of CIC for residents. On [DATE] at 2:00 pm, during an interview, Registered Nurse (RN) #3 confirmed she was educated on what a change in condition is, the appropriate mode of communication to providers, nursing responsibilities on follow-up and documentation, consequences of delayed intervention, and the importance of timely notification. RN #3 stated the education discussed early recognition and intervention to prevent negative outcomes to residents and reinforced numerous times appropriate communication practices. On [DATE] at 2:07 pm, during an interview, RN #4 stated education was recently conducted that discussed what a change in condition is, the appropriate mode of communication to providers, nursing responsibilities on follow-up and documentation, consequences of delayed intervention, and the importance of timely notification. On [DATE] at 2:15 pm, during an interview, the Unit Manager (UM) #1 stated each facility nurse just completed education on what a change in condition is, the appropriate mode of communication to providers, nursing responsibilities on follow-up and documentation, consequences of delayed intervention, and the importance of timely notification.On [DATE] at 2:30 pm, during an interview, Licensed Practical Nurse (LPN) #2, #3, and #4 stated they were recently educated on what a change in condition is, the appropriate mode of communication to providers, nursing responsibilities on follow-up and documentation, consequences of delayed intervention, and the importance of timely notification.On [DATE] at 3:15 pm, during an interview, the UM #2 confirmed attending education on what a change in condition is, the appropriate mode of communication to providers, nursing responsibilities on follow-up and documentation, consequences of delayed intervention, and the importance of timely notification.

Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 2 (R #3 and #17) of 2 (R #3 and #17) residents reviewed when staff failed to: Ensure oxygen (O2) was administered per physician orders for R #3. Follow physician orders to obtain STAT (immediately, without delay) laboratory values (numerical measurements from blood, urine, or other bodily fluids that indicate your body's health status, organ function, and potential disease states) and a STAT X-ray (a photographic or digital image of the internal composition of something, especially a part of the body, produced by X-rays being passed through it and being absorbed to different degrees by different materials) for R #17. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:R #3: A. Record review of facility's O2 Concentrator (a medical device designed to deliver supplemental oxygen to individuals with low blood oxygen levels due to various health conditions) Policy, dated 08/07/23, revealed the following: Turn on unit and check for proper alarm function, Set litter flow per order, Attached prescribed O2 delivery device, Apply O2 delivery device to the resident. B. Record review of R #3's face sheet revealed an admission date of 09/03/25 and the following diagnoses. Chronic obstructive pulmonary disease (COPD; lung disease) Acute respiratory failure with hypoxia (a sudden inability of the lungs to provide enough O2 to the blood), Acute respiratory failure (sudden inability of the lungs to properly exchange O2 and/or carbon dioxide). C. Record review of R #3's Physician Orders, dated 09/04/25, revealed the following: O2 via nasal cannula (a small, flexible tube that delivers O2 to the nose through soft prongs), 5.5 liters per minute (LPM) continuously to maintain O2 saturations greater than 90% (percent), May send patient to the emergency room (ER) for altered mental status secondary to hypoxia. R #3 is mobile and requires a portable O2 tank and room concentrator. D. Record review of R #3's care plan, dated 09/04/26, revealed the following: R #3 is at risk for respiratory complications related to recent hospitalization secondary to chronic hypoxic respiratory failure, R #3 is at risk of falls related to respiratory failure, R #3 is at risk for skin breakdown related to respiratory failure, R #3 will have no sign/symptoms of respiratory distress. E. Record review of R #3's change in condition (CIC; any noticeable deviation from a person's normal health baseline, whether it is an improvement or a decline in physical, functional, or mental state), dated 11/06/25, revealed the following: R #3 appeared lethargic (sluggish, fatigued) and more tired than on the previous day. The resident was having difficulty speaking, only mumbling, and could barely be understood. R #3's O2 saturation was 80-81% (normal O2 saturations are 95 to 100%), while on 6 liters of supplemental O2. The Registered Nurse (RN) adjusted his position by raising the head of the bed, attempted to rouse him, and offered the resident some water. R #3 is currently presenting with severe hypotension and hypoxia (O2 saturations of 70% on 6 LPM of O2), accompanied by lethargy and mumbling speech. These findings are highly suggestive of an acute exacerbation of R #3's underlying congestive heart failure (CHF; impaired heart function). Lung examination revealed diminished breath sounds at the bases. No in-house interventions were provided as per resident's request to be transferred to the emergency room (ER) for higher level of care. F. On 03/17/26, during observations of R #3, the following was observed: At 11:40 AM, R #3's portable O2 device (a carriable O2 container that provides O2 to help a person breathe) was in the off position and set at zero LPM. At 11:43 AM, R #3's portable O2 device was on and set at 4 LPM (R #3's physician orders are for 5.5 LPM) by Registered Nurse (RN) #1. At 2:13 PM, R #3 was observed in bed not wearing a nasal cannula. The O2 concentrator was on, set at 4 LPM, but without a nasal cannula attached to the concentrator. At 2:25 PM, R #3's O2 saturations were checked by Licensed Practical Nurse (LPN) #1 using a pulse oximeter (a device that measures the O2 level in the blood), and R #3's O2 saturations were at 86% on room air (not on O2). G. On 03/18/26 at 9:21 AM, during an observation, R #3 was observed lying in bed without O2 use. R #3's O2 concentrator was on and set to 4 LPM, but a nasal cannula was not attached to the device. H. On 3/19/26 at 10:21 AM, during an observation, R #3's portable O2 device was empty and unable to deliver O2 to R #3. I. On 3/17/26 at 11:47 AM, during an interview, RN #1 stated R #3's portable O2 device was turned off and should not have been. She stated all residents who need O2 should have their portable O2 device on and set to the prescribed LPMs. J. On 3/17/26 at 2:29 PM, during an interview, LPN #1 stated R #3 should be on 5.5 LPM of O2 per physician orders. She stated R #3 requires assistance with his O2 therapy. LPN #1 stated it was her expectation R #3 have his O2 on per physician orders. She stated if residents don't have their O2 on and set to the prescribed LPM, they could have respiratory failure. K. On 3/17/26 at 2:32 PM, during an interview, Certified Nursing Assistant (CNA) #1 stated she removed R #3's nasal cannula from the O2 concentrator. She stated the nasal cannula was on the floor and she did not bring a replacement back to R #3's room. CNA #1 confirmed R #3 should have had a nasal cannula readily available, but she did not bring one to R #3's room. L. On 3/18/26 at 9:23 AM, during an interview, CNA #2 confirmed R #3 did not have a nasal cannula attached to the O2 concentrator in his room and R #3 was not receiving O2. She said R #3 should have a nasal cannula connected to the O2 concentrator. M. On 3/19/16 at 10:25 AM, during an interview, LPN #2 stated R #3's portable O2 device was empty, and R #3's O2 saturation level was at 84% on room air. She stated it was her expectation residents who require O2 have full portable O2 devices. N. On 03/19/26 at 2:46 PM, during an interview, the Director of Nursing (DON) stated it was her expectation O2 be administered per physician orders. She stated residents could experience respiratory complications if the order was not followed. The DON confirmed R #3 was not provided continuous O2 via nasal cannula at 5.5 LPM and should have been. R #17: O. Record review of R #17's face sheet revealed an admission date of 01/06/26 with the following diagnoses: Fracture right femur (serious break of the thigh bone), Type II diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin), Cognitive communication loss (deficits resulting in difficulty with thinking and how someone uses language), Pain in right hip. P. Record review of #17's after-hours provider progress note, revealed the following: Dated 01/09/26 at 10:00 pm: Registered Nurse (RN) calling to report left knee pain. R #17 has left knee swelling with decreased range of motion. Concern for possible injury/fracture. Order the following: STAT complete blood count (CBC; determines general health status, screens for, and monitors for a variety of disorders to include anemia), STAT comprehensive metabolic panel (CMP; measurement of blood sugar, electrolytes, fluid balance, kidney and liver function), STAT C-reactive-protein (CRP; blood test to measure acute inflammation) test, STAT X-ray of left knee. Q. Record review of R #17's physician orders revealed the following: Dated 01/10/26, physician orders for a STAT CBC, CMP, and CRP for severe left knee pain. Dated 01/10/26, physician's order for a STAT X-ray of R #17's left knee, for severe left knee pain. R. On 03/16/26 at 2:23 pm, during an interview, R #17's daughter stated R #17 was at the facility for recovery after surgery from a fracture on his right femur. She stated R #17 arrived at the facility on 01/06/26 and by 01/09/26, he was having severe pain in his left knee. She stated a facility nurse called the after-hours on-call provider and laboratory values an x-ray was ordered to be completed immediately. R #17's daughter stated when she arrived on 01/10/26, a facility nurse told her R #17's laboratory values and X-ray had not been completed because the physician orders for each were not documented correctly. R #17's daughter stated R #17 was in a significant amount of left knee pain, so she asked for him to be sent to the hospital since the laboratory values and X-ray were not completed. R #17's daughter confirmed both R #17 and her were upset due to the delay in obtaining the X-ray and laboratory values that were ordered STAT by a physician. S. On 03/17/26 at 8:39 am, during an interview, the Director of Nursing (DON) stated R #17's STAT physician orders for laboratory values and an X-ray were not documented correctly, which led to a delay in completing each order. The DON confirmed R #17's laboratory values and X-ray should have been obtained immediately per physician orders, but that did not happen.

Based on record review and interviews, the facility failed to ensure residents received the necessary treatment and services to promote healing of a surgical wound (a cut or incision in the skin that is usually made by a scalpel during surgery) for 1 (R #1) of 1 (R #1) resident reviewed when the facility failed to: Provide surgical wound care per physician orders for R #1. If wound care is not being provided as ordered by a physician, then residents are likely at risk of wound deterioration, infection, delayed healing, and other complications.The findings are: A. Record review of the facility's wound management policy, dated 09/15/25, revealed the following: Provide safe and effective care to promote optimal skin health and promote healing, Review pre-admission information to prepare for residents' skin/wound needs prior to admission/re-admission, For surgical wounds follow specific orders,Preform daily monitoring of wounds or dressing for presence of complications or declines, Monitor status of dressing, the tissue surrounding the dressing, and signs of decline in wound status. B. Record review of R #1's face sheet revealed an admission date of 09/03/25 with the following diagnoses: Encounter for surgical aftercare following surgery on the digestive system (surgical aftercare following surgery on the digestive system), Incisional hernia without obstruction (a type of hernia that occurs at the site of a previous surgical incision without blockage to the intestines),Unspecified intestinal obstruction unspecified as to partial versus complete obstruction (a blockage in the intestines where it is not clear if it is partial or complete). C. Record review R #1's physician orders, dated 12/17/25, revealed the following: Wound Care to abdomen, cleanse with wound cleanser and pat dry. Pack with optical AG rope (a type of antimicrobial dressing or material containing silver (Ag) used to help heal wounds and prevent infection). Cover with foam dressing every day shift, from 12/17/25 through 12/23/25. D. Record review of R #1's Treatment Administration Record (TAR), dated 12/17/25 through 12/23/25, revealed R #1's surgical wound care treatment was documented as being completed every shift as ordered. E. Record review of R #1's nursing progress notes, dated 12/22/25, revealed the following: Changed midline abdominal surgical wound site today (12/22/25), due to R #1's last dressing change occurring on 12/18/25. Removed old dressing dated 12/18/2025, because wound care was not being completed (as ordered). Increased drainage present with thick brown serosanguineous (a type of wound drainage that contains clear, yellowish fluid), and increased redness around the surgical wound site. Notified wound nurse of worsening appearance of R #1's wound. F. Record review of R #1's communication form, dated 12/29/25, revealed the following: Dated 12/22/25: Skin assessment revealed a reddened abdominal incision with purulent (a thick yellow, green, or brown fluid that usually shows there's an infection) drainage. Resident states dressing had not been changed since 12/17/25. New physician orders and culture (a laboratory test that identifies microorganisms in a wound to determine if it is infected and guide appropriate treatment) obtained. The wound culture was positive for gram negative and gram positive for bacteria (germs causing infections in the body), indicating R #1's surgical wound was infected. R #1's daughter was notified of missed surgical wound treatments and positive culture. G. On 03/17/26 at 11:04 AM, during an interview, R #1's daughter stated in December 2025, a facility nurse contacted her to report R #1's surgical wound bandage had not been changed for several days. She stated a wound culture was obtained, which tested positive for an infection. H. On 03/19/26 at 1:45 PM, during the interview, the Infection Preventionist/Unit Manager (IPUM) stated R #1's abdominal incision had become inflamed and reddened and tested positive for methicillin resistant staphylococcus aureus (MRSA; a type of bacteria that causes skin infections and is resistant to many antibiotics, making it harder to treat). She stated scheduled wound care was missed for R #1 from 12/18/25 through 12/22/25. The IPUM stated adherence to physician-ordered wound care is critical to prevent wound deterioration or infection. The IPUM confirmed R #1's surgical wound care was not completed per physician orders and should have been. I. On 03/25/26 at 11:42 AM, during an interview, the Director of Nursing (DON) stated it was her expectation wound care be accurately documented and performed according to physician orders. The DON confirmed R #1's surgical wound care was not completed per physician orders and should have been.

Based on observations and interviews, the facility failed to ensure staff properly stored and secured medications and medical supplies for all residents residing on the 300 unit when: The unit treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) was not secured and left unattended. The unit medication cart (a mobile storage unit equipped with drawers and locking mechanisms to hold medications) was not secured and left unattended. If the facility fails to secure medication and treatment carts, then residents are likely to experience unauthorized access to medications and medical supplies, potentially resulting in injury or illness. The findings are: A. On 03/17/26 at 2:39 PM, during an observation of the 300 unit, the wound care treatment cart was unlocked and opened. Further observations revealed the cart had wound care supplies, tweezers, topical creams (a medication applied directly to the skin to treat a specific area), and scissors available. The facility nursing staff was not present in the area or near the treatment cart. B. On 03/17/26 at 3:10 PM, during an observation of the 300 unit, the medication cart was unlocked and opened. Further observations revealed the cart had Buspirone (medication used for depression), Glipizide (medication used for diabetes), Mirtazapine (medication used for depression), Venlafaxine (medication used for depression), Carbamazepine (medication used for seizures), Gabapentin (medication used for seizures), Colace (medication used for constipation), eye drops, and lancets (small needles designed to puncture skin to obtain blood samples for testing) available. The facility nursing staff was not present in the area or near the medication cart. C. On 03/17/26 at 2:43 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed the unit treatment cart and medication cart was unlocked and opened. She stated she was responsible for both carts, and they should be locked when not in use. The LPN #1 also stated medication carts should never be left open because a resident could ingest medications not prescribed to them, resulting in the resident becoming ill. D. On 03/18/26 at 1:37 PM, during an interview, the Director of Nursing (DON) stated staff should never leave a medication cart or treatment cart unlocked and unattended. The DON stated it is her expectation all medication and treatment carts are locked when not in use. She stated if a medication or treatment cart were left unlocked, residents could access contents and sustain injury.

Based on a record review and interviews, the facility failed to ensure medical records were complete for 2 (R #'s 1 and 25) of 2 (R #'s 1 and 25) residents reviewed when the facility: Documented R #1's surgical wound care treatment in R #1's Electronic Health Record (EHR) as completed, when the wound care treatment was not completed per physician orders.Failed to document R #25's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) in R #25's EHR after R #25 experienced a change in condition (CIC; any noticeable deviation from a person's normal health baseline, whether it is an improvement or a decline in physical, functional, or mental state).This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents. The findings are: R #1: A. Refer to F0686 for related findings. B. Record review of R #1's Treatment Administration Record (TAR), dated 12/17/25 through 12/23/25, revealed R #1's surgical wound care treatment was documented as being completed every shift as ordered. C. Record review of R #1's nursing progress notes, dated 12/22/25, revealed the following: Changed midline abdominal surgical wound site today (12/22/25), due to R #1's last dressing change occurring on 12/18/25. Removed old dressing dated 12/18/2025, because wound care was not being completed (as ordered). Increased drainage present with thick brown serosanguineous (a type of wound drainage that contains clear, yellowish fluid), and increased redness around the surgical wound site. Notified wound nurse of worsening appearance of R #1's wound. D. Record review of R #1's communication form, dated 12/29/25, revealed the following: Dated 12/22/25: Skin assessment revealed a reddened abdominal incision with purulent (a thick yellow, green, or brown fluid that usually shows there's an infection) drainage. Resident states dressing had not been changed since 12/17/25. New physician orders and culture (a laboratory test that identifies microorganisms in a wound to determine if it is infected and guide appropriate treatment) obtained. The wound culture was positive for gram negative and gram positive for bacteria (germs causing infections in the body), indicating R #1's surgical wound was infected. R #1's daughter was notified of missed surgical wound treatments and positive culture. E. On 03/17/26 at 11:04 AM, during an interview, R #1's daughter stated in December 2025, a facility nurse contacted her to report R #1's surgical wound bandage had not been changed for several days. She stated a wound culture was obtained, which tested positive for an infection. F. On 03/25/26 at 11:42 AM, during an interview, the Director of Nursing (DON) stated it was her expectation wound care be accurately documented and performed according to physician orders. The DON confirmed R #1's surgical wound care treatment was documented as completed for the dates 12/17/25 through 12/22/25, but that was not accurate. R #25: G. Refer to F0580 for related findings. H. Record review of R #25's Electronic Health Record (EHR), dated 03/18/26, revealed R #25's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) that were taken on 03/17/26 at 4:59 am were not documented after R #25 experienced a change in condition (CIC; any noticeable deviation from a person's normal health baseline, whether it is an improvement or a decline in physical, functional, or mental state). I. On 03/18/26 at 11:30 am, during an interview, the DON stated R #25's vital signs were not documented in R #25's EHR on 03/17/26 after R #25 experienced a CIC. The DON confirmed R #25's vital signs should be documented in the EHR after the CIC, but they were not.

Based on record review and interview, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #17) of 1 (R #17) residents reviewed for baseline care plans, when: R #17's baseline care plan was incomplete and inaccurate due to the baseline care plan failing to include multiple diagnoses with interventions for R #17. If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care). The findings are: A. Record review of R #17's face sheet revealed an admission date of 01/06/26 with the following diagnoses:Fracture right femur (serious break of the thigh bone),Type II diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin),Cognitive communication loss (deficits resulting in difficulty with thinking and how someone uses language),Pain in right hip. B. Record review of R #17's baseline care plan, dated 01/07/26, revealed only one of R #17's admitting diagnoses was included in the care plan (skin integrity of the right hip after surgery). The care plan did not include any other care areas for R #17. C. On 03/17/26 at 8:10 am, during an interview, the Unit Manager (UM) #1 stated R #17's baseline care plan should include activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating), fall risk interventions, wounds and skin care, advanced directives (legal documents that outline your healthcare preferences and designate decision-makers if you are unable to communicate your wishes), and more specialized care like diabetic management. The UM #1 confirmed R #17's baseline care plan was not a complete baseline care plan and should be.

PAST NON-COMPLIANCEBased on record review and interviews, the facility failed to ensure residents were free from misappropriation of property for 1 (R #2) of 1 (R #2) resident reviewed, when a transport driver took money from a resident. This deficient practice could result in financial loss, emotional distress, and compromise of resident trust and safety. The findings are: A. Record review of the facility's Code of Conduct revealed staff were not to ask for or accept tips, gifts, loans, and/or monetary transactions from residents or their family members. Further review revealed the facility has a zero tolerance for any type of misappropriation or exploitation. B. Record review of the facility's follow-up investigation report, dated 11/19/25, for misappropriation of resident property identified the following corrective actions: All drivers were re-educated of the facility's zero-tolerance policy against misappropriation of resident property. A sign was placed in each transportation van to indicate to residents and family members tips were strictly prohibited and would subject the driver to disciplinary action.C. Record review of the Driver Training Sign-In Sheet, dated 11/24/25, revealed 14 drivers received training on the facility's Code of Conduct with example of how drivers were not to ask for or accept tips, gifts, loans, and/or monetary transactions from residents or their family members.D. Record review of R #2's face sheet revealed R #2 was originally admitted to the facility on [DATE].E. Record review of R #2's minimum data set (MDS, which was part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) completed on 10/16/25 indicated R #2 had a brief interview for mental status (BIMS; screening for cognitive impairment) score of 15 (score of 15 - 13 is cognitively intact). F. On 12/11/25 at 1:40 pm, during interview with R #2, he stated on 10/24/25 he left the facility to go to the bank. R #2 stated his transport driver accompanied him into the bank. R #2 stated the driver recounted stories about his family and mentioned needing money multiple times. R #2 stated driver spoke about how his family had a history of being upstanding people who always paid others back. R #2 stated he felt inclined to loan the driver $100, and the driver told him he would pay resident back with his next paycheck. R #2 stated after about a month, he hadn't heard from the driver and went up to the front desk where he requested staff to call the driver so he could speak to him. R #2 stated this is when he felt the driver was not going to pay him back. R #2 stated he was going to let the situation go but the facility intervened. R #2 stated he was appreciative of the facility who paid him back the $100.G. On 12/12/25 at 10:30 am, during interview with the administrator (ADM), she stated on 11/19/25 R #2 went to the transport clerk and told her he was trying to get ahold of the driver who he loaned $100 to. ADM stated R #2 gave a description and named the driver. ADM stated the clerk immediately told ADM. ADM stated she then called the transport dispatch center, who transports for Genesis facilities, to get information about the driver. ADM stated she conference called the driver who admitted to taking money from R #2 but stated it was given as a tip. ADM stated the driver was placed on administrative leave the same day. ADM stated all other drivers were interviewed and stated they knew not to accept money from residents. ADM stated all of the transport drivers were reeducated and completed Code of Conduct training. ADM stated audit was completed and facility interviewed other residents who utilized transportation, no other residents reported any issues. ADM stated the transport company terminated the driver and the facility reimbursed R #2 for the $100.

Based on record review and interview, the facility failed to report a medication error involving 1 (R #1) of 1 (R #1) to the State Agency as required. This failure limited regulatory oversight and placed the residents at risk for serious harm by delaying external review and corrective action.If a facility fails to report medication errors in accordance with abuse prevention and reporting requirements, then the facility limits the State Agency's ability to ensure resident safety, increasing the risk of unaddressed harm and repeated incidents.The findings are:A. Record review of the facility's Abuse Prohibition Policy revised 11/14/25, revealed the facility prohibits abuse, mistreatment, neglect, exploitation, misappropriation of patient property, and injuries of unknown source and requires immediate reporting, investigation, and protection of patients. The policy specifies that allegations resulting in serious bodily injury must be reported immediately but no later than two (2) hours, and allegations not resulting in serious bodily injury must be reported within twenty-four (24) hours, with final investigation results reported within five (5) working daysB. Record review of R #1's Face Sheet revealed she was admitted on [DATE] with diagnoses including morbid obesity (severely overweight) and Type 2 diabetes mellitus (DM2, a disease in which the body cannot make or properly use insulin)C. Record review of the physician orders dated 08/01/25 showed an active order for Mounjaro (tirzepatide) 12.5 mg subcutaneous (under the skin) once weekly, and an active order for Emgality (migraine medication)120 mg/units per milliliter (u/ml) to be administered monthly for migraine prophylaxis.D. On 12/11/25 at 2:25 p.m., during an interview with the Administrator, she stated the facility did not report the medication error to the State Agency. The Administrator stated she was surprised no report had been submitted and identified that it would have been her expectation that an error of this magnitude be reported. She further stated the facility may not have reported the incident due to high staff turnover and operational challenges, including the Director of Nursing being on leave, the training of a new Director of Nursing, and ongoing staffing instability at the time of the incident.

Based on record review and interviews, the facility failed to prevent a significant medication error when staff administered a second dose of Mounjaro (GLP-1 Trizepatide) 12.5 milligrams (mg) within 24 hours to 1 (R#1) of (R #1). The facility also failed to ensure accurate medication administration practices consistent with the resident's prescribed regimen. The Findings are: A. Record review of the facility's Medication Administration policy, dated January 2025, revealed licensed nurses must administer medications in accordance with the written orders of the prescriber.B. Record review of R #1's Face Sheet revealed she was admitted on [DATE] with diagnoses including morbid obesity (severely overweight) and Type 2 diabetes mellitus (DM2, a disease in which the body cannot make or properly use insulin)C. Record review of the physician orders dated 08/01/25 showed an active order for Mounjaro (tirzepatide) 12.5 mg subcutaneous (under the skin) once weekly, and an active order for Emgality (migraine medication)120 mg/units per milliliter (u/ml) to be administered monthly for migraine prophylaxis.D. Record review of the facility's Change in Condition (CIC) report dated 09/25/25 revealed staff administered Mounjaro to R #1 on 09/25/25 instead of the ordered Emgality injection. The CIC documented the resident had already received her scheduled weekly Mounjaro dose on 09/24/25, resulting in the resident receiving two doses of Mounjaro within 24 hours.E. Record review of R #1's progress notes dated 09/25/25, documented by the Nurse Practitioner (NP), revealed the NP contacted Poison Control regarding a duplicate medication dose. Poison Control advised the duplicate dose could cause nausea, vomiting, diarrhea, abdominal pain, abdominal distention, and hypoglycemia (low blood sugar) and recommended enhanced monitoring. The NP ordered the resident's glimepiride (an oral antidiabetic medication used to lower blood glucose levels) and Actos (pioglitazone-an oral antidiabetic medication used to improve insulin sensitivity and control blood sugar) to be held for five days and ordered blood glucose monitoring four times daily.F. Record review of R #1's September 2025, medication administration record (MAR) revealed staff continued routine blood sugar checks already in place for diabetes management but did not increase monitoring beyond the resident's baseline schedule.G. Record review showed no documentation the facility reassessed the resident for side effects, no nursing narrative assessing symptoms, and no monitoring beyond routine diabetic checks.H. On 12/11/25 at 1:35 p.m., during an interview with the Interim Director of Nursing (DON), she stated staff administered the wrong injection, giving Mounjaro instead of Emgality. She stated it is her expectation the resident would not of received two doses of Mounjaro, as this could of cause adverse reaction to the resident.I. On 12/11/25 at 2:25 p.m., during an interview with the Administrator, she stated the nurse immediately reported the error and she learned of the event during the Interdisciplinary Team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident) meeting on 09/26/25. She stated the monitoring consisted of routine blood sugar checks and observation for symptoms. She stated no symptoms were reported by staff.J. On 12/11/25 at 3:15 p.m., during an interview with the Medical Director, she stated a duplicate dose of Mounjaro requires monitoring for hypoglycemia (low blood sugar, normal blood sugar measurement is 70 to 99 mg/dL) and adverse symptoms. She stated the error met the criteria for a significant medication error and stated it should have been reported to the state.K. On 12/12/25 at 8:00 a.m., during an interview with RN #1 she stated the resident had a weekly injectable migraine medication and a weekly Mounjaro injection stored in the same refrigerator. She stated the medications looked exactly the same. She reported the electronic MAR continued prompting administration of Mounjaro, contributing to the error. After realizing the mistake, she stated she notified the resident, the nurse practitioner, the guardian, and the charge nurse. She stated Poison Control was contacted, and staff monitored the resident's blood sugars and symptoms.L. On 12/12/25 at 8:27 a.m., during an interview with Charge Nurse, she stated she worked at the facility during the time R #1 received a duplicate dose of Mounjaro. She stated the resident was scheduled to receive a weekly injectable migraine medication but was administered Mounjaro instead. The Charge Nurse stated the medication error was related to the nurse that admistered the medication not reading the medication label carefully.

Based on observation and interview, the facility failed to ensure medications were stored securely when a medication cart remained unlocked and unattended on the 200 Hall. This failure created the potential for unauthorized access to medications, including controlled substances, for 1 of 1 medication carts observed. The findings are: A. Record review of the facility's Medication Storage and Security Policy, revised January 2025, revealed the facility requires all medications to be kept secured at all times. The policy states medication carts must remain locked when not in the direct possession of licensed staff, and controlled substances must be stored in a separately locked, permanently affixed compartment. The policy further states staff must ensure medications are protected from unauthorized access by residents, visitors, or staff.B. On 12/12/25 at 9:17 a.m., observation of the 200 Hall revealed a medication cart positioned in the hallway with the top drawer unlocked. No staff were present in the immediate area, and the cart remained unattended and accessible to residents walking through the hallway.C. On 12/12/25 at 9:18 a.m., during an interview, RN #5 stated she had just stepped away for a moment into a resident's room and confirmed she left the cart unlocked. RN #5 stated the cart contained narcotics stored inside the locked box, but the remaining drawers contained other resident medications. RN #5 stated, If the medication cart is left unlocked a resident could get into the cart and take medication that does not belong to them.D. On 12/12/25 at 3:32 p.m., during an interview with interim DON, she stated it is her expectation all medications carts should remained locked at all times. She stated if the medication carts are not locked then a resident could go into the medication cart and take medication that does not belong to them.

Based on record review and interviews, the facility failed to ensure a resident's Advance Directives (a document which provides an individual's wishes for emergency and lifesaving care) were honored for 1 (R #101) of 1 (R #101) residents when staff provided cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation) to R #101 when the resident had a documented Do Not Resuscitate (DNR; lifesaving measures are not desired) Advanced Directive on file at the facility. If staff do not follow a resident's Advanced Directives, then the resident may feel undignified and as if they do not have control over her own choices.The findings are: A. Record review of R #101's face sheet revealed an admission date of [DATE]. B. Record review of R #101's New MexicoMedical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves)form,dated [DATE] andsigned by R #101, revealed the residentchose DNR. C. Record review of R #101's physicians progress notes, dated [DATE], revealed R #101 discussed her options for code statuswith her doctorand selected DNR status. D. Record review of R #101's physicians orders dated [DATE] revealed a Do Not Resuscitate status. E. Record review of R #101's nurses progress notes, dated [DATE] at 2:00 am, revealedthe resident was well and did not have any changes from her baseline (normal condition). The resident requested to go to the restroom. When the resident returned from the restroom, she complained of nausea. The resident began to feel better, but she was tired and wanted a nap. R #101 became unconscious. Staff called 911 (emergency service number) and started CPR at 2:05 am. The resident regained consciousness. When Emergency Medical Services (EMS) arrived, staff notified EMS that R #101 documented a DNR status on her MOST form. R #101 became unconscious again, and EMS did not perform CPR. Resident was pronounced dead at 2:25 am. F. On [DATE] at 4:00 pm during an interview, the Administrator (ADM) stated she could not recall whether she was informed of the incident, and it was not reported to the State Agency. She stated she was not aware of any staff training directly related to the failure of honoring resident code status. G. On [DATE] at 4:10 pm during an interview, the Director of Nursing (DON) stated the facility enters all residents as full code status on admission. He further stated they realized R #101 was a DNR status when they collected the paperwork for the Emergency Medical Technicians (EMTs). H. On [DATE] at 4:15 pm during an interview, an anonymous nursing staff stated they referred to the resident's medical record to determine code status during an emergency event. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified to have occurred on [DATE] when the facility provided CPR to R #101. The facilityAdministratorwas notifiedin personon [DATE] at 4:33 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on [DATE] at 11:12 am. Plan of Removal Corrective Action: - The identified resident that was affectedwas no longera resident ofthe facility. - Current residents have the ability to be affected by this deficient practice. - On [DATE], an initial audit was conducted to ensure all resident code statuses and MOST forms match. The DON/designee ensured all code status orders in the EMR matched the MOST forms.One resident was identified. The resident'sorder in the EMR updated to DNR to match the resident's MOST form. - The Center reviewed the Code Status Order Policy and noted that allresidentsrequire a code status order as soon as possible upon admission and, if the resident experiences cardiopulmonary arrest prior to indicating their advance directive wishes, the Center will default to Full Code and perform CPR. - The Center will provide the resident/resident representative with the opportunity to indicate their advanced directive wishes at admission. Their wishes will be reflected on the MOST form and an order will be entered into the EMR. - On [DATE], all licensed nurses in the building will be educated by the Director of Nursing/designee on this process, specifically to review the resident's medical record to include the hospital discharge paperwork and admission paperwork to ensure a resident's code status is accurate. - If the resident's wishes are different from the hospital medical records or admission orders, the nurses will immediately document theresident'swishes in the medical record, notify the physician, obtain the correct order, and complete the MOST form. - All other licensed nurses will be educated on their next scheduled shift. - The DON/designee will monitor each new admission/readmission daily for three months to ensure that the resident/resident representative is provided with the opportunity to indicate their advanced directive wishes at admission, the MOST form is completed as applicable, and the code status order is updated in the EMR to match the resident's wishes. - The DON/designee will follow up to ensure corrections are made immediately and additional education is provided as needed to ensure compliance. - The DON/designee will report the outcome measures of the monitoring to the Quality Assurance Performance Improvement (QAPI) monthly for 3 months or until full compliance is noted. Implementation of the POR was verified onsite on [DATE], and the IJ was removed on [DATE] at 12:30 pm. The scope and severity was reduced from a J to an E. Implementation of the POR was verified by the following: -Record review of the facility's Code Status Policy, dated [DATE], revealed the following: - Upon admission/readmission, a code status is required as soon as possible as part of the resident's admission order set. - Staff should verify patient's wishes with regard to code status upon admission. - Record review of the facility's audit of all current residents,dated [DATE],revealed one other resident had unmatching code status on MOST form and face sheet. Staff corrected immediately so all information in the resident's record matched. -Record review of the facility's follow-up audit of all current residents,dated [DATE],revealed all current residents had matching code status orders on their MOST forms and face sheets. - Record review of staff signature sheets,dated [DATE] and [DATE], revealed education was provided to the licensed staff, regarding MOST form accuracy, advance directive orders, and residents documented code status on the face sheetshould be the same. - On [DATE] at 11:55 am during an interview, Registered Nurse (RN) #5 stated nursing staffhad a training on [DATE] regarding MOST form accuracy, advance directive orders, and residents documented code status on the face sheetshould be the same. - On [DATE] at 12:06 pm during an interview with the DON, he stated an audit of all residents' MOST forms and code status orders were completed to verify they contained matching information. He stated the facility identified a discrepancy for one other resident during the audit. He stated nursing staff who were on shift yesterday received the training regarding MOST form accuracy, advance directive orders, and the face sheet matching. He stated the nurses who were not on shift on [DATE] will receive the training on their next shift. The DON stated the Plan of Correction will be discussed at the next scheduled Quality Assurance and Performance Improvement (QAPI) meeting. - On [DATE] at 12:10 pm during an interview, RN #6 stated she received training on [DATE] onMOST forms. She stated the MOST form was signed on admission. She stated if the resident was unable to speak or sign, then staff should call the resident's family for the code status. She stated staff could also look up a resident's code status from their hospital documentation. She stated if staff were unable to find a code status for a resident, then the resident would be considered full code status. - On [DATE] at 12:17 pm during an interview, RN #7 stated staffhad MOST training on [DATE]. He stated staff are trained to complete MOST forms when a resident was admitted . He stated if a resident was unable to sign, then staff were to reach out to their Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) or the resident's family. He stated staff could also look at the resident's hospital paperwork to verify their code status. He stated the admitting nurse should update the resident's code status in their medical record upon admission or same day. - On [DATE] at 12:26 pm during an interview, Licensed Practical Nurse (LPN) #2 stated she received instruction on [DATE] that residents needed to sign the MOST forms upon admission. She stated if the resident was non-verbal, then staff should call family or the POA for the resident's code status. - On [DATE] at 12:30 pm during an interview, RN #3 stated staff received training on [DATE] regarding resident code status. She stated staff were instructed to immediately contact the resident's POA or next of kin when a resident was unable to speak. She stated staff were instructed to check a resident's medical record if the POA did not respond.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. Nurses and Certified Medication Aides (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) pens and discarded them within 28 days of opening date for 5 (R #8, R #12, R #15, R #32 and R #66) of 5 (R #8, R #12, R #15, R #32 and R #66) residents reviewed. This deficient practice is likely to lead to all five residents receiving medications that are less effective or expired. 2. Staff secured medications and made them inaccessible to unauthorized staff for one medication cart in the 100 hall and one treatment cart in the 400 hall. Improperly stored medications could result in a resident, staff member, or visitor taking medications not prescribed to them. This deficient practice had the potential to affect all 60 residents in both halls as identified by the Resident Census provided by the Administrator on 06/22/25. The findings are: Insulin Pens A. Record review of the facility's Insulin Pens Policy, dated 05/01/25, revealed the following: - Insulin pens will be clearly labeled with patient name and date used. - Insulin pens do not require refrigeration after opening. Follow manufacturer recommendations for product expiration. B. On 06/26/25 at 10:16 am, observation of the 200 Hall medication cart revealed the following: - Insulin aspart (a rapid-acting insulin),100 units/milliliter (ml) multiple-dose pen was opened on 05/16/25. The insulin pen belonged to R #66. - Insulin glargine (a long-acting insulin),100 units/ml multiple-dose pen was opened and not dated. The insulin pen belonged to R #66. - Insulin Basaglar (a long-acting insulin),100 units/ml multiple-dose pen was opened and not dated. The insulin pen belonged to R #12. - Insulin Admelog (a rapid-acting insulin),100 units/ml multiple-dose pen was opened and not dated. The insulin pen belonged to R #12. - Insulin Admelog,100 units/ml multiple-dose pen was opened and not dated. The insulin pen belonged to R #32. - Insulin glargine,100 units/ml multiple-dose pen was opened and not dated. The insulin pen belonged to R #15. - Insulin aspart,100 units/milliliter (ml) multiple-dose pen was opened and not dated. The insulin pen belonged to R #8. C. Record review of the manufacturer's instructions for insulin Admelog multiple dose vial, dated 2023, revealed staff were instructed to throw away all opened vials after 28 days of use, even if there was insulin left in the pen. D. Record review of the manufacturer's instructions for insulin aspart multiple dose vial, dated 02/2023, revealed staff should throw insulin aspart pen away after 28 days, even if it still has insulin left in it. E. Record review of the manufacturer's instructions for insulin Basaglar (glargine) multiple dose pen, dated 2024, revealed staff should throw away the pen after 28 days, even if it still has insulin left in it. F. Record review of R #66's Physician Orders revealed the following: - Dated 02/27/25, an active order to receive insulin aspart. - Dated 11/09/24, an active order to receive insulin glargine. G. Record review of R #12's Physician Orders revealed the following: - Dated 03/04/25, an active order to receive insulin Basaglar. - Dated 08/26/24, an active order to receive insulin Admelog. H. Record review of R #32's Physician Orders, dated 10/01/24, revealed R #32 had an active order to receive insulin Admelog. I. Record review of R #15's Physician Orders, dated 04/23/25, revealed R #15 had an active order to receive insulin glargine. J. Record review of R #8's Physician Orders, dated 05/21/25, revealed R #8 had an active order to receive insulin aspart. K. On 06/26/25 at 10:19 am, during an interview, Nurse #3 stated she should have dated the insulin pens when she first opened them. She stated she should have discarded the opened insulin pens within 28 days of the opening date. L. On 06/26/25 at 10:45 am, during an interview, the Director of Nursing (DON) stated staff must date the opened insulin pens and discard them within 28 days of the opening date. He stated he expected nurses and CMAs to check insulin pens for opening date every day and before using them. M. On 06/26/25 at 2:02 pm, during an interview, the facility's Consultant Pharmacist (CP) #1 stated she expected Nurses and CMAs to date the opened insulin pens and discard them within 28 days of the opening date. Treatment Cart N. Record review of the facility's Storage of Medication policy, dated January 2025, revealed the following: - Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements. Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinet, or other suitable containers. O. On 06/22/25 at 5:43 am, an observation revealed an unlocked respiratory treatment cart in 400 hall with a set of keys stored on the side of the cart. The cart contained the following floor stock medications: - Seven Day vaginal cream (medication to treat vaginal infection), - Albuterol sulfate 2.5 mg (medication to treat and prevent the narrowing of the airways), - Sodium chlorine 3 percent (%) vial hypertonic (medication used to help thin and loosen mucus in the airways, making it easier to cough up). P. On 06/22/25 at 5:56 am during an observation and interview, Licensed Practical Nurse (LPN) #1 confirmed the respiratory treatment cart was unlocked. LPN #1 stated he was not aware he should have locked the cart. He stated he performed respiratory care for residents on 400 hall during the night shift since a Respiratory Therapist (RT) was not scheduled to work nights. LPN #1 stated the key to lock the treatment cart belonged to the RT staff. He stated it was easier to leave the treatment cart unlocked overnight so all LPNs could access it. Q. On 06/24/25 at 8:50 am, during an observation and interview, RT #1 stated she should have locked the treatment cart. She stated nurses who work nights were trained to perform respiratory care, and they had access to the respiratory treatment cart. She stated she expected night nurses to lock the cart when unattended. Medication Cart R. On 06/22/25 at 9:38 AM, during an observation,the 100 Unit medication cart was unlocked, opened, and unattended. S. On 06/22/25 at 9:58 AM, during an interview, Registered Nurse (RN #1) stated the 100 hall nurseswereresponsiblefor the medication cart, and it should be locked when not in use. T. On 06/26/25 at 3:06 PM, during an interview, the Director of Nursing (DON) stated the medication cart should always be locked if it was not actively in use by the nurse. The DON stated it was his expectation for staff to lock the medication cart when unattended.

Based on observation, interview, and record review the facility failed to ensure the low temperature dishwasher (low temperature dishwashers utilize chemicals for sanitation) worked properly to sanitize the dishes and was repaired timely. If the facility is not properly sanitizing the dishes, then there was the potential for foodborne illnesses which could affect all of the 116 residents listed on the resident census provided by the Administrator on 06/22/25. The findings are: A. Record review of the temperature log for the low-temperature dishwasher showed staff documented 200 parts per million (PPM; a unit used to express the concentration of a substance in a solution) for each meal on 06/23/26. B. On 06/24/25 at 10:27 am, during a kitchen observation, Kitchen Staff #2 checked the low-temp dishwasher's sanitizer level. Kitchen Staff #2 tested the sanitizing solution three times, but the test strips did not show any sanitizer passing through the machine. C. On 06/24/25 at 10:43 am, during an interview, the Kitchen Manager (KM) stated the test strips did not register any sanitizer in the dishwasher, beginning after lunch on 06/23/25. The KM said a call was made to an outside servicing company. The KM stated she instructed kitchen staff to run the dishes through the dishwasher twice until the company technician arrived to fix the problem. She stated Kitchen Staff #1 brought the issue to her attention on the morning of 06/23/25. D. On 06/24/25 at 10:50 am, during an interview, a Corporate Staff Member said staff told him the dishwasher problem started on Sunday. He stated the kitchen staff began washing the dishes twice. He said the staff could use the three-compartment sink (a sink with three sections to wash, rinse, and sanitize) to wash and sanitize dishes. E. On 06/24/25 at approximately 12:15 pm, during an interview, the outside service company technician said the facility called him and left voice messages on 06/21/25 (Saturday) and 06/22/25 (Sunday). He stated he advised the facility to use the three-compartment sink to sanitize the dishes. He stated he did not check his voice messages until Monday morning, but he could not get to the facility on Monday, 06/23/25. The technician stated one of the tubes supplying sanitizer to the dishwasher was broken. He stated the dishes were not sanitized, which was a critical failure. F. On 06/24/25 at 12:32 pm, during an interview, the KM said she instructed kitchen staff to wash the dishes twice. She stated the outside servicing company might have told her about using the three-compartment sink for washing and sanitizing, but she was very busy. G. On 06/26/25 at 8:27 am, during an interview, the Administrator said she expected staff to follow the recommendations of the outside servicing company technician.

PAST NOT COMPLIANCE Based on record review and interview, the facility failed to notify the physician for 1 (R #68) of 3 (R #68, R #7, and R #49) residents, when they failed to immediately notify R #68's physician of the resident's missed seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain) medications. This deficient practice result in the resident's physician being unaware of resident's current condition, resulting in delayed treatment. The findings are: A. Record review of R #68's face sheet showed the resident was admitted into the facility on [DATE] with the following diagnoses: - Traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head), - Seizures (involuntary shaking of the body), - Persistent vegetative state (chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings), - Tracheostomy [a hole surgeons make through the front of the neck and into the windpipe (trachea) so the patient can breath], - G-Tube (a tube inserted through the belly that brings nutrition directly to the stomach), - Dysphagia (difficulty swallowing). - This list of diagnosis is not all inclusive. B. Record review of R #68's physician medication order, dated 12/01/23, showed an order for levetiracetam (anti-seizure medication) oral solution, 100 milligrams per milliliter (mg/ml). Give 10 ml via G-Tube (via stomach tube) two times a day for seizure disorder. C. Record review of R #68's medication administration record (MAR), dated December 2023, showed staff did not administer R #68's levetiracetam evening dose on 12/14/2023 and his morning and evening doses on 12/15/2023. D. Record review of the facility's Notification of Transfer or Discharge form, dated 12/16/23, revealed R #68 was transferred to the hospital for breakthrough seizures and low blood oxygen saturation (low oxygen in the blood stream). E. Record review of R #68's electronic medical record (EMR) and the patient's chart revealed the following: 1. A nursing progress note, dated 12/16/23 at 8:00 am, Notified by housekeeping and certified nursing aide (CNA) that the resident (R #68) isn't doing well. Vitals unstable, O2 (oxygen) saturation below 90 (normal blood oxygen saturation is between 100 and 90 percent), heart rate above 100 bpm (beats per minute) up to 150's (normal heart rate for males is 60 to 100 BPM). Oxygen concentrator applied up to 5 lpm (liters per minute), O2 (oxygen) saturation went up to 90. Seizure then started intermittently. Called POA (power of attorney) and called 911 right away. 2. The records did not contain information to show why staff did not administer the levetiracetam to R #68 on 12/14/23 evening and 12/15/23 morning and evening. 3. The records did not contain documentation to show staff notified R #68's provider about the resident's change in condition or missed medications. F. Record review of R #68's hospital discharge summary, dated 12/28/2023, stated the following about R #68's condition upon admission to the emergency roiagnom on [DATE], Prior to admission, patient had 3 episodes of tonic-clonic seizures (Tonic-clonic seizures involve both tonic (stiffening) and clonic (twitching or jerking) phases of muscle activity) that lasted approximately 1 minute each per wife. Initial seizures were not witnessed, however, patient had a subsequent seizure that lasted for approximately 20 minutes which subsequently resolved after Versed (quick acting antiseizure medication) given via EMS (emergency medical services) .Per patient's wife, she was notified on 12/20/23 that patient missed 3 doses of anti-seizure medications at facility, not just one like previously thought, possibly being the cause of breakthrough seizures. G. Record review of the facility-initiated investigation regarding R #68's missed medication, dated 12/18/2023, staff provided written statements that the levetiracetam was not available in the medication cart, and that is why staff did not administer the medication as ordered. H. On 03/26/24 at 10:36 am, during an interview with the Director of Nursing (DON), he confirmed the following: 1. The levetiracetam was not available in the medication cart in the prescribed liquid form. 2. The levetiracetam was available in the facility's Omnicell (fully automated, digital, medication storage and delivery machine) in tablet form, which could have been crushed and delivered via R #68's G-Tube. 3. The staff did not notify the provider of R #68's missed seizure medications. 4. Staff should have notified the provider about R #68's missed seizure medications. I. Facility initiated investigation and corrective action plan, dated 12/18/2023, revealed the following: - Persons responsible for oversight Center Executive Director (CED) and Director of Nursing (DON). - Plan was specific to: Missed medications/notification of provider. - What was done: 1. DON conducted a 7 day look back audit to determine if any other critical medications were not administered due to not being available and corrected issues as they were found. 2. DON/Designees conducted a whole-house Medication Administration Record (MAR)-to-Cart audit to ensure all ordered medications were present and available in the cart. 3. Social Services Director (SSD) conducted interviews on the 300 hall to determine if any residents had concerns about receiving their medication. 4. Nursing Practice Educator (NPE)/Designee re-educated nurses/Certified Nursing Aides (CNAs) on the process of ordering medications timely and the escalation process (how to correct) to follow if medications were not available for administration. NPE will review the process with newly hired nurses/CNAs. 5. Nurses were re-educated on the process of ordering medications from the pharmacy timely (at least 5 days prior to running out) to ensure that medications remain available. Nurses were re-educated on the escalation process to follow if medications are not available to include accessing the Omnicell if medication is available within the Omnicell, notifying the medical provider, considering an alternative medication (within the Omnicell) with the medical provider, and calling the pharmacy to communicate urgency and request a STAT (NOW) delivery. 6. DON/designee conducted weekly audits of the process to ensure sustainability of the corrective action plan. This entailed a designated night nurse auditing and re-ordering medications for the cart once a week. Designated nurse submitted a list of re-ordered medications to the DON for auditing purposes. The DON reported progress to the QAPI (Quality Assurance and Performance Improvement) monthly for the next three months. J. Record review and verification of the corrective action was completed onsite. On 12/18/2023 the facility began auditing all residents in the building for any missed medications. Trainings, auditing, and verification started immediately after the facility identified the failed practice on 12/18/23. Trainings and education of staff were documented in the corrective action plan. The seven day look back audit was completed to identify any missed medications facility wide. No other residents were identified with this deficient practice at the time of the survey.

PAST NOT COMPLIANCE Based on record review and interview, the facility failed to keep a resident free from significant medication errors for 1 (R #68) of 3 (R #68, R #79, and R #7) residents randomly sampled, when they failed to administer R #68's levetiracetam (an anti-seizure medication) on the evening of 12/14/2023 and morning and evening of 12/15/2023 as per physician's order. This deficient practice resulted in R #68 having adverse side effects such as breakthrough seizures (occur when a person has a seizure after controlling their condition with medication for at least 12 months.) The findings are: A. Record review of R #68's face sheet showed the resident was admitted into the facility on [DATE] with the following diagnoses: - Traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head), - Seizures (involuntary shaking of the body), - Persistent vegetative state (chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings), - Tracheostomy [a hole surgeons make through the front of the neck and into the windpipe (trachea) so the patient can breath], - G-Tube (a tube inserted through the belly that brings nutrition directly to the stomach), - Dysphagia (difficulty swallowing). - This list of diagnosis is not all inclusive. B. Record review of R #68's physician orders, dated 12/01/23, showed an order for levetiracetam (anti-seizure medication) oral solution, 100 milligrams per milliliter (mg/ml). Give 10 ml via G-Tube (via stomach tube) two times a day for seizure disorder. C. Record review of R #68's medication administration record (MAR), dated December 2023, showed staff did not administer R #68's levetiracetam evening dose on 12/14/2023 and his morning and evening doses on 12/15/2023. D. Record review of R #68's electronic medical record (EMR) and the patient's chart revealed the following: 1. A nursing progress note, dated 12/16/23 at 8:00 am, Notified by housekeeping and certified nursing aide (CNA) that the resident (R #68) isn't doing well. Vitals unstable, O2 (oxygen) saturation below 90 (normal blood oxygen saturation is between 100 and 90 percent), heart rate above 100 bpm (beats per minute) up to 150's (normal heart rate for males is 60 to 100 BPM). Oxygen concentrator applied up to 5 lpm (liters per minute), O2 (oxygen) saturation went up to 90. Seizure then started intermittently. Called POA (power of attorney) and called 911 right away. 2. The records did not contain information to show why staff did not administer the levetiracetam to R #68 on 12/14/23 evening and 12/15/23 morning and evening. E. Record review of R #68's hospital discharge summary, dated 12/28/2023, stated the following about R #68's condition upon admission to the emergency roiagnom on [DATE], Prior to admission, patient had 3 episodes of tonic-clonic seizures (Tonic-clonic seizures involve both tonic (stiffening) and clonic (twitching or jerking) phases of muscle activity) that lasted approximately 1 minute each per wife. Initial seizures were not witnessed, however, patient had a subsequent seizure that lasted for approximately 20 minutes which subsequently resolved after Versed (quick acting antiseizure medication) given via EMS (emergency medical services) .Per patient's wife, she was notified on 12/20/23 that patient missed 3 doses of anti-seizure medications at facility, not just one like previously thought, possibly being the cause of breakthrough seizures. F. Record review of the facility-initiated investigation regarding R #68's missed medication, dated 12/18/2023, staff provided written statements that the levetiracetam was not available in the medication cart, and that is why staff did not administer the medication as ordered. G. On 03/26/24 at 11:38 am during interview with Director of Nursing (DON), he stated staff did not administer R #68's evening dose on 12/14/2023 and his morning and evening doses on 12/15/2023, because the medication was not in the medication cart. The DON also stated the facility conducted a chart review on 12/18/2023 of R #68's change in condition and transfer to the emergency room . He said they noted R #68 appeared to have missed three doses of his levetiracetam (Keppra) medication prior to his seizures, and they initiated an investigation. The DON stated the levetiracetam was available in the facilities omnicell (fully automated, digital, medication storage and delivery machine) in tablet form, which could have been crushed and delivered via R #68's G-Tube. I. Facility initiated investigation and corrective action plan, dated 12/18/2023, revealed the following: - Persons responsible for oversight Center Executive Director (CED) and Director of Nursing (DON). - Plan was specific to: Missed medications/notification of provider. - What was done: 1. DON conducted a 7 day look back audit to determine if any other critical medications were not administered due to not being available and corrected issues as they were found. 2. DON/Designees conducted a whole-house Medication Administration Record (MAR)-to-Cart audit to ensure all ordered medications were present and available in the cart. 3. Social Services Director (SSD) conducted interviews on the 300 hall to determine if any residents had concerns about receiving their medication. 4. Nursing Practice Educator (NPE)/Designee re-educated nurses/Certified Nursing Aides (CNAs) on the process of ordering medications timely and the escalation process (how to correct) to follow if medications were not available for administration. NPE will review the process with newly hired nurses/CNAs. 5. Nurses were re-educated on the process of ordering medications from the pharmacy timely (at least 5 days prior to running out) to ensure that medications remain available. Nurses were re-educated on the escalation process to follow if medications are not available to include accessing the Omnicell if medication is available within the Omnicell, notifying the medical provider, considering an alternative medication (within the Omnicell) with the medical provider, and calling the pharmacy to communicate urgency and request a STAT (NOW) delivery. 6. DON/designee conducted weekly audits of the process to ensure sustainability of the corrective action plan. This entailed a designated night nurse auditing and re-ordering medications for the cart once a week. Designated nurse submitted a list of re-ordered medications to the DON for auditing purposes. The DON reported progress to the QAPI (Quality Assurance and Performance Improvement) monthly for the next three months. J. Record review and verification of the corrective action was completed onsite. On 12/18/2023 the facility began auditing all residents in the building for any missed medications. Trainings, auditing, and verification started immediately after the facility identified the failed practice on 12/18/23. Trainings and education of staff were documented in the corrective action plan. The seven day look back audit was completed to identify any missed medications facility wide. No other residents were identified with this deficient practice at the time of the survey.

Based on observations, record reviews, and interviews, the facility failed to ensure that six of six residents (Resident (R)23, R83, R50 , R65, R79 and R90 ) reviewed for tracheostomy (trach) care out of a total sample of 33 residents had the necessary supplies at the bedside in the event of a life-threatening emergency, and failed to train staff on appropriate emergency tracheostomy care in the event that a resident's airway was compromised, which placed residents with a tracheostomy at increased likelihood of serious harm or death. On 12/13/22 at 2:32 PM, the Administrator, the Regional Nurse, and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) at F695-K: Respiratory/Tracheostomy Care and Suctioning. The Immediate Jeopardy was identified on 12/12/22 when the survey team identified the concerns related to the facility without emergency tracheostomy supplies and staff training for emergency preparedness for maintaining airways if trachs were dislodged from the airway for R23, R83, R50, R65, R79, and R90. Findings include: A. Review of facility-provided training documents revealed no documents with tracheostomy emergency management training. B. A request was made for a facility policy related to emergency care for tracheostomies and none was provided. C. 1. Review of R23's undated ADMISSION RECORD located in his Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with multiple diagnoses to include acute respiratory failure and tracheostomy. D. Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/22/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not assessed and was severely impaired cognitively, had a tracheostomy and was provided suction, and oxygen. E. Review of R23's physician's Orders under the Orders tab in the EMR for 12/22 revealed . 6 Bivona [brand of tracheostomy] and Ambu bag [bag valve mask (BVM), sometimes referred to as an Ambu bag, is a handheld tool that is used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths] at bedside .at all times . The Order excluded R23's specific type of tracheostomy (cuffed or uncuffed) and no further tracheostomy emergency management kit items. F. Review of R23 's comprehensive Care Plan under the Care Plan tab located in his EMR dated 11/28/22 revealed .Keep ambu bag and extra trach tube and obturator [used to insert a trach tube] in resident's room. There were no emergency management interventions, specifics for tracheostomy (size, type, or style) or emergency tracheostomy supply kit. G. During an observation on 12/12/22 at 9:32 AM R23's stoma site was covered with a split gauze dressing. R23 had oxygen administered via trach mask. R23 had an ambu bag on the shelf on the left side of his bed. R23 had an unpackaged unsterile obturator in a clear Ziploc bag above the head of his bed pinned to the wall. R23 did not have an emergency tracheostomy kit at his bedside. R23 had two boxes on the shelf beside his bed that included a Bivona Silicone Tracheostomy tube 6 mm (millimeter) cuff and a 7 Shiley Adult Flexible Tracheostomy tube cuffless disposable inner cannula 7 mm. H. During an observation and interview on 12/12/22 at 1:49 PM the Registered Nurse Agency (RNA) 1 verified R23 had a number six Biovono tracheostomy uncuffed in his stoma. RNA1 confirmed R23 did not have an emergency tracheostomy kit at his bedside, a replacement same size tracheostomy or a smaller tracheostomy, lubricant, or hemostats. RNA1 confirmed the nursing staff provided residents with trach suctioning as needed. RNA1 confirmed R23 had an opened (unclean/non-sterile) number six Biovono in his bedside table. RNA1 stated she thought Certified Nursing Assistants (CNAs), respiratory and nursing staff were able to replace a resident's decannulation tracheostomy, because it would be considered an emergency if resident's trach was decannulated or dislodged. RNA1 confirmed she had replaced a resident's tracheostomy about three months ago at the facility for a resident. RNA1 confirmed the facility had not provided her with emergency trach management competency in the past year, or hands-on competency for re-insertion of tracheostomies. RNA1 confirmed the facility expected her to replace a resident's decannulated or dislodged tracheostomy. I. During an observation and interview on 12/12/22 at 2:37 PM the Respiratory Therapy Director (RTD) confirmed R23 had a number six Biovona tracheostomy in his stoma. The RTD confirmed R23 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant, a size smaller tracheostomy, or hemostats at his bedside and should have. The RTD confirmed R23 had an unopened Shiley #7 cuffless in his bedside table. RTD confirmed R23 did not have a number six Biovona tracheostomy or a smaller size at his bedside and should. The RTD confirmed he had not provided the facility nursing staff with emergency trach management or replacing decannulated or dislodged tracheostomy competencies. He stated he thought nursing staff could replace a decannulated or dislodged tracheostomy. The RTD confirmed respiratory therapy department staff was not at the facility for 24 hours a day. RTD stated the facility stored unclean obturators over the resident's bed for easy access, in the event of a resident's trach decannulation/dislodgement. The RTD stated he would not use the unclean un-sterile obturator (stored in a Ziploc bag) above the resident's bed to reinsert a resident's tracheostomy and would use a new sterile tracheostomy. J. During an interview on 12/12/22 at 3:58 PM the DON confirmed she had not provided any staff with emergency tracheostomy management training recently. The DON confirmed she was unsure which nursing staff (Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) were able to perform reinsertion of dislodgement of tracheostomy. K. During an interview on 12/13/22 at 10:40 AM with CNA5 confirmed the facility had not provided her with tracheostomy emergency management training. CNA5 confirmed she was responsible for providing care for residents with tracheostomy. L. During an interview on 12/13/22 at 11:53 AM the Housekeeper (HK)1 confirmed the facility had not provided her with tracheostomy emergency management training. HK confirmed she was responsible for providing cleaning services to the resident's rooms with tracheostomies M. Review of R83's undated ADMISSION RECORD located in his EMR revealed he was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy status and acute respiratory failure. N. Review of R83's quarterly MDS with an ARD of 10/31/22 and located in the EMR under the MDS tab, revealed a BIMS without a score and was not assessed. He had a diagnosis of traumatic brain injury. He was provided oxygen, suctioning and tracheostomy care. O. Review of R83's physician's Orders under Orders tab for 12/22 located in his EMR revealed .Bivona and Amub [ambu] bag at bedside .at all times . 08/15/22 and did not include the specific size or type (cuffed or uncuffed) and other tracheostomy emergency management kit items. P. Review of R83 's comprehensive Care Plan under the Care Plan tab located in his EMR revealed .Keep ambu bag and extra trach tube and obturator in resident's room [ROOM NUMBER]/28/21. There were no emergency management interventions, specifics for tracheostomy (size, type, or style) or emergency tracheostomy supply kit. Q. During an observation on 12/12/22 at 9:52 AM R83 had an obturator in a clear Ziploc bag on the board over the head of his bed, unpackaged (not sterile). R83 did not have an emergency tracheostomy kit, and no trach supplies at his bedside visible. R. During an observation and interview on 12/12/22 at 2:00 PM RNA1 verified R83 had a number six Biovono tracheostomy uncuffed in his stoma. RNA1 confirmed R 83 did not have an emergency tracheostomy kit at his bedside. S. During an observation and interview on 12/12/22 at 3:05 PM the RTD confirmed R83 had a number six Biovona uncuffed tracheostomy in his stoma. The RTD confirmed R83 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant, a size smaller tracheostomy, or hemostats at his bedside and should have. The RTD confirmed R83 had an unclean/unsterile obturator in a clear Ziploc bag hanging on the wall over the head of his bed. T. During an interview on 12/13/22 at 11:06 AM Respiratory Therapist (RT)1 confirmed R83's trach had decannulated many times at the facility. RT1 stated she thought he was pulling it out his trach. RT1 confirmed R83 was sent out of the facility to have his trach replaced. RT1 confirmed she was providing care for all the facility's residents with tracheostomies. RT1 confirmed the facility had not provided her with tracheostomy emergency management training/competency or return demonstration of re-insertions of tracheostomies annually. RT1 confirmed the respiratory staff placed residents used/unsterile obturator, over the resident's bed for emergency re-use, during an accidental decannulation or dislodgement of resident's trach. RT1 confirmed all decannulation or dislodgement of a resident's trach was considered an emergency. RT1 stated she expected the facility to provide all the staff with emergency trach training including the CNA staff, OT (Occupational Therapy), PT (Physical Therapy), housekeeping staff and nursing. RT1 stated her expectation for the nursing staff if a resident's trach became dislodged was resources/supplies were readily available including the emergency trach kit to replace the trach or send the resident out. U. Review of R50's undated ADMISSION RECORD located in the EMR revealed he was admitted to the facility on [DATE] with multiple diagnoses to include acute and chronic respiratory failure and traumatic brain injury. V. Review of R50 's quarterly MDS with an ARD of 09/29/22 and located in the EMR under the MDS tab, revealed a BIMS was not assessed, he was severely cognitively impaired, had a tracheostomy, and was provided oxygen and suctioning. W. Review of R50's physician's Orders under Orders tab, for 12/22 located in the EMR revealed . 7 Bivona and Ambu bag at bedside .at all times . 02/22/22. The orders did not include the specific type (cuffed or uncuffed) and other tracheostomy emergency management kit items. X. Review of R50 's comprehensive Care Plan under the Care Plan tab located in the EMR revealed .Keep ambu bag and extra trach tube and obturator in resident's room [ROOM NUMBER]/23/22. There were no emergency management interventions, specifics for tracheostomy (size, type, or style) or emergency tracheostomy supply kit. Y. During an observation on 12/12/22 at 12:10 PM revealed R50 had a split dressing under his trach site, and it was clean and dry with a soft trach collar around his neck. R50 did not have a visible emergency tracheostomy kit at his bedside. R50 had an unpackaged unsterile obturator in a clear Ziploc bag and hanging on the wall over his headboard. Z. During an observation and interview on 12/12/22 at 1:53 PM RNA1 verified R50 had a number six Biovono tracheostomy cuffed in his stoma. RNA1 confirmed R50 did not have an emergency tracheostomy kit at his bedside, a smaller tracheostomy, lubricant, or hemostats. AA. During an observation/interview on 12/12/22 at 2:56 PM with the RTD confirmed R50 had a number six Biovona cuffed tracheostomy in his stoma. RTD confirmed R 50 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant a size smaller tracheostomy, or hemostats at his bedside and should have. He further confirmed the resident had an unclean/unsterile obturator in a clear Ziploc bag, hanging on the wall, over the head of his bed. BB. Review of R65's undated ADMISSION RECORD located in his EMR revealed he was admitted to the facility on [DATE] with multiple diagnoses to include tracheostomy status, acute respiratory failure, and chronic respiratory failure. CC. Review of R65's admission MDS with an ARD of 10/10/22 and located in the EMR under the MDS tab, revealed a BIMS without a score and was not assessed, he was provided oxygen, suctioning and tracheostomy care. DD. Review of R65's physician's Orders under the Orders tab for 12/22 located in the EMR revealed no order for trach brand, type, size, cuff less/cuffed or emergency management tracheostomy supplies. EE. Review of R65's comprehensive Care Plan under the Care Plan tab located in the EMR revealed . Keep ambu bag and extra trach tube and obturator in resident room . There was no information for trach brand, type, size, and cuff less or uncuffed or intervention for emergency management tracheostomy or additional specific tracheostomy emergency management supplies. FF. Review of R65's Progress Notes under the Notes tab located in the EMR revealed on 11/26/2022 at 1:48 AM .Resident accidentally pulled out his trach while checking the tightness of his trach tie. Reinserted trach . GG. During an observation and interview on 12/12/22 at 2:04 PM with RNA1 verified R 65 had a number six Biovono tracheostomy uncuffed in his stoma. RNA1 confirmed R65 did not have an emergency tracheostomy kit at his bedside, a smaller tracheostomy, lubricant, or hemostats. HH. During an observation and interview on 12/12/22 at 2:50 PM the RTD confirmed R65 had a number six Biovona cuffless tracheostomy in his stoma. RTD confirmed R65 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant a size smaller tracheostomy, or hemostats at his bedside and should have. The RTD confirmed R65 did not have a #6 Biovona cuffless or smaller size at his bedside. RTD further confirmed R65 had an unclean/unsterile used obturator in a zip lock bag, hanging over the head of his bed. II. During an interview on 12/13/22 at 10:23 AM R65 stated his tracheostomy came partially out in November and a nurse (unsure) name replaced his trach without difficulty. R65 stated he was unsure what equipment the nurse used for the tracheostomy to advance back into his stoma. R65 stated it was hard to breathe and difficult to speak. R65 stated the nurse basically realigned the tracheostomy and pushed it back in. JJ. During an interview on 12/13/22 at 10:37 AM Certified Occupational Therapy Assistant (COTA) confirmed she was providing care for R65. She confirmed the facility did not provide her with hands on or in-serve for trachs or emergency management in the past year. KK. Review of R79's undated Admission Record, located in the EMR under the Profile tab, revealed R79 was admitted to the facility on [DATE] with multiple diagnoses to include acute Respiratory Failure with hypoxia and tracheostomy status. LL. Review of R79's admission MDS with an ARD of 06/15/22 and located EMR under the MDS tab, revealed a BIMS score of 14 out of 15 indicating R79 was cognitively intact. MM. Review of R79's comprehensive Care Plan, dated 11/28/22 under the Care Plan tab located in the EMR revealed, .R79 is at risk respiratory complications r/t [related to] respiratory failure, tracheostomy . R79 will have no complications developed by tracheostomy for 90 days .R79 will have no signs or symptoms of respiratory distress for 90 days. Further review of the care plan revealed no information for suctioning, for emergency management of tracheostomy, no style, size, or cuff or uncuffed tracheostomy information, and no intervention related to tracheostomy care including suctioning, cleaning, or ensuring, oxygenation. NN. Review of R79's Physician's Orders, under the Orders tab located in the EMR revealed the following: .Trach size 6, Bivona, cuffed undated; No directions specified for order. .change trach tube Bivona every three months and as needed (PRN) dated 07/11/22. .trach suctioning as needed pre/post treatment: Evaluate heart rate, respiratory rate, pulse oximetry and breath sounds dated 06/08/22. .Tracheostomy care every day and evening shift and as needed dated 06/08/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. OO. Further review of the physician Orders revealed no order for an emergency tracheostomy kit at the bedside. PP. Review of R79's Treatment Administration Record (TAR), located in the EMR and dated for 11/01/22-11/30/22, revealed: .change trach tube Bivona every 3 months and as needed (PRN) dated 7/11/22, with no staff's initials documented indicating the procedure was completed from 11/01/22 through 11/30/22. .trach suctioning as needed pre/post treatment: Evaluate heart rate, respiratory rate, pulse oximetry and breath sounds dated 06/08/22, Review of this TAR revealed staff initials documented for 11/01-11/02; 11/08-11/09; 11/13; 11/18; 11/21-11/22; 11/26-11/27; indicating care was provided on these dates by nursing. QQ. During an observation on 12/12/22 2:59 PM, R79 was observed in his room sitting upright in bed awake and alert. R79 did not have emergency tracheostomy equipment (sterile gloves, lubricant, a size smaller tracheostomy, or hemostats) readily assessable by the bedside. RR. During an observation/interview on 12/12/22 at 2:59 PM with Respiratory Therapist Director (RTD) who confirmed R79 had a number six Biovona cuffed tracheostomy in his stoma . RTD confirmed R79 did not have a tracheostomy emergency kit at his bedside, did not have sterile gloves, lubricant a size smaller tracheostomy, or hemostats at his bedside. RTD confirmed R79 should have a tracheostomy emergency kit at this bedside including a smaller tracheostomy. RTD confirmed R79 had an unclean/unsterile obturator in a clear Ziploc bag hanging on the wall over the head of R79's bed. RTD confirmed R79 had an unopened number six Biovona cuffed in the drawer of his bedside table. SS. Review of R90's undated Admission Record, located in the EMR revealed R90 was admitted to the facility on [DATE] with multiple diagnoses to include acute respiratory failure with hypoxia and tracheostomy status. TT. Review of R90's admission MDS with an ARD of 07/20/22 and located EMR under the MDS tab, revealed a BIMS score of 15 out of 15 indicating R90 was cognitively intact. UU. Review of R90's comprehensive Care Plan, under the Care Plan tab located in the EMR and revised on 08/24/22 revealed . R90 is at risk for respiratory complications related to tracheostomy and need for oxygen therapy .R90 will have no complications developed by tracheostomy for 90 days .R90 will have no signs or symptoms of respiratory distress for 90 days .Suction tracheostomy and airway as needed (PRN) .Tracheostomy care twice per day (BID) and PRN for extra secretions .Tracheostomy tube changed per physician order . VV. Review of R90's Physician's Orders, under the Orders tab located in the EMR revealed the following: . Tracheostomy tube size 7.5, [NAME], cuffless undated; No directions specified for order. . Tracheostomy care every 12 hours as needed (PRN) dated 09/18/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. WW. Review of R90's TAR located in the EMR and dated for 11/01/22-11/30/22, revealed: . Tracheostomy care every 12 hours as needed (PRN) dated 9/18/22 without specific definition of tracheostomy care such as cleaning the skin around the stoma and assessing for complications. .Tracheostomy suctioning as needed pre/post treatment: Evaluate Heart rate, respiratory rate, pulse oximetry and breath sounds dated 7/17/22. XX. Review of his TAR revealed nursing staff initials were only documented for the dates 11/02/22; 11/08/22; 11/27/22; indicating tracheostomy suctioning was provided. Further review of this TAR revealed, staff initials only on the date 11/07/22; indicating tracheostomy care was provided. YY. During an observation on 12/12/22 at 11:04 AM R90 was observed in her room lying in bed sleeping. R90 did not have emergency tracheostomy equipment readily assessable by the bedside. There was no water left in humidifier container while in use. ZZ. During an observation/interview on 12/12/22 at 2:53 PM with the RTD confirmed R90 had a number 7 1/2 Shiley cuffed tracheostomy in her stoma. RTD confirmed R90 did not have a tracheostomy emergency kit at her bedside, did not have sterile gloves, lubricant a size smaller tracheostomy, or hemostats at her bedside. The RTD confirmed R90 should have a tracheostomy emergency kit at her bedside including a smaller tracheostomy. The RTD confirmed R90 had an unclean/unsterile obturator in a clear Ziploc bag hanging on the wall over the head of R90's bed. The RTD confirmed R90 had an unopened number 7 1/2 Shiley cuffed trach in the drawer of her bedside table. The RTD confirmed R90 oxygen trach mask was laying on her bedside table, (with no date of change) and not stored in a bag. AAA. During an interview on 12/12/22 at 3:09 PM the RTD confirmed he had not provided the facility clinical staff with emergency tracheostomy management or information regarding dislodgement of tracheostomy. BBB. During an interview on 12/12/22 at 3:58 PM the DON said she had not provided any staff with emergency tracheostomy management training recently. CCC. During an interview on 12/12/22 at 6:27 PM the RTD stated the facility previously had more respiratory (RT) staff available and the facility had 24 hours a day RT coverage, but recently they lost some of the RT staff that worked the night shift. The RTD confirmed the facility did not have sterile hemostats to use to hold stoma open in the event of dislodgement of a resident's tracheostomy. The facility provided an acceptable removal plan on 12/14/22 at 2:58 PM. The removal plan included physician order revisions, placing emergency tracheostomy supplies at the bedside in the resident's room, in-servicing nursing staff on required tracheostomy emergency supplies, competency of re-insertion of a tracheostomy and educating ancillary staff, care plan revisions, policy development of emergency management of trachs. Following interviews with facility staff, observation of tracheostomy supplies, clinical record review of revised care plans, physician orders, and review of staff in-services/competency for emergent trach care and re-insertion, the survey team verified implementation of the Removal Plan and removed the IJ on 12/15/22 at 12:03 PM. The Administrator, the Regional Nurse, and Director of Nursing (DON) were notified that the IJ was removed. During the exit conference the Administrator, the DON and the Regional Nurse were notified that the IJ was removed but the deficient practice existed at F695-E (pattern potential for more than minimal harm). Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) Respiratory/Tracheostomy Care and Suctioning (F695 S/S: K). . 40417

Based on observations, record review, and staff interviews, the facility failed to ensure staff followed adequate infection control measures to prevent the spread of COVID-19 among 36 of 113 facility residents. A COVID-19 outbreak began on 11/22/22 with 36 cases of facility-acquired infections from 11/22/22 to 12/12/22. All 36 residents (Resident (R) 79, R26, R31, R43, R61, R1, R64, R34, R49, R3, R6, R80, R9, R47, R19, R16, R32, R18, R2, R14, R73, R5, R106, R29, R111, R11, R25, R88, R74, R63, R13, R366, R109, R78, R108, and R107) had co-morbid diagnoses (the presence of more than one disorder in the same person), which placed them at risk of severe illness or death, 15 of the 36 residents experienced adverse COVID-19 symptoms (difficulty breathing and/or chest pain pressure) (R26, R31, R61, R1, R64, R34, R3, R18, R14, R74, R63, R366, R78, R108, and R107), and three (R1, R49, and R366) of the 36 residents were hospitalized due to COVID-19 complications. Findings include: A. Spread of COVID-19 Infection in the Facility; per the Centers for Disease Control and Prevention (CDC) COVID Data Tracker website, accessed on 12/12/22 at https://covid.cdc.gov/covid-data-tracker, the facility's community transmission rate of COVID-19 was high. B. Upon entrance to the facility on [DATE] at 8:45 AM, the Administrator stated a number of residents currently had COVID-19. A list of residents with COVID-19 was requested from the facility but was not provided. At 9:30 AM, a list of residents with COVID-19 residing on the 200 hall was requested, and at 10:00 AM the Infection Preventionist (IP) provided a list of 16 residents highlighted as having COVID-19. Review of signage on the doors in the 200 hall and verbal confirmation by Licensed Practical Nurse (LPN) 3 at 10:30 AM revealed only 13 residents in the 200 Hall currently had COVID-19. C. Review of the undated facility line listing of residents with COVID-19, provided on paper by the Infection Preventionist (IP) on 12/12/22 at approximately 4:30 PM, revealed there were 22 total residents who currently had COVID-19 in the building. Of these, three residents were living on the 100 hall, 13 residents were living on the 200 hall, five residents were living on the 300 hall, and one resident was living on the 400 hall. Observations throughout the facility on 12/12/22 beginning at 8:45 AM revealed there was no designated space to house the residents with COVID-19 or suspected exposure, and staff were caring for residents with COVID-19 and residents without. D. Further review of the facility's line listing revealed 47 residents had tested positive for COVID-19 from 11/22/22 to 12/10/22. Of those residents, 36 contracted COVID-19 while residing in the facility for over five days. Three of the 36 residents were not vaccinated for COVID-19 (R74, R63, and R366), and three of the 36 residents were hospitalized related to COVID-19 complications. Fifteen of the 36 residents experienced symptoms of COVID-19: E. Review of R79's undated home screen of the Electronic Medical Record (EMR) revealed R79 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R79 had a tracheostomy and diagnoses of acute respiratory failure and degenerative disease of the nervous system. F. Review of R26's undated home screen of the EMR revealed R26 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R26 had diagnoses of Parkinson's disease, heart disease, weakness, and malnutrition. Per the line listing, R26 experienced chest congestion and sore throat. G. Review of R31's undated home screen of the EMR revealed R31 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R31 had diagnoses of chronic obstructive pulmonary disease, pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), congestive heart failure, anxiety, and weakness. Per the line listing, R31 experienced chest congestion and sore throat. H. Review of R43's undated home screen of the EMR revealed R43 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R43 had diagnoses of stroke with right-sided paralysis, malnutrition, muscle weakness, anxiety, and depression. I. Review of R61's undated home screen of the EMR revealed R61 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/09/22. Per the undated Medical Diagnosis tab of the EMR, R61 had diagnoses of morbid obesity, diabetes, asthma, sleep apnea, and pulmonary hypertension. Per the line listing, R61 experienced coughing. J. Review of R1's undated home screen of the EMR revealed R1 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/08/22. Per the undated Medical Diagnosis tab of the EMR, R1 had diagnoses of sepsis, osteomyelitis, pressure ulcers, diabetes, depression, bipolar disorder, and anxiety. Per the line listing, R1 experienced chest congestion and new or worsening confusion. Review of R1's 12/08/22 change of condition Provider Summary, located in the Notes tab of the EMR, revealed, Resident c/o [complained of] 'not feeling well. Has been shouting and demanding immediate attention. Resident has been crying, stating 'I'm losing my mind.' Refuses to remain in room even after repeated explanation of necessity to quarantine in room. Review of R1's 12/09/22 General Note, located in the Notes tab of the EMR, documented, Head to toe assessment done. Staff noted a small bump on head-right side. Resident denies pain. Neurological checks initiated. Resident assisted to bed. Resident noted to be confused and lethargic. Per MD [physician] on call . resident was transferred to ER [emergency room ] for further evaluation. K. Review of R64's undated home screen of the EMR revealed R64 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/08/22. Per the undated Medical Diagnosis tab of the EMR, R64 had diagnoses of pulmonary embolism, acute respiratory failure, diabetes, arthritis, and atrial fibrillation. Per the line listing, R64 experienced coughing, headache, and nasal congestion. L. Review of R34's undated home screen of the EMR revealed R34 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/08/22. Per the undated Medical Diagnosis tab of the EMR, R34 had diagnoses of chronic obstructive pulmonary disease, respiratory failure, congestive heart failure, cirrhosis of the liver, diabetes, weakness, and anxiety. Per the line listing, R34 experienced chest congestion and sore throat. M. Review of R49's undated home screen of the EMR revealed R49 was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/06/22. Per the undated Medical Diagnosis tab of the EMR, R49 had diagnoses of sepsis, osteomyelitis, pressure ulcers, diabetes, depression, bipolar disorder, and anxiety. Review of R49's 12/08/22 Summary for Providers, located in the Notes tab of the EMR, revealed, The resident has fluctuating oxygen saturation. Monitored closely and changed the oxygen support from nasal cannula to simple face mask and regulated to 6 LPM [liters per minute]. Observed that the resident is still tachypneic [breathing rapidly] and using accessory muscle to breathe. He also has a productive cough and crackles breathe sounds upon auscultation. Placed the patient in a high Fowler's position . Recommendations: Send to the hospital for higher care and further evaluation and management. N. Review of R3's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/06/22. Per the undated Medical Diagnosis tab of the EMR, R3 had diagnoses of chronic obstructive pulmonary disease, obesity, atrial fibrillation, obstructive sleep apnea, heart failure, pulmonary fibrosis, vascular dementia, respiratory failure, and stage II pressure ulcers. Per the line listing, R3 experienced fever, chest congestion, sore throat, and vomiting. O. Review of R6's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R6 had diagnoses of dementia, chronic obstructive pulmonary disease, diabetes, depression, anxiety, and hypothyroidism. P. Review of R80's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R80 had diagnoses of coccidioidomycosis meningitis (valley fever fungus in the brain), weakness, and hyperlipidemia. Q. Review of R9's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R9 had diagnoses of cerebrovascular disease, heart failure, depression, schizophrenia, epilepsy, hypothyroidism, hyperlipidemia, and gastro-esophageal reflux disease. R. Review of R47's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R47 had diagnoses of epilepsy, traumatic brain injury, end stage renal disease, weakness, and anemia. S. Review of R19's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R19 had diagnoses of diabetes, anemia, migraine, cerebral infarction (blockage), depression, hypertension, and gastro-esophageal reflux disease. T. Review of R16's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R16 had diagnoses of dementia, arthritis, glaucoma, hypothyroidism, hypertension, osteoporosis, and macular degeneration. U. Review of R32's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R32 had diagnoses of cerebral infarction, chronic kidney disease, chronic respiratory failure, hyperlipidemia, depression, epilepsy, hypertension, and muscle weakness. V. Review of R18's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/05/22. Per the undated Medical Diagnosis tab of the EMR, R18 had diagnoses of heart disease, hyperlipidemia, depression, spinal fusion, anxiety, arthritis, chronic pain, edema, hypertension, and gastro-esophageal reflux disease. Per the line listing, R18 experienced coughing, sore throat, and headache. -Review of R2's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R2 had diagnoses of cerebral infarction, schizoaffective disorder, chronic obstructive pulmonary disease, depression, Alzheimer's disease, morbid obesity, and hypertension. W. Review of R14's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/03/22. Per the undated Medical Diagnosis tab of the EMR, R14 had diagnoses of osteomyelitis, diabetes, obesity, hypothyroidism, psychotic disorder, hyperlipidemia, hypertension, Down syndrome, depression, insomnia, cerebral infarction, and heart disease. Per the line listing, R14 experienced coughing, chest congestion, and sore throat. X. Review of R73's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/03/22. Per the undated Medical Diagnosis tab of the EMR, R73 had diagnoses of cerebral infarction, viral hepatitis B, hypertension, hydrocephalus, and depression. Y. Review of R5's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/03/22. Per the undated Medical Diagnosis tab of the EMR, R5 had diagnoses of congestive heart failure, muscle weakness, anxiety, diabetes, chronic respiratory failure, schizophrenia, epilepsy, hypothyroidism, and bipolar disorder. Z. Review of R106's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R106 had diagnoses of cerebral infarction, congestive heart failure, muscle weakness, insomnia, diabetes, and hyperlipidemia. AA. Review of R29's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R29 had diagnoses of cerebral infarction, ulcerative colitis, and terminal dementia. BB. Review of R111's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R111 had diagnoses of spinal stenosis, hypertension, diabetes, muscle weakness, obesity, cerebral infarction, and dementia. CC. Review of R11's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R11 had diagnoses of respiratory failure, sepsis, hyperlipidemia, chronic obstructive pulmonary disease, emphysema, chronic kidney disease, osteoporosis, hypertension, prostate cancer, malnutrition, and muscle weakness. DD. Review of R25's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R25 had diagnoses of lumbar fracture, muscle weakness, dementia, epilepsy, osteoporosis, and acute kidney failure. EE. Review of R88's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 12/02/22. Per the undated Medical Diagnosis tab of the EMR, R88 had diagnoses of cerebral infarction, cellulitis, weakness, chronic wound, and hypertension. FF. Review of R74's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/30/22. Per the undated Medical Diagnosis tab of the EMR, R74 had diagnoses of peripheral vascular disease, arthritis, hypertension, gout, muscle wasting, and urinary incontinence. Review of the facility's undated resident COVID-19 vaccination records, provided on paper by the IP on 12/12/22, revealed R74 had not been vaccinated for COVID-19. Per the line listing, R74 experienced coughing, runny nose, and sore throat. GG. Review of R63's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/28/22. Per the undated Medical Diagnosis tab of the EMR, R63 had diagnoses of diabetes, hypothyroidism, hyperlipidemia, atrial fibrillation, heart disease, gastro-esophageal reflux disease, arthritis, foot wounds, hypertension, peripheral vascular disease, and stroke. Review of the facility's undated resident COVID-19 vaccination records revealed R63 had not been vaccinated for COVID-19. Per the line listing, R63 experienced coughing. HH. Review of R13's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/28/22. Per the undated Medical Diagnosis tab of the EMR, R13 had diagnoses of anemia, esophageal ulcer, hernia, cirrhosis, diverticulosis, muscle wasting, chronic respiratory failure, morbid obesity, and atrial fibrillation. II. Review of R366's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/25/22. Per the undated Medical Diagnosis tab of the EMR, R366 had diagnoses of acute respiratory failure, seizures, anemia, traumatic brain injury, tracheostomy, and gastrostomy. Review of the facility's undated resident COVID-19 vaccination records revealed R366 had not been vaccinated for COVID-19. Per the line listing, R366 experienced fever and elevated heart rate. Review of R366's 11/25/22 General Note, located in the Notes tab of the EMR, revealed Patient needed suction [for respiratory secretions] @1830 [at 6:30] pm some blood noted with secretions, on call [physician] notified and order received to send patient out ER [to the emergency room ]. JJ. Review of R109's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/25/22. Per the undated Medical Diagnosis tab of the EMR, R109 had diagnoses of sepsis, dementia, hyperlipidemia, type 1 diabetes, and encephalopathy. KK. Review of R78's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/23/22. Per the undated Medical Diagnosis tab of the EMR, R78 had diagnoses of vertebral fracture, weakness, hypertension, hyperlipidemia, and vascular dementia. Per the line listing, R78 experienced fever. LL. Review of R108's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/22/22. Per the undated Medical Diagnosis tab of the EMR, R108 had diagnoses of encephalopathy, muscle weakness, pneumonia, anxiety, and atrial fibrillation. Per the line listing, R108 experienced coughing. MM. Review of R107's undated home screen of the EMR revealed the resident was admitted to the facility on [DATE] and tested positive for COVID-19 on 11/22/22. Per the undated Medical Diagnosis tab of the EMR, R107 had diagnoses of end stage renal disease, diabetes, spinal stenosis, muscle weakness, depression, and hypertension. Per the line listing, R107 experienced coughing, chest congestion, and a runny nose. NN. Interview with the Medical Director on 12/14/22 at 12:13 PM revealed she was available to consult with issues related to COVID-19 treatment, and she was involved in prescribing the treatments for residents with COVID-19, but she was not involved in management of the recent COVID-19 outbreak or infection control education. OO. In an interview with the IP on 12/15/22 at 10:30 AM, the IP stated the most recent COVID-19 outbreak began on 11/22/22 with a resident on the 100 Hall. The resident was not admitted to the facility with COVID-19 but went out to dialysis several times a week and could have contracted COVID-19 at the dialysis center. Outbreak testing was conducted on the 100 Hall with staff and residents, and one additional positive resident was discovered on 11/23/22 on the 100 Hall. On 11/28/22, one resident tested positive in the 400 Hall and there were four residents who tested positive in the 100 hall. Outbreak testing was conducted with staff and residents in the 100 and 400 halls. The IP stated R63, who resided on the 200 hall, was friends with the residents who had COVID-19 on the 100 hall, was very social, and spent his days visiting with other residents. Additionally, R63 and the residents on the 100 hall ate their meals together in the dining room. The IP stated R63 most likely spread COVID-19 from the 100 hall to the 200 and 300 halls between 11/28/22 and 12/12/22. On 12/13/22, there were four new positive residents on the 100 hall, 13 new positive residents on the 200 hall, five positive residents on the 300 hall, and one new positive resident on the 400 hall. Outbreak testing was conducted for all staff on all halls. PP. Review of the facility's 06/07/21 COVID-19 policy revealed, Follow the process in the COVID-19 Outbreak Management Tiers for patients or employees with confirmed COVID-19 . Perform contact tracing for both suspected and confirmed cases . Centers will have a plan based on CDC/CMS/state/local recommendations to prevent transmission, such as having a dedicated space in the facility for cohorting and managing care for patients with COVID-19. Per the CDC 09/23/22 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#:~:text=in%20the%20facility.-,Duration%20of%20Transmission-Based%20Precautions,-The%20following%20are, Place a patient with suspected or confirmed SARS-CoV-2 [COVID-19] infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room . Facilities could consider designating entire units within the facility, with dedicated HCP [health care professionals], to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts . Limit transport and movement of the patient outside of the room to medically essential purposes . Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel. QQ. Failed Infection Control Practices Observation in the 200 hall on 12/12/22 at from 9:57 AM to 11:20 AM revealed a large red pitcher with a black lid sitting on top of the clean Personal Protective Equipment (PPE) cart that was holding clean gloves and hand sanitizer. The pitcher was visibly soiled with liquid stains on the lid. At 11:20 AM, Certified Nurse Aide (CNA) 1 picked up the pitcher, refilled it, and delivered it to R18, who was COVID-19 positive. CNA1 did not sanitize the PPE cart where the pitcher had been. RR. Observation in the 200 hall on 12/12/22 at 11:01 AM revealed five bins marked clean gowns that were set at intervals in the hallway. A bin outside of room [ROOM NUMBER] contained two loose disposable gloves mixed in with the clean gowns. A bin outside of room [ROOM NUMBER] to the right had a loose disposable glove mixed in with the clean gowns. A second bin near room [ROOM NUMBER] contained three loose disposable gloves mixed in with the clean gowns. SS. Observation in the 200 hall on 12/12/22 at 11:19 AM revealed R74 walking out of her room, which had a transmission-based precautions sign on the door and a COVID-19 positive roommate. The resident had a cloth mask tied around her neck, but it was dangling from her neck and not covering her nose or mouth. From 11:19 AM to 12:45 PM, R74 continued to ambulate up and down the hallway without any encouragement from staff to put on her mask. Review of R74's 07/09/22 Care Plan, located in the Care Plan tab of the EMR, revealed R74 had impaired cognition and impaired safety awareness. The Care Plan did not address any refusals or inability to wear a mask. TT. Observation on 12/12/22 at 11:25 AM revealed Certified Nursing Assistant (CNA)1 went into R18's room which was a COVID positive room. The CNA wore goggles and a mask, however, did not have a gown on. UU. Continued observation on 12/12/22 at 11:34 AM revealed CNA1 went into room [ROOM NUMBER] without wearing a gown. She was observed to lower her mask and kiss and hug the resident in the room. CNA6 came into room wearing full PPE. CNA1 then stated she didn't know the resident in room [ROOM NUMBER] was on quarantine and then stated, The door was open, so I did not see the sign on the door .actually it is his fault (points to CNA6) because he did not close the door and I did not see it. There was a second sign noted outside the door by the resident names to the left of the door documenting covid precautions. VV. Observation in the 400 hall on 12/12/22 at 11:53 PM revealed CNA5 entered R79's room, who had COVID-19, wearing a gown, gloves and an N-95 mask. The CNA did not have on eye protection, though a pair of goggles were resting on top of the CNA's head. WW. Observation in the 200 hall on 12/12/22 at 1:00 PM revealed an empty clean gown bin with two loose disposable gloves on the bottom. At 1:03 PM, the IP was observed to bring a bag of clean gowns to the hall and put the clean gowns in the bin on top of the gloves. XX. Observation in the 200 hall on 12/12/22 at 1:11 PM revealed Nurse Aide (NA) 1 was preparing to deliver a meal tray to R19, who was COVID-19 positive. Though NA1 was wearing an N-95 mask and eye protection, she did not don a gown and gloves, and was told to enter the room without her PPE on by CNA6. Upon exiting the room, NA1 did not wash or sanitize her hands, then went directly to the meal cart and handled another room tray. In an interview on 12/12/22 at 1:17 PM, NA1 stated she did not typically work on the 200 hall and had not been told which residents on the hall were on transmission-based precautions for COVID-19 or given directions on donning the appropriate PPE. The NA stated gown and gloves should be worn in rooms on transmission-based precautions, but she did not know where the clean gowns were kept. YY. During an interview on 12/12/22 at 7:30 PM with the Administrator and DON, the staff were alerted to the above observations. The DON stated staff were expected to wear all PPE when caring for a resident with COVID-19, including gown and gloves in addition to the N-95 mask and eye protection. The Administrator stated these observations were concerning, and she needed to follow up with some of the staff related to potential COVID-19 exposures. ZZ. Observation in the 200 hall on 12/13/22 at 12:09 PM revealed a bin without a lid with clean gowns inside. The bin also contained two loose disposable gloves and a crumpled-up plastic bag. LPN3 stated the bin was supposed to contain only clean gowns, but staff may have mistaken the bin for a trash can as it did not have a lid. LPN3 removed the bin from the hallway. AAA. Observation in the 200 hall on 12/13/22 at 12:11 PM revealed a second bin, with the lid closed and labeled, Clean Gowns, with a loose disposable glove and a resident's sock inside. LPN3 stated it looked to her as if the glove and sock came with the gowns from the laundry, but she could not be sure that the glove and sock were clean. LPN3 removed the bin from the hallway. BBB. Observation in the 200 hall on 12/13/22 at 12:48 PM revealed the Recreation Assistant (RA) had donned an N-95 mask, gown, eye protection, and gloves to visit with R1, who was positive for COVID-19. The RA doffed her gown and gloves before exiting the room, then exited into the hallway without performing hand hygiene. She then walked off the 200 hall to the facility's common area, where she adjusted another resident's mask, touching the resident's mask and face without first sanitizing her hands. In an interview with the RA on 12/13/22 at 12:57 PM, she verified she did not wash or sanitize her hands when leaving R1's room or before touching another resident in the common area. The RA stated she had not been instructed in the proper procedure for donning and doffing PPE and performing hand hygiene. CCC. Observation on the 200 hall on 12/14/22 at 12:26 PM revealed a closed bin labeled Clean Gowns outside of room [ROOM NUMBER]. There were three loose disposable gloves lying on top of the gowns. Interview with CNA9 at 12:30 PM revealed she thought that the gloves had been through the laundry with the gowns and that most likely, the gloves were clean. When asked if she would continue to use gowns from the bin, she stated, Yes, the bin says the gowns are clean. The CNA did not remove the bin from the floor. DDD. In an interview on 12/15/22 at 10:30 AM, the IP stated the staff on the 100 hall were used to having COVID-19 positive residents and using PPE because it was the post-acute unit. He stated the staff in the 200 hall were not used to using PPE and dealing with COVID-19, so they had a harder time dealing with the influx of COVID-19 positive residents. The IP stated he had not provided any additional education on COVID-19 or PPE use to the staff in the 200 hall, as he had focused all of his training efforts in the 100 hall. The IP stated all staff received training through a monthly All Staff Meeting. The IP stated staff that did not attend the monthly meetings received the information via email to read independently. He said there was a way to track whether or not the staff had viewed the training materials, but he had not been tracking whether or not all staff reviewed the training materials. The IP provided training materials, which included training on use of Contact plus airborne precautions for care of residents with COVID-19, which included hand hygiene, an N-95 mask, gown, eye protection, and gloves. The material also documented, Patient must wear a face mask when out of room and maintain social distancing . Please do not remove dedicated or single use disposable equipment from this room . when dedicated equipment is not possible, disinfect shared equipment. EEE. Review of the facility's 10/18/22 and 10/20/22 In-Service Sign-In Sheets, provided on paper by the IP, revealed education was provided on COVID-19 and isolation. The staff in attendance included LPN3. There was no evidence that CNA6, NA1, CNA9 or the RA had received the training. FFF. Review of the facility's 09/06/22 In-Service Sign-In Sheet documented education was provided on COVID-19. The staff in attendance included LPN3 and CNA6. There was no evidence CNA9, NA1, or the RA had received the training. GGG. Review of the facility's 06/07/21 COVID-19 policy revealed, In addition to Standard Precautions, Contact and Airborne Precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance. For the purpose of this policy, Airborne Precautions is defined as wearing an N95/approved KN95 respirator upon entry to the patient's room, in addition to the recommended Personal Protective Equipment (PPE), keeping the door to the patient's room closed and no negative pressure room required . Implement universal use of facemasks/respirators and eye protection while in the Center . Clean and disinfect the environment, especially high touch surfaces, using an EPA approved . hospital grade disinfectant . Patients on Transmission-Based Precautions are restricted to their room except for medically necessary purposes . If a patient has to leave his/her room, he/she must wear a facemask or cloth face covering, perform hand hygiene, limit movement in the Center, and perform social distancing . When possible, all patients, whether they have COVID-19 symptoms or not, should cover their noses and mouths with tissue when staff are in their rooms . Provide COVID-19 education as indicated to employees, patients, and visitors. HHH. Per the CDC 09/23/22 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, Limit transport and movement of the patient outside of the room to medically essential purposes . Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved p

Based on interviews and record reviews, the facility failed to ensure that nursing staff were properly trained and had the appropriate competencies on Tracheotomy (a small surgical opening that is made through the front of the neck into the windpipe allowing air to flow in and out) care/showering for 1 ( R #1) of 3 ( R #1, 2 and 3) residents. This deficient practice resulted in R #1 becoming unresponsive requiring immediate intervention when a plastic trash bag was used to cover R #1's airway during a shower so water would not get into the trach. The findings are: A. Record review of R #1's medical record revealed that resident had a diagnoses of Acute Respiratory Failure with Hypoxia (results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), Tracheostomy, Neuromuscular Dysfunction of Bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination), Degenerative Nervous System Disease (disorder of the central nervous system characterized by gradual and progressive loss of neural tissue and neurologic function), Amyotrophic Lateral Sclerosis ALS is a progressive neurological disorder which results in weakened muscles and deformity), Hypertension (high blood pressure) and Dysphagia (difficulty swallowing). B. Record review of a facility reported incident on [DATE], complaint intake #63126 indicated that on [DATE] R #1 was receiving a shower and a plastic trash bag had been placed over the trach so no water would get into the trach during the shower. This caused the resident to become unconscious due to a lack of air. The following was taken from the the facility report: CNA (Certified Nursing Assistant) reported that (name of R #1) became unresponsive and she immediately called out for help. Respiratory Therapist (RT) responded immediately and noted that (name of R #1) was not breathing. RT provided ventilation via ambu bag (rescue breathing provided through the trach by ambu bag instead of doing CPR). Two additional nurses also responded and assisted with removing (name of R #1) from the shower room to his bed. Nurse noted (name of R #1) was pale with shallow breathing. RT placed resident on oxygen via tracheostomy. (name of R #1) started to respond to verbal stimuli (a lethargic patient often needs a gentle touch or verbal stimulation to initiate a response). Attending Physician was in the Center and also was called to assess (name of R #1). Education provided to CNA to keep the tracheostomy airway free and clear. Education will be provided to all staff to keep the airway free and clear during all care tasks . C. On [DATE] at 2:55 pm, during an interview with CNA #5, she stated that she was washing R #1 and noticed that his eyes started rolling back. She called out for help and a staff member came and brought the Ambu bag and started pumping air through the trach. She stated that she had covered the top part of the trach with plastic and that is how she always did it. They (staff) said that was probably why he lost consciousness. CNA #5 stated that she had not received any special training to work on that unit. CNA #5 said that R #1 wasn't able to assist her with the shower and that he can move his hands a little bit but he isn't strong enough to assist or help. D. Record review of a note dated [DATE] indicated the following: CNA (Certified Nurse Assistant) was giving resident (R #1) shower when resident became unresponsive. CNA called out to RT and nurse for assistance. RT provided resident with breathing via ambu bag (self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). Nurse and staff (CNA) removed the resident from shower room and transferred the resident to bed via shower chair and mechanical lift (are devices designed to help caregivers move a person from a sitting to standing position and from one place to another). Nurse noted resident pale. RT applied oxygen via trach. Resident increased alertness. Resident was evaluated by (name of physician). Resident with no known history of unresponsive episodes. Suctioning of phlegm (is mucus produced by the respiratory system) and secretions provided by RT. Noted o2 (Oxygen) saturation increased from 85% to 90% with o2 and suctioning. CNA reported resident cough up lots of phlegm secretion during shower prior to unresponsive episode . E. On [DATE] at 10:00 am, during interview with CNA #3, she stated she had been working on the 400 unit (primary unit for the Tracheostomy residents). CNA #3 stated that the responsibilities for working the 400 unit are basically the same as working on any unit. She stated that she had not received any training recently and wasn't really trained to work that unit. She stated that when giving a shower to a trach resident you have to be careful because you don't want the trach to get wet or get water in it. She stated that she would cover it. She stated that she had only given bed baths to the trach residents and had not done a shower. She stated that she had not gotten any recent or specific training on how to give a shower to a trach resident. F. On [DATE] at 10:14 am, during an interview with CNA #4, she stated that she had been working on that unit for two or three months. She works on 300 and 400 primarily. She stated that CNA #3 helped her to get familiar on the floor. She stated that with the trach residents you need to have more caution with them. CNA #4 stated that she had only showered R #3, but R #3 is basically independent and she only needs help with washing her hair. CNA #4 stated that R #3 will cover her trach herself during showers. CNA #4 said that if she were going to do it (cover the trach), she would use a towel or a plastic trash bag. She stated that she has learned from the other CNA's and was only told to not get it wet. She stated that she had not received any recent or specific training around showering a resident with a trach. G. On [DATE] at 11:38 am, during an interview with Respiratory Therapist (RT), she stated that she is not aware of any specific training around showers and trach residents. She stated that the main thing to always know is that the trach is unobstructed (not blocked, clear and open). She stated that with R #1 she wasn't working the day the incident happened but what she was told is that plastic was put over the trach so water wouldn't get into it. She stated that R #1 would probably deteriorate (becoming progressively worse) faster than others if he wasn't getting enough air, because he is very weak. A couple of minutes. She stated that the safest thing to do would be to not cover it with anything. She stated that she was not sure how the CNA's are trained when they are hired, or before working on this unit. H. On [DATE] at 12:36 pm, during an interview with Respiratory Therapist Director, he stated that he had no direct training with the CNA's. He had done a few training's with the nurses. He stated that after the incident when R #1 was already back in his room, that is when he saw R #1. When asked if R #1 had passed out or had stopped breathing, he stated that he wasn't sure if R #1 passed out or stopped breathing. He stated his understanding is the RT that was working at the time of the incident grabbed the Amub bag (manual resuscitator force-feeds air or oxygen into the lungs in order to inflate them under pressure) and started to give him air and he (R #1)came back quickly. He stated that he heard that a plastic trashcan bag had been used to cover the trach during the shower. He stated that nothing should be wrapped around the trach. I. On [DATE] at 2:00 pm during an interview with the Nurse Educator, she stated that she had done some training since the incident about how to shower a resident with a trach with the CNA's, but not all of them. She stated that they only focused on the showering part for the training because they wanted to make it simple and to the point, so the message didn't get lost. She stated that they have been tag teaming the training trying to get everyone, but they have focused on the 400 hall. She stated that not everyone has been trained. The Nurse Educator provided a list of all the staff members that had been trained so far. J. Record review of the training sheets provided by the Nurse Educator indicated the following, on [DATE] after the incident and [DATE], 12 staff members were trained on trachs and showering. On [DATE] and [DATE] three more staff members were trained on showering trach residents. K. Record review of the staffing sheets that were provided by the facility revealed the following: 1. the time of interview with both CNA #3 and #4 who were working on the 400 hall on [DATE] (date of their interviews) neither had received the training for showering a resident with a trach. 2. Three other CNA's (#5, #6 and #7) had also worked the 400 hall without training from the date of the first training on [DATE] to [DATE]. L. On [DATE] at 10:45 am, during an interview with Center Nursing Executive (CNE), she stated that the 400 hall staff are being trained. She stated that she and nurse educator are doing the trainings on how to shower a resident who has a trach.The CNE stated that the training started the day of the incident [DATE] and the next day. She stated that they focused on those staff that work 400 hall because not everyone in the facility works on that hall. The CNE did agree that any new staff member (CNA) should be trained before working that hall. She stated that with agency staff they get an onboarding packet. During a follow-up conversation with CNE she stated that for the nurses there is a training in vital learn that covers suctioning, breathing treatments, and changing the stoma cloth, but there was nothing for the CNA's. The CNE stated that she checked if the agency onboarding packet contained the training sheet on showering a resident with a trach and she stated no, it wasn't put in there, but she will make sure that it is now. She stated that the training sheet is in the new hire packet. M. On [DATE] at 2:02 pm, during an interview with the Pulmonologist (specialize in the respiratory system and treat breathing-related conditions), when asked what his expectation was for staff being trained to work on the trach unit he stated that he isn't' in charge of this unit. He stated that every staff member working on this unit should have some basic training. He stated that he thinks there should be specific training protocol of steps, one for CNA and one for Licensed Practical Nurse (LPN)/Registered Nurse (RN). He said even Respiratory could use one. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J [Isolated Jeopardy] to resident health and safety being identified on [DATE] at 1:20 pm. The facility took corrective action by implementing an acceptable Plan of Removal on [DATE] at 12:30 pm which was verified onsite and the scope and severity was lowered to a G. Based on the Plan of Removal, the interventions included: 1. All tracheostomy residents have been identified and reviewed for bathing and the care plan/Kardex has been updated to reflect safety instructions related to not covering or obstructing the airway at any time, including during showers. 2. A nurse must check with the CNA prior to any shower to ensure they understand the airway, and not to get water in the trach, or cover the trach at any time before/during/after the shower. The airway must remain unobstructed at all times. Both signatures are needed to ensure training and understanding of the training. 3. The Director of Nursing (DON/CNE)/designee will begin education [DATE] and continue until all staff have been educated prior to their next shift. Any direct care staff member on leave of absence (FMLA) (Family Medical Leave Act), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires and agency staff will be educated prior to their first shift. 4. The Center Nurse Executive/designee will review all new admission for tracheostomy needs in clinical meetings to ensure that shower preferences are noted, safety needs have been reviewed, shower resources are available, care plan/kardex is updated, and check offs for the nurse/CNA for shower is implemented . 5. DON/(CNE) and/or designee will observe 3 showers a week to ensure process is being followed, as well as interview 5 direct care staff to ensure they can speak to the process x (times) 3 months. DON will bring results of audits to the QAPI (Quality Assurance Performance Improvement) committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved.

This is a past noncompliance deficiency. Based on record review and interview, the facility failed to monitor for change in condition of a surgical wound for 1 (R #10) of 4 (R #'s 10, 11, 12, and 13) residents reviewed for wound care. This deficient practice likely resulted in R #10's wound worsening while no new interventions were implemented over a 6 week period which required debridement (removal of damaged tissue) in the hospital. The findings are: A. Record review of the EHR (Electronic Health Record) revealed that R #10 was admitted to the facility on [DATE] with the following pertinent diagnosis; Atherosclerosis of Native Arteries (buildup of fats, cholesterol and other substances in and on the artery walls) with Gangrene (Dead tissue caused by an infection or lack of blood flow) of Right Leg, Type 2 Diabetes Mellitus (a disease that affects the way the body regulates and uses sugar) with Chronic Kidney Disease (gradual loss of kidney function), Diabetic Peripheral Angiopathy (a disease affects the blood vessels that carry oxygen-rich blood to the body), Obesity (over weight), Ischemic Cardiomyopathy (when the heart can no longer pump enough blood to the rest of their body), Hypothyroidism (when the thyroid gland doesn't produce enough thyroid hormones), Generalized Muscle Weakness, and Peripheral Vascular Disease (a slow and progressive circulation disorder that reduces blood flow to the legs and arms). B. Record review of a facility reported incident, received on 08/24/22, revealed that on 08/15/22, R #10 was found to have a surgical wound on her right foot where proper wound care was not being delivered to promote wound healing. The investigation also revealed that R #10 did not attend a follow-up visit for a post-surgical wound evaluation. C. Record review of physician note, dated 07/15/22, revealed that R #10 was readmitted to the hospital in 06/2022 [06/20/22- 06/28/22], for a R [right] foot osteomyelitis [an infection in the bone caused by bacteria or fungi], for which she underwent a R [right] transmetatarsal amputation [surgical removal of toes due to severe infection or lack of oxygen supply]. D. Record review of physician orders revealed the following wound care orders: Date 06/29/22, RLE [Right Lower Extremity- right foot] surgical incision wound care: cleanse with wound cleanser, pat dry, apply xeroform [type of wound dressing] to sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision). Pack tunneling wound with iodoform [type of wound dressing]. Cover with ABD pad [type of bandage]. Wrap in Kerlix [type of bandage] followed by ACE bandage. RN (Registered Nurse) to evaluate wound weekly. One time a day for surgical wound care. E. Record review of weekly skin integrity reports revealed the following: 1. 07/02/22: Wound size- 2.2 x (by) 3.8 x N/A (length by width by depth in centimeters). Wound bed- Epithelial. Drainage- none. Surround skin- Attached/discoloration-black/blue, extent- 2 cm (centimeters), no swelling. Dressing- Intact. 2. 07/12/22: Wound size- 3.1 x 5.6 x N/A. Wound bed- Epithelial (The most outer layer of skin). Drainage- None. Surrounding skin- Attached/discoloration-black/blue, extent- 3 cm, no swelling. Dressing- intact. 3. 07/21/22: Wound size- 3.6 x 6.1 x N/A. Wound bed- Eschar (dead tissue that sheds form healthy skin, similar to a scar)/100% eschar, Drainage- Light/Serosanguineous (blood and liquid), no odor. Surrounding skin- attached, normal in color, no swelling. Dressing- Intact, c/o (complaints of) pain during wound change, nurse notified and resident medicated 4. 07/28/22: Wound size- 4.0 x 4.9 x N/A. Wound bed- Eschar/100% eschar. Drainage- none. Surrounding skin- Attached, normal in color, no swelling. Dressing- intact 5. 08/04/22: Wound size- 3.7x 5.3 x N/A. Wound bed- Epithelial/eschar. Drainage- Light- Serous (typical wound drainage from a healing wound unless there is excessive swelling). Surrounding skin- Macerated (the softening and breakdown of skin due to excessive moisture): Wet, white, waterlogged tissue, no swelling. Dressing- Intact 6. 08/15/22: Wound size- 2.9 x 5.2 x N/A. Wound bed- Eschar 100%. Drainage- None. Surrounding tissue- Attached, dry. Dressing- Intact F. Record review of Nurse Practitioner notes, dated 08/15/22, revealed Right foot wound - . Patient requires urgent follow up with the surgeon who performed the amputation as she appears to have necrotic tissue [dead tissue that must be removed] as well as sutures in place. In review of records, patient saw a [Name of physician] after hospital discharge. Spoke to office of [Name of physician], he was not the surgeon who performed her amputation and so did not evaluate the current surgical wound. Their office was able to fax me records so that we had the name of the correct surgeon, which was [Name of physician]. He sees patients at the [Name of clinic]. Called that clinic, they were able to schedule an appointment for 2 PM today (08/15/22). Time and location of appointment provided to facility staff to arrange transport. G. On 12/08/22 at 2:24 pm, during an interview with the Wound Care Nurse, when asked to describe her initial observations of R #10's surgical wound, she explained that she started working in the facility during the later half of July 2022, and when she saw R #10, Her wound appeared necrosis and gangrene where the sutures were. She also had an open area on the bottom [sole of foot] that had some slough [dead skin tissue]. I noticed the sutures were still there and they needed to be removed but needed to be debrided [removal of dead tissue by a physician] before removal. She then explained that R #10 would have to see the surgeon, who would debrided the wound before being able to remove the sutures. H. On 12/09/22 at 12:00 pm, during an interview with LPN #1, she stated that the first time she saw the wound, was the day she reported it to the CNE. She knew immediately that it was infected. She stated that it had purulent drainage and had an odor. She put in the change in condition on 08/14/22. I. On 12/09/22 at 10:06 am, during an interview with the Nurse Practitioner, when asked to describe R #10's right toe amputation, she explained that R #10 went to the hospital for heart issues, she was seen by a vascular team and during her stay, the vascular team decided that R #10 needed her right toes amputated but they consulted with a podiatry team and the podiatry team performed the amputation, however; the podiatry team was not listed in her hospital documentation so, the facility was not aware of their consultation. After R #10 returned to the facility, she attended a follow-up visit with the vascular team, where the facility thought that R #10 was being treated for her surgical cite. When asked to recall the condition of the wound on 08/15/22, she stated at that time when they [facility staff] alerted me, she had sutures and some eschar. When asked if her wound care orders should have been changed prior to 08/15/22, she explained Sometimes with complicated wound closures we don't always remove the sutures immediately and because of her health history. Its hard to say . Because we were under the impression that the vascular clinic had looked at it and chose not to remove the sutures. The NP cofnirmed that the status of R #10's wound was not brought to her attention until 08/15/22. J. Record review of EHR revealed that R #10 was seen for follow-up care on 06/29/22. No additional follow-up appointments on file. K. On 12/09/22 at 11:38 am, during an interview with CNE (Center Nurse Executive), when asked if a provider should have been notified for signs of infection on 08/04/22 when the surrounding skin of the wound was observed to be macerated, the CNE confirmed, yes. She then explained that R #10 was a surgical patient, and should have been followed by podiatry (foot) services, however; the facility did not receive documentation demonstrating the follow-up podiatry services needed for R #10 as she was already being followed by a vascular team (a physician who specializes in treating diseases and conditions found in the arteries and veins) (during her hospital stay on 06/20/22-06/28/22), the facility was under the impression that the vascular team was following the surgical wound. CNE confirmed that when she interviewed the nurse providing wound care after the change in condition was identified, the nurse confirmed that she had not been assessing the wound because she though podiatry was monitoring the wound's progress. The CNE then explained that when she became aware of R #10's wound status on 08/15/22, that R #10 was scheduled for a podiatry appointment on 08/17/22 at 2:00 pm. She then explained that she initiated multiple processes, including; 1. Educated R #10's primary nurse on wound care and identifying signs or symptoms of infections. 2. Performed a facility-wide skin audit. 3. During stand-up (a staff meeting used to review patient care and needs), staff began to carefully review discharge paperwork and made sure to confirm that residents who were returning from acute care had follow-up appointments. If they did not see any follow-up orders in their discharge paperwork, staff called to make an appointment. 4. For surgical wounds, the facility's wound care team began to follow those wounds as well to ensure that the outside surgical team was aware of the wound status. 5. Established a wound care team: A wound care product consultant began consultations for wound products on 02/14/22. A wound care nurse began working in the facility on 07/12/22. A wound care team was contracted on 08/29/22 to provide wound-care services. After the contracted wound care provider enters the building and assess wounds, the CNE and the wound care provider review the assessment and observations to ensure wound improvement. The wound care provider also consults with the product consultant to ensure proper usage of wound care products. L. Record review of a wound care audit, date 08/15/22, revealed that all wounds in the facility were identified and physician orders and care plan were updated to reflect all residents' wound status and needs. M. Record review of wound binder revealed that the facility is conducting weekly wound assessments since 08/17/22. Record review of R #'s 11, 12, and 13 identified in the sample revealed that wound treatments appeared effective as evidence of wound healing.

Based on record review and interview, the facility failed to ensure that 1 (R #1) of 3 (R #s, 1, 2 and 3) residents noted to have multiple risk factors [such as an impaired ability to move] associated with the development of pressure ulcers (PU's) [localized injury to the skin and/or underlying tissue usually over bony prominence, as a result of pressure, or pressure in combination with shear and/or friction] received all needed services to prevent development of and provide timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Not ensuring that a Registered Nurse (RN) timely assessed a new PU wound for R #1 once wound was identified by an Licensed Practical Nurse (LPN). RN did not actually see the wound other than pictures for 19 days after the wound was identified. 2. Not implementing new wound orders/interventions for 5 days after the discovery of a new wound. 3. Not obtaining pressure relieving specialty mattress for R #1 upon the discovery of new wound for unknown number of days, despite R #1 being consistently required to be in an upright position due to tube feeding. These deficient practices likely resulted in R #1 developing a facility acquired PU which developed into a stage 4 PU [PUs that can be staged are classified into one of four stages based on the layers of tissue affected, a stage 4 PU is the most severe stage and denotes a wound that affects skin, fatty tissue, muscle and sometimes bone] and could likely have contributed to his re-hospitalization and ultimately to his placement on palliative [comfort only] care. The findings are: A. Record review of census record revealed R #1 was admitted to the facility from a hospital on 11/23/21. He was initially on the 100 unit at the facility then transferred to the 400 unit at the facility on 12/06/21. R #1 was later discharged to the hospital on 01/04/22 and did not return to the facility. B. Record review of admission record revealed R #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] {series of 33 bones that run from the base of the skull to the coccyx commonly known as the tail bone and is located just below the sacral bone}which are the smallest and uppermost in location within the spinal column], burst fracture [descriptive term for an injury to the spine in which the vertebral body is severely compressed [flattened by pressure]. They typically occur from severe trauma] of unspecified lumbar vertebrae [bones that make up the spinal column or backbone, specifically within the lower back]. C. Record review of the nursing admission note dated 11/23/21 at 11:50 am revealed in pertinent part, .hard cast to LLE [left lower extremity/leg], AFO [ankle foot orthosis, one of many different types of braces for feet and ankle stabilization] to RLE [right lower extremity/leg], Miami J [ a neck brace used to prevent head and neck movement after a spinal cord injury or surgery] collar Upper extremity impairments on both sides. Lower extremity impairments on both sides. Left arm extremity weakness. Right arm extremity weakness. Left leg extremity weakness. Right leg extremity weakness Incision(s): Description: [MEDICATION(S)] spine [upper and mid back]. Wound(s): Description: dry skin, old scab to sacrum [large, triangular bone at the base of the spine] hard cast to LLE . lines or devices JP [Jackson Pratt, a type of bulb suction/drain device . to LLQ [left lower quadrant, of abdomen], GT [gastrostomy tube, tube that goes into the stomach, in this case to feed a resident who cannot safely eat normally] to LUQ [left upper quadrant of abdomen]. Description of Lift Transfer Needs: Total Lift [the resident is not able to assist to move up or down in bed or in and out of bed]. D. Record review of Braden Risk Scale: [an evidenced-based tool, that predicts the risk for developing a facility-acquired pressure injury. The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk is for developing an acquired ulcer or injury]. There are six categories measured within the Braden Scale: sensory perception {the resident's ability to respond meaningfully [example, to move away from something that hurts] to pressure-related discomfort, moisture [skin moist from urine, stool or sweating}, activity {example, ability to walk}, mobility {ability to move about in bed}, nutrition, and friction or shear {combination of downward pressure and friction}. 19-23 = no risk, 15-18 = mild risk, 13-14 = moderate risk, 11-12 = high risk, less than 9 = severe risk. R #1's Braden Scale score on 11/23/21 was documented as 11. E. Record review of R #1's health record revealed no further description of sacral [sacrum] skin status from 11/23/21 to 12/07/21. No additional skin checks of the buttock, sacral or coccyx area were found documented. F. Record review of Wound Evaluation documentation found in the EHR, (program called SWIFT) [a wound evaluation tool available in the electronic health record (EHR) that allows for photographs, measurements and descriptions of the wound bed and surrounding skin to be captured.] document for 12/08/21 revealed new sacral wound described as MASD [moisture associated skin damage] measuring 6.38 centimeters (cm) in length and 5.85 cm in width. Described as having light drainage and moisture barrier applied. Practitioner notified and responsible party notified. Note was written by LPN (Licensed Practical Nurse) #3. Photograph attached to assessment appears to be of a wound with mixed dark brown/black, yellow and pink tissue. G. Record review of progress note from Advanced Practice Registered Nurse (APRN) Wound Clinician on 12/13/21 [not timed] revealed, During his (R #1) hospitalization he developed moisture associated [CONDITION(S)] to the coccyx area. It was reported on admission, but nurse reports it is enlarging now with more peeling skin . He (R #1) notes his coccyx/buttock hurts. He has a large area on the left buttock and on the right [buttock] of open denuded [exposed] skin with black eschar [dry dead tissue] and crusted areas both sites. His skin has xeroderma [extreme dryness of skin] and is flaking and peeling around the wounds. Currently patient has [MEDICATION(S)]-based cream that remains around the area of wounds. H. Record review of treatment orders for the sacral skin/wound revealed, 1. On 11/23/21 to 12/13/21, Barrier cream [creams that prevent moisture from sitting on skin such as with petroleum or [MEDICATION(S)] in them] to buttock and peri [around] area with incontinent [loss of voluntary control of stool or urine output] care. CNA [Certified Nursing Assistant] may apply every day and night shift. 2. On 12/13/21 to 01/05/22, Skin care to sacral wound/MASD [moisture associated skin damage] Cleanse with foam cleanser and pat dry. Apply medicine [wound care product] to petroleum gauze (butter gauze with [MEDICATION(S)] using with tongue blade, apply to all open, slough skin). Apply protective barrier wipe to all peri-wound, top with Sacral foam. Every day and night shift for severe MASD. 3. On 12/15/21, Promatt Plus Powered foam & alternating air [a specialty mattress that helps turn a resident and also relieves pressure better than a standard facility mattress] . for sacral wound 4. On 12/29/21, Promatt Plus Powered (foam & alternating air) . for sacral wound. I. Record review of wound assessments after the 12/08/21 initial assessment for the sacral wound revealed: 1. On 12/15/21, pressure wound was unstageable [they could not be sure of the stage due to dead tissue obscuring the wound bed] with slough [soft dead tissue] and eschar [dried dead tissue], 9.53 cm in length and 6.53 cm in width. The attached photograph documented a wound with soft yellow and brown dead tissue with a deeper defect visible on the right side with yellow and red tissue in it. 2. On 12/18/21, pressure wound was unstageable, 8.05 cm in length and 5.95 cm in width, photograph documents an open deeper wound with yellow brown slough [soft dead tissue] and pink underlying tissue exposed. 3. On 12/24/21, pressure wound was unstageable, 7.67 cm in length and 8.98 cm in width with a depth of 1.5 cm and with undermining [eroded tissue is under the skin at the wound edges] of 1.2 cm. the photograph of the wound documents less yellow brown tissue in the wound bed and more pink tissue. J. On 01/31/22 at 2:03 pm, during interview, Unit Manager (UM) #1 revealed, the nurses [staff nurses assigned to care for the resident] do the wound care and they document in the SWIFT program. [Name of the Advanced Practice Registered Nurse (APRN) with wound care specialty] comes in usually twice a week Monday and Fridays She does consults and writes the topical [the dressings, medications placed on the wounds for treatment] orders [for the wounds]. K. On 01/31/22 at 3:04 pm, during an interview with LPN #3, she revealed, We are supposed to do skin checks every week, we look at all the [residents] skin. If there are wounds, we do a SWIFT. I am not allowed to stage pressure ulcers because I am an LPN, so I put MASD (regarding the wound she identified on R #1 on 12/08/21). I knew it was a pressure ulcer [on 12/08/21 for R #1's sacral wound]. A RN [Registered Nurse] or the wound care nurse can come and say what it is [stage it if a PU]. I told everybody, [about the new wound on R #1 on 12/08/21]. I don't think that we do an official consult for [name of APRN wound consultant]. We can leave her a note or tell her when she comes in [to the facility]. L. On 01/31/22 at 3:15 pm, during an interview with LPN # 2 regarding how LPN's at the facility stage PU's she revealed, they [the facility] don't let LPN's stage the wounds here. I don't know why. M. On 02/01/22 at 10:55 am, during an interview with LPN #3 she revealed, that it was a Thursday [12/08/21] when she first noted R #1's sacral wound, when she returned the next week [on Monday, 12/13/21] it had blown up [became much worse] . it is because the resident refused to turn. N. On 02/02/22 at 2:03 pm, during an interview with the a Risk Manager at the hospital where R #1 was transferred on 01/04/22, she revealed, he ( R #1) was diagnosed on admission, (01/04/22), with a Stage 4 Pressure Ulcer to the coccyx and that while in the hospital it was decided that he should be put on palliative care. O. On 02/03/22 at 2:58 pm, during an interview with APRN Wound Specialist, who consults on wounds at the facility she revealed, I go there [to the facility] once a week on Mondays. The problem is that I was told about him (R #1) at the end of the day [on 12/13/21]. It would have been on the thirteenth [12/13/21] that I was first told to see him, but he was out at an appointment so I had to write the initial orders based on the photograph [from 12/08/21]. It was a DTI [Deep Tissue Injury, a pressure-related deep tissue injury under intact skin which often proceeds the development of a stage 3-4 pressure ulcer even with optimal treatment]. The following Monday the twentieth [12/20/21], he was again at a doctors appointment. The APRN confirmed that she did not actually see R #1's wound on 12/13/21 and 12/20/21. Regarding the pressure releiving mattress, she stated I am often the one that orders the mattress [specialty mattress's that help relieve pressure for resident with PU or at risk for getting PU's] and would have ordered it on the thirteenth [12/13/21]. Yes, other people can order the beds [specialty mattresses] but I am often the one who does it. That may have been around the time that our provider [the bed/mattress vendor] was out of alternating air beds [a type of specialty mattress that helps relieve pressure]. That may be why I reordered it on the twenty ninth [12/29/21]. The APRN was unable to confirm if or when the pressure relieving mattress was delivered for R #1. P. On 02/04/22 at 8:30 am, with, CNA (Certified Nursing Assistant) #3 who had worked with R #1 on the 100 unit, [where he resided from 11/23/21 -12/06/21] There was redness [on R #1's bottom] we would put cream on it Q. On 02/04/22 at 8:38 am, during an interview with CNA #2, I barely worked with him .it was a little red [his sacral area] when he came to 400 [unit] [after 12/06/21]. He would turn [reposition] for us. R. On 02/04/22 at 8:58 am, during an interview with CNA #1 working on the 100 hall [11/23/21 to 12/06/21] front of hall [first name of R #1], I remember changing him, his butt was red and had a little bit of a scabby sore. He would turn, we couldn't turn him much [completely on his sides] because of sitting up [because of his feeding tube he needed to sit up in bed]. He made sure we kept him clean, he knew when he went [to the bathroom] and he was very vocal about that. S. On 02/04/22 10:40 am, during an interview with RN #2. She revealed, admitting R #1 [on 11/23/21 to the facility] and taking care of him a few times after that. She revealed that, if she said something was a scab it was an abrasion, if it was a wound I would have called it that. She revealed she would see his buttocks at least daily because, he had such a long spine incision that needed care. It was intact [his sacral/coccyx/buttock area]. If it was red or bruised looking I would have documented that. T. On 02/04/22 at 12:20 pm during an interview with the Chief Nursing Executive (CNE) [Can you show me that anyone evaluated the wound for treatment needs between 12/08/21 and 12/13/21 when the APRN Wound Care Consultant came in to evaluate?] She revealed, I have not been able to find any evidence that anything was done, no orders were found for treatment and no evaluations other than the one done on the eighth [12/08/22]. She revealed she had never been made aware of R #1's sacral wound while he was a resident at the facility. She revealed she has not been asked to evaluate any of the residents wounds at the facility and that as she was an emergency department nurse prior to beginning to work in long term care [nursing homes] she had no experience with anything but acute wounds [new, not chronic like PU's, such as from automobile trauma]. U. On 02/07/22 at 8:20 am, during an interview with LPN #3 [working day shift for facility] she revealed, she noted the wound on 12/08/21 on R #1's [sacrum] and notified Dr [name of the Medical Director] and the nurse on the next shift. V. On 02/07/22 at 8:30 am during an interview with LPN #2 [working day shifts for facility], we are supposed to tell an RN [when she as LPN finds a new wound] but there isn't one [an RN] to tell. LPN #2 confirmed that often there is not a RN available to immediately assess for wounds. W. Record review of clinical schedules for 12/01/21 - 12/20/21 revealed there was no RN on the schedules for 12/01/21 or on 12/05/21. There was an RN on the night shift only [not on the day shift] on 12/02/21, 12/03/21, 12/06/21, 12/07/21,12/08/21, 12/12/21 and 12/13/21.

R #203 was admitted to the facility on [DATE] and was assessed for no bed rails to be used on her bed. On [DATE], R #203 was found unresponsive with her head between the bed rail and the mattress. The facility staff were unable to revive her. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J [isolated immediate jeopardy for one resident] being called [DATE] at 5:46 pm. The Center Executive Director [CNE] was notified at this time. The facility took corrective action and provided an acceptable Plan of Removal (POR) on [DATE] Implementation of the POR was verified onsite. Based on the Plan of Removal, the interventions included: Plan of removal: Corrective Action: -Licensed nurses completed a bed rail evaluation on all 81 residents to determine the need for bed rails and conducted a visual inspection to validate appropriate utilization of bed rails based on the assessment on [DATE]. -Licensed nurses reviewed physician orders and consent forms on all residents identified with bed rails on [DATE] and updated the care plan and Kardex [medical information system used by nursing staff as a way to communicate important information on their patients] to reflect the use of bed rails as well as type of rail in use vs. no rail in use. CNA (Certified Nursing Assistant) Kardex under the mobility section will reflect the side rail usage. Any discrepancies were immediately corrected. -Maintenance Director and or designee inspected and secured the bed rails not needed as an enabler in the down position [with zip ties] on [DATE]. -The Maintenance Director and or designee placed an order for 30 new beds on [DATE] to update the existing inventory to allow for a detached control function and minimize the need to secure the bed rails with zip ties. -On [DATE], the Nurse Practice Educator and or designee educated all staff present in the facility on the use of safety of bed rails, entrapment and where to find information on the resident who have been assessed and approved for use of bed rails. Education included the use of zip ties to secure the bed rails in the down position if a bed rail is not needed as an enabler [sic] and prohibiting the removal of the zip ties without approval. Scope and Severity was reduced from the level J to a level 3, G. Based on observation, interview, and record review the facility failed to prevent an accident for 2 [R #203 & R #456] of 2 [R #203 & R #456] residents reviewed by: 1. Not ensuring that a residenty assessed to not have a bed rail in use, did not have a bed rail 2. Not providing enough supervision for a resident who was an elopement risk (the act of leaving the facility unsupervised). This deficient practice likely contributed to R #203's death when she became wedged between the mattress and bed rail and was unable to free herself and the elopement of R #456. The findings are: Findings for R #203: A. Record review of the face sheet for R #203 revealed the following: R #203 was admitted to the facility on [DATE] from the hospital, she had diagnoses of: Infection in hip from prosthesis [artificial hip joint], [CONDITION(S)] [heart ' s upper and lower chambers beat out of coordination. This causes poor blood flow and increases the risk of blood clots, stroke, and heart failure], [CONDITION(S)] [a condition in which your [CONDITION(S)] doesn't produce enough of certain crucial hormones], Heart failure, Chronic hypoxic respiratory failure [respiratory system is unable to remove enough carbon [MEDICATION(S)] from the blood, causing it to build up in your body], Hypertension [high blood pressure], Kidney Disease [gradual loss of kidney function], [CONDITION(S)] [Inflammation of one or more joints. It is the most common form of arthritis that affects joints in the hand, spine, knees and hips], Manière's disease [rare disorder of the inner ear that causes episodes of [CONDITION(S)], the sensation of spinning It also leads to hearing problems], Neuromuscular disease [A disorder that causes lack of strength, fatigue and inability to do day to day activities]. This list does not include all diagnoses. B. Record review of the Minimum data Set (MDS for R #203 dated [DATE] revealed that resident requires extensive assistance (resident involved in activity, staff provide weight bearing support) with two persons for physician support for bed mobility (how resident moves to and from lysing position, turns side to side, and positins body while in bed). C. Record review of the bed rail evaluation/assessment for R #203 dated [DATE] indicated the following: No Bed Rail(s) to be used. No gap was found between head or foot board and mattress. Patient observed in bed without bed rails in the up position or other rail devices. Results: Not able to independently turn side to side. Not independent in moving up and down in the bed. Not able to independently pull self from laying to sitting position. Not able to balance self while transferring to and from bed. Not able to independently support self. Unable to independently enter/exit bed safely. Unable to independently transfer safely to and from bed. Bed Rails will not be used, alternatives tried and were successful. D. Record review of the progress notes dated [DATE] indicated the following, alerted to rsd [resident] room at approx [approximately] 1625 [4:25 pm] that rsd had a fall, alerted [sic] therapy staff members for assistance. Upon entry to room noted that rsd was at the edge of the bed on knees, face down with jaw and head in between side rail and mattress. Writer [sic] assessed rsd and noted no spontaneous respirations [natural breaths] or response to verbal or physical stimuli [more than one triggers for change]. Writer [sic] unable to free rsd and therapy staff assisted to free rsd head. Rsd placed on floor and CPR [Cardio Pulmonary Resuscitation] initiated immediately. 911 called by fell ow nurses. EMS [Emergency Medical Services] arrived at approximately 1640 [4:40 pm]. EMS took over CPR at that time. Staff nurse notified by EMS at approx 1730 [5:30 pm] that all resuscitative [restoration of life] efforts were ceased and ER doc [doctor] called code to stop. CNE [Center Nurse Executive] notified family and OMI [Office of the Medical Examiner]. E. On [DATE] at 3:01 pm, during an interview with Registered Nurse (RN) #2 she revealed that she was working with R #203 on the day of the incident and is also the nurse that found her unresponsive. R #203 was originally admitted into a room that did not have bed rails on the bed. She was moved to a different room where bed rails were installed on the bed. She stated that on [DATE], she found the bed rails for R #203 were up and in use on the bed. RN #2 stated that R #203 couldn't move herself very much while she was in bed and therapy was working with her. She really didn't have muscle tone or control. She stated on that day [[DATE]] a Certified Nursing Assistant (CNA) had walked into R #203's room and turned around and told her [RN #2] that R #203 was on floor. When she [RN #2] went into #203's room she saw that R #203's knees were touching the floor, her arms were hanging down in front of her and her eyes were open and fixed [pupils that do not respond to light or other stimuli]. Her knees were touching the floor at a 45-degree angle and her arms were hanging down in front of her. R #203's eyes were open and fixed. RN #2 checked R #203's pulse and there was no pulse. At that time, she called for help from the Physical Therapy Assistant, because she needed help getting R #203 to the floor. RN #2 stated that R #203's head was stuck in the bed rail and after they laid her on the floor, she started compressions and EMS was called. She stated that when she was trying to check R #203's pulse she wasn't able to check it on one side, because the bed rail was up against her neck. She had to check it [the pulse] on the other side. F. On [DATE] at 10:30 am, during an interview with Physical Therapy Assistant [PTA], he revealed that he had been working on with the residents on that hall during the time of the incident [[DATE]]. There was a fall and he heard RN #2 screaming for him, saying that she needed help now. When he got to the room, he saw R #203's head was in the rail, knees next to the bed on the floor and she was not moving. He revealed that they couldn't really assess R #203, because her body was fixed in between the railing. Until he lifted her up, she was unable to come out of the rail. No offloading [movement or adjustment/redistribution of weight] of her lower body was occurring, likely, because she had already passed. The PTA stated that R #203's knees and her feet were flat on the ground, her arms were dangling, and her head was in the rail face down. G. On [DATE] at 11:24 am, during an interview with the Center Nurse Executive [CNE], on [DATE], she was called down to the hall where R #203 was located because they [the staff] needed help with doing CPR on a resident. When she got to the room [R #203's] RN #2 was really upset, and she kept saying that her [R # 203's] head was stuck [in the bed rail]. They continued to do CPR until EMS got there and they took over. She [R #203] was never resuscitated. She stated that when she looked at R #203 she did not have any marks on her neck and there was no apparent signs of head trauma [serious injury to head]. She stated that her chest had a triangle like mark on it from her chin resting on it [her chest].The CNE stated that they measured the mattress to the bed rail and it was only four inches, which is regulation. She stated No, she wasn't supposed to have a bed rail on her bed. She did not qualify to have bed rails. H. On [DATE] at 3:12 pm, CNA #8 stated that R #203 was not able to support herself at all. He stated that the bed rails would always get pulled up unless they were changing her, or therapy was doing something with her. I. On [DATE] at 3:30 pm, during an interview with R #98, she stated that R #203 was her roommate and she died on [DATE]. She stated that on the day she [R # 203] died , therapy came in and R #203 was telling therapy that she was going home that day. R #98 stated that therapy told R #203 that she needed to get stronger before she could go home. She stated that while therapy was working with R #203 she [R #203] started to doze off and around 3:30 pm or 4:00 pm, R #203 started talking in her sleep. She kept talking and was becoming more agitated [feeling troubled or nervous]. She [R #98] stated that she pressed the call light, because her roommate [R #203] was being noisy. A CNA came in and put R #203's legs back on the bed, because they were hanging off. About 15 minutes or so later, she [R #203] started talking really loud, so R #98 pushed the call button again. She stated that around 4:15 pm or 4:30 pm, R #203 started yelling help me, help me. R #98 explained that she only heard R #203 she didn't see her because of the curtain that was between them. R #98 stated that R #203 was still asleep when she was calling out for help. Then the nurse came running in and the nurse told someone, maybe the CNA that it wasn't good and to call 911. J. On [DATE] at 4:00 pm, during an interview with CNA #9, she stated that she remembers checking on R #203 on [DATE] and that she had tucked her feet back in. She stated that her roommate R #98 wanted R #203 to be quiet, because she kept talking to herself. She became aware of the incident involving R #203 after she finished helping a different resident. CNA #9 stated that the only time that the bed rails are down on the beds in this hall [200 hall] are when they are changing a resident or PT (Physical Therapy) is working with them. She wasn't aware that any of the bed rails were tied down currently. She also stated that she wasn't aware that some residents should not have bed rails. She stated that they use the bed rails all the time, because it keeps the residents safe. Findings related to bed rails: K. Record review of the facility bed rail policy revised [DATE] revealed Prior to use of a bed [all, staff will attempt the use of appropriate alternatives. If the alternatives were not adequate to meet the patient's needs, the patient will be evaluated for the use of bed rails. The Bed Rail Evaluation will be completed upon admission, re-admission, change in qed or mattress, and with a significant change in condition. L. On [DATE] at 11:05 am, during an interview with the Maintenance Director. He stated that he was not working the day the accident happened on [DATE]. He stated that his Assistant put the zip ties on the beds with bed rails [to prevent movement].He stated that a lot of these beds you can't take off the bed rails, because they control the beds and that is why zip ties had to be used [to keep bed rail in down position since they cannot be removed]. He stated that there have been a few instances where a resident's family member has cut off the zip ties and one time where a resident had removed the zip ties herself so that the bed rails could be raised. M. On [DATE] at 2:05 pm during an interview, CNA #6 reported she does not know when a resident needs a bedrail. She reported when changing residents, if they tend to move a lot on their own they [the CNA's] will use a bedrail. CNA #6 expressed she is not formally informed by the facility if a resident is in need of a a bedrail. CNA #6 uses cues from the resident such as the resident moving a lot to determine if the resident is in need of a bedrail. CNA #6 then reported that when residents are transferred out of the 100 wing (the quarantine wing, upon admission, all residents temporarily remain on the 100 wing for 2 weeks before moving to their assigned room, per infection control practices), the residents' needs will be told to the staff on the resident's new wing, including the need for bed rails. They just have to let the Maintenance Supervisor (SM) know to install them [bed rails]. CNA #6 reported that bedrails are also put in the up position when the resident is getting changed in their bed as the resident holds on to the bedrail to assist with their brief change. Once the change is complete and the resident is clean, the bedrails are put back down. CNA #6 only recently learned about bedrail entrapment. Prior to that, she had no knowledge of what entrapment was. N. On [DATE] at 2:50 pm, during an interview with CNA #5 and CNA #6; CNA # 5 reported she would only know from a transfer from the 100 hall, if a resident needs bedrails. She watches the resident to see if they need bedrails. She also asks the 100 hall nurse for information about residents needing bedrails. CNA #6 then reported that bed rails are used if the residnet requests it however; the bed rails must be approved and SM must be notified. CNA #6 also reported that bed rails are used during a brief change for safety measures if another staff member is not available to assist. CNA #6 then reported that she has never had any formal training on bedrail entrapment; she only knows about it from the nurse. O. On [DATE] at 3:05 pm, during an interview with CNA #7, she revealed that some of the residents do have bed rails, and some don't. She stated that no one [facility management] has said anything to them about bed rails until the accident with R #203. She stated that she never really paid attention before, but she is paying more attention now. P. On [DATE] at 3:12 pm, during interview CNA #8 stated that he likes the bed rails, because it keeps the residents safe while they are in bed. He stated that the resident can also use the bed rails to assist the CNA when they [the resident] is being changed. Q. On [DATE] at 3:18 pm, during an interview with CNA #10, stated that she never really paid attention [to the use of bed rails] before now. If the bed had the bed rails on it, they would use them. She stated that she never knew about any kind of entrapment [the act of being physically trapped] that could occur with the use of bed rails. R. On [DATE] at 4:45 pm, during an interview with Center Executive Director [CED] he stated that when he first came here to this building there were so many beds with rails. He said that the families love the bed rails and request them and have threatened to [NAME] him over it. He stated there are 65 beds in this facility that we are unable to remove the bed rails from the beds because they have the function of the bed on the bed rail. It controls and operates the bed. So, that has been one of the issues that I had been dealing with as far as the bed rails go. Findings for R #456: S. Record review of complaint intake form R #456 was at the facility for a short amount of time to receive therapy before returning to her home at an assisted living facility on [DATE]. Upon her return home, it was reported that bruising was found on multiple places of her body. T. Record review of the face sheet for R #456 revealed the resident's pertinent diagnosis is dementia with behavioral disturbances. Further review of the face sheet revealed that the resident was admitted to the facility on [DATE] and was discharged on [DATE]. U. On [DATE] at 11:07 am, during an interview with the complainant, it was stated that R #456 had eloped from the facility on [DATE] and this caused the facility to discharge her to her assisted living facility as she was displaying behaviors and they felt that she would be more comfortable in a familiar surrounding. After R #456 returned to her assisted living facility, bruising was found on [DATE] and the bruises seemed old so, it is suspected that the bruising was a result of her elopement. V. Record review of nursing note dated [DATE] revealed that Mental Health/Behavior reviewed. Physical behaviors, directed towards others, other behaviors NOT directed towards others and wandering occurs occurs up to 5 days a week. Pt. [patient] is experiencing anxiety [a feeling of excess worry] about surroundings. Pt. is experiencing impulsive behavior [to act or do something in the moment without thinking of the consequences]. Pt has had sleep-cycle issues up to 5 days a week. Additional mental health/behavior comments: increased behaviors this shift. rsd [resident] will hit self and pull own hair when asked many questions. removes oxygen frequently, is observed by staff sitting self on the floor. Requires significant monitoring and redirection. W. On [DATE] at 12:46 pm, during an interview with the MDS (Minimum Data Set- a method of assessing patients to respond to their care needs) nurse, when asked if she remembers R #456, she explained, She was exit seeking from the day she arrived. It will be hard to find someone who remembers her as she was only here for a short amount of time. Since she was exit seeking, she had a wander guard (a device, when worn by a person, that triggers an alarm when the person exits the building of residence). The wander guard only works for the front door. It would not prevent the doors to the facility from opening, if she goes to the back doors. All the back doors lead to a secure gate that surrounds the perimeter [outer boundary of property]. The doors have always been working. It was challenging because we were having window visits and we would open the gates for families to do window visits. X. On [DATE] at 2:07 pm, during an interview with Maintenance, when asked to explain the use of a wander guard, he explained that when a resident wears a wander guard, the wander guard will prevent residents from exiting the front doors as they will not open. If a resident reaches any of the doors at the end of each hall, the door will open (they must be accessible for emergency purposes) and an alarm will sound and the nurses will disarm the alarm at the nurse's station. After a resident exits any of the hall exit doors, they will meet a fence that surrounds the building which is secured with a combination lock. When asked to explain the incident involving R #456, he explained We had to get an order for her [R #456] wander guard. At that time they were allowing family members to come do window visits [fence was and back doors were unlocked] and she, if I remember correctly, pushed the door open and went with a family member who was leaving and the staff who went to look for her thought she was with the family who finished doing a window visit. She made it to [name of nearby clinic] and they called us.

Based on record review and interview, the facility failed to provide the necessary treatment and services for a residents' pressure ulcer (areas of damaged skin caused by pressure, shear or friction) identified on admission for 1 [R #202] of 5 [R #'s 12, 55, 92, 93, and 202] residents reviewed for pressure ulcers. This deficient practice resulted in the resident having a pressure ulcer go untreated and unmonitored; which could likely have contributed to R #202 developing [CONDITION(S)] [an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever] and passing away. The findings are: A. Record review of R #202's hospital medical records indicated that on 05/17/21 while R #202 was in the hospital she had a right calf wound that measured 2.5 centimeters [cm] in length, and 5 cm in width. Resident also had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CRF can also happen when your lungs cannot get the carbon [MEDICATION(S)] out of your blood. A buildup of carbon [MEDICATION(S)] in your blood can cause damage to your organs] with [CONDITION(S)] [Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath], Hypertension [high blood pressure], Polyosteoarthritis [does not affect other organs of the body it only affects the joint part of the body]. This is not an all inclusive list. B. Record review of the nursing progress notes dated 05/24/21 [date of admission], indicated the following: A skin check was completed and revealed that R #202 had a discoloration on the left foot reddish patch rash. On the RT [right] leg skin tear, a right leg Pressure Ulcer and a Coccyx [also known as the tailbone, is a small, triangular bone located at the bottom of the spine] unstageable [full thickness tissue loss in which the base of the ulcer is covered by slough (dead skin tissue that may have a yellow or white appearance) pressure injury]. C. Record review of R #202's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change QOD [every other day] PRN [as needed] if saturated every other day. Monitor site daily. Order was discontinued on 05/26/21. This order was completed on this day [05/26/21] and was discontinued on the same day. D. Record review of the nursing progress notes dated on 05/27/21, R #202 was seen at the emergency room [ER] for right lower leg (RLL) [CONDITION(S)] [a common, potentially serious bacterial skin infection] with the wound infection. R #202 was prescribed antibiotics (medications to help treat the infection) and was sent back to the facility, on the same day. E. Record review of R #202's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with an ABD pad, and secure with Kerlix. To change [dressing] QOD and as needed if saturated. F. Record review R #202's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . G. Record review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . H. Record review of R #202's MAR for the months of May 2021 and June 2021, revealed that the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . I. Record review of the right lower leg wound evaluation was dated 06/05/21. Prior to this date, there was no evaluation or pictures of the RLL wound. J. Record review of R #202's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . K. Record review of the MAR for May 2021, did not reveal any treatment being completed for the coccyx wound. L. Record review of the nursing progress notes dated 06/01/21, revealed the following: [Name of R #202] complains of severe pain to her tailbone, stating that no matter what position she is in, it always hurts. M. Record review of R #202's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change QD [every day] and prn. Apply barrier cream to surrounding tissue every day shift for wound care. N. On 11/19/21 at 11:01 am, during an interview, the Center Quality Specialist [CQS] confirmed that while she was reviewing R #202's medical record, there were no treatment orders for the coccyx wound. Treatment orders for the coccyx wound were not written until 06/01/21, eight (8) days after R #202's admission to the facility. O. On 11/16/21 at 8:02 am, during an interview with Center Executive Director [CED] he stated that they now have a Nurse Practitioner [NP] who comes in once per week and is overseeing the wounds. The nurses do the wound care but the NP oversees that care. The CED stated that the physician that was here back in June 2021 is no longer here with the facility and no longer working for [name of company]. P. On 11/16/21 at 9:30 am, during a telephonic interview, RN #4 stated that he probably did the wound care evaluation for R #202 but he does not remember R #202. RN #4 stated that he does wound care evaluations for all the residents that have wounds when they need to be done which usually weekly. He works PRN (as needed) at this facility Q. Record review of R #202's wound evaluation that would include a measurement of the wound indicated no wound evaluation was completed for the coccyx wound during her stay in the facility. R. Record review of R #202's progress note dated 06/11/21, indicated the following: Wound on coccyx has dark black discharge, wound dressed with wound cleanser Nurse Practitioner [NP] notified. S. Record review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . T. Record review of the E-interact Transfer Form [transfer to hospital] dated 06/11/21, indicated in the Other relevant information section that resident had altered mental status. Infection apparent in wound. [Did not indicate which wound]. R #202's vitals before being sent to the hospital and documented on the transfer form were as follows: blood pressure 142/78, heart rate 111, respiration rate 20, temperature 98.6, oxygen saturation 95% and her pain level was a 3. U. Record review of the hospital medical records dated 06/14/21, indicated that the unstageable sacral [coccyx] wound was noted to be 12 cm width by 11 cm length by 0.1 cm deep with moderate purulent (a 'milky' drainage, which is a sign of an infection) wound was noted to be malodorous [had a smell] with dried blood. V. Record review of R #202's hospital medical records dated 06/14/21, indicated the right calf wound was 13.5 length cm x 9 cm width. W. Record review of the hospital medical records for R #202 dated 06/11/21, indicated that the resident was admitted with septic shock [a widespread infection causing organ failure and dangerously low blood pressure], Congestive Heart Failure [CHF is a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath] and had an infection in her coccyx wound that had purulent drainage and was malodorous [having a foul smell]. R #202 was moved to the Intensive Care Unit (ICU) and eventually passed while at the hospital on 06/17/21. X. On 11/10/21 at 3:14 pm, during an interview, a family member and Power of Attorney for R #202, stated that he spoke with her [R #202] a lot when she was at the facility because he wasn't allowed to come in; and she complained a lot of pain in her butt. When he would ask staff about why she was having so much pain in her butt they would tell him it was positioning. The family member said that he was never told that she had a pressure ulcer on her butt. When she [R #202] had a change in mentation [process or result of mental activity] and concerns of infection in her wound at the hospital. She was septic and went into the intensive care unit [ICU] and passed away June 17th 2021. Y. On 11/11/21 at 9:38 am, during an interview, Minimum Data Set [MDS] coordinator, stated that she does see that only one wound evaluation was completed for R #202 and that was for the leg wound on 06/05/21. She confirmed that there was no wound evaluation on the coccyx and that treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Z. On 11/19/21 at 11:01 am, during an interview, Center Quality Specialist [CQS] confirmed that she was seeing in the medical chart for R #202 what I was seeing about the coccyx wound not having orders until 06/01/21 and that an evaluation for that wound was not completed. She stated that overseeing this building is new to her and she is looking at wounds. She was not sure where the breakdown occurred around the coccyx wound. AA. On 12/20/21 at 9:35 am, during an interview with RN #13, she stated that when a resident comes into the facility they do skin assessments right away to make sure they catch any skin issues. They pass this information along to the dayshift and they always do this verbally. She stated that sometimes the nurses generalize their verbal reports and things are missed. She stated that they have the swift system [is a skin and wound management system that includes point-of-care precision imaging, measurement and analysis tools], but not everyone has been trained how to use it. she stated that the pictures of the wounds and the wound care treatment orders take place on day shift. RN #13 was not sure why this wound was missed. She also stated that really good CNA's will see a wound during brief changes and showers and will always let the nurse know what they are seeing or it something is new or getting worse, but not all CNA's are going to do that. BB. On 12/20/21 at 10:45 am, during an interview with the Nurse Practitioner [NP], the NP stated that she never saw R # 202's wound and never put in any treatment orders for it. She confirmed that a wound evaluation/assessment was not completed right away for the leg wound and was never completed for the sacral wound. She stated that this would always be part of the admission process, to identify a wound and take a picture and do measurements. She stated that before she started working in the building she was aware that they were having problems with keeping a wound care nurse, someone to oversee the wounds. So she was brought on to help out with that. She stated that she see's in R #202's medical chart that for Activities of Daily Living [ADL] mobility muscle strength on the right side lower extremity was 0 indicating that she didn't have the use of the right lower side of her body and the left side muscle strength was minimal.

Based on record review and interview, the facility failed to ensure that residents were free from neglect for 2 (R #1 and 2) of 5 (R #s 1-5) residents reviewed for falls, urinary tract infections and showers. This deficient practice resulted in R #1 sustaining a urinary tract infection and R #2 sustaining a fracture to the left distal clavicle (collarbone) after a fall, followed by a delay in treatment. The findings are: Findings for Resident #1: A. Record review of the R #1's Discharge Summary from a local hospital dated 01/15/17 indicated, Brief HPI (History of Present Illness)/Hospital Course [AGE] year old woman with history of UTIs (Urinary Tract Infections) presented with septic shock due to UTI . B. Record review of R #1's History and Physical dated 01/24/17, revealed the following: .She was sent out to ED (Emergency Department) on 01/15/17 with chest pain. She was found to [MEDICAL CONDITION] (a systemic [MEDICAL CONDITION] response to an infection) due to UTI .The attending physician reports [DIAGNOSES REDACTED]. C. Record review of the Care Plan meeting notes dated 03/16/17, indicated the following people were in attendance: Staff member from activities, dietary, nursing, social services, (name of member from the insurance health care group), R #1 and her POA (power of attorney). The following was discussed, .(Name of R #1) and her POA are concerned of not receiving showers as scheduled. It was reported that the resident had not received a shower since Friday, 03/10/17. R #1's shower schedule was every Monday, Wednesday and Friday. The nursing staff reported that R #1 was scheduled to be bathed on 03/17/17. D. On 04/17/17 at 3:40 pm, during interview, the Long Term Care Coordinator (member from the insurance health care group), stated that during the Care Plan Meeting dated 03/16/17, it was discussed as to why were the residents not receiving as many showers? The answer from the nursing staff member was due to the facility being short staffed. E. Record review of R #1's ADL (Activities of Daily Living) records for the months of 12/01/16 to 04/18/17, revealed the following: 1. December - there were 9 missed or not documented shower opportunities out of 13 scheduled shower days, 2. January - there were 5 missed or not documented shower opportunities out of 13 scheduled shower days, 3. February - there were 5 missed or not documented shower opportunities out of 12 scheduled shower days, 4. March - there were 6 missed shower or not documented opportunities out of 14 scheduled shower days, 5. April - as of 04/18/17, there were 3 missed or not documented shower opportunities out of 7 scheduled shower days. F. Record review of the facility's shower schedule (undated) for the 200 unit residents, indicates that R #1 should have received a shower every Monday, Wednesday and Friday. G. On 04/18/17 at 3:15 pm, during an interview, the Long Term Care (LTC) Unit Manager confirmed that showers were not being documented like they should be. He stated that a nurse can initiate the shower schedule in PCC (Point Click Care), then that would trigger on the treatment administration record (TAR), that showers for these particular residents would be on Monday, Wednesday and Friday. The LTC Unit Manager did feel that the showers were being given to the residents, but the showers were not being documented. H. Record review of the Resident Council Meeting dated 03/17/17 revealed the following: .shortage of staff for dressing, showers, etc . I. Record review of the facility's policy titled Activities of Daily Living (ADLs), dated 11/28/16, indicated the following: Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Findings for R #2: J. Record review of R #2's progress note dated 03/16/17 revealed the following: A change of condition has been noted. The symptoms include Falls: 03/15/2017 at night .Change reported to Primary Care Clinician: 03/16/17 3:55 am, Orders obtained include: first aide to skin tears to right arm . K. Record review of R #2's progress notes dated 03/16/17 revealed the following: Report from night nurse (name of nurse) stating that resident had a fall last night. Certified Nurses Aide (CNA) reports that resident yelled out when she was attempting to put shirt on resident this morning. Resident this morning complaining of bilateral upper extremity pain. Call to (R #2's Adult Day Program)-left message for provider. L. Record review of the Minimum Data Set (MDS) 3.0, Section C, dated 02/06/17, indicated that R #2 scored a 5 on the Brief Interview for Mental Status (BIMS). Which indicates that R #2 reflects a cognitive status of severe impairment. M. On 04/18/17 at 2:30 pm, during interview, Licensed Practical Nurse (LPN) #2 stated that during shift report from LPN #4 on 03/16/17, R #2 had a change in condition by experiencing a fall. During the night shift R #2 did not voice any complaints of pain. LPN #2 stated that during her shift, that the CNA who dressed R #2 the next morning, stated that R #2 yelled in pain while being dressed. LPN #2 stated that she had placed two calls to (R #2's provider program) to speak with R #2's PCP (primary care physician) regarding pain medications and treatment. She stated she did not receive a call back from the (R #2's Adult Day Program) provider. No orders for pain medications or treatment were obtained. N. On 04/18/17 at 2:16 pm, during interview, the Center Executive Director (CED) stated that a HFL&C (Health Facility Licensing & Certification) Incident Report, was sent to the State on 03/16/17. The State does not have any documentation about this incident which occurred on 03/15/17 at 8:40 pm. She stated that there were several [MEDICATION NAME] sent to the Department of Health intake department and she was not sure what happened to the original reportable on this incident. She was not able to locate the original and was told to do a hand-written report, which was sent on 04/07/17. Which was 21 days after the incident. O. Record review of the progress notes dated 03/18/17 revealed the following: This is a follow-up note from the accident/incident/fall in past 72 hours that occurred on 03/16/17 (sic). Status of condition: improved. Resting in bed. Cooperative with medications. No signs and symptoms of pain. Dressings intact to right arm. Assessed for pain and new injuries status [REDACTED]. P. Record review of the progress notes dated 03/19/17 revealed the following: Resident with fall on 03/15/17 at night, large bruise noted to residents left scapula area measures approx. 4.5 x 6 inches and smaller one on left shoulder measuring 1 x 2 inches. Resident denied any pain to bruised area. Q. Record review progress notes dated 03/20/17, revealed the following: Most paperwork received from (R #2's provider program) and resident is now a DNR (do not resuscitate) . R. Record review of the progress notes dated 03/21/17 written by LPN #2, revealed the following: This is a follow-up note from the accident/incident/fall in past 72 hours that occurred on 03/15/17. Status of condition: no change. Resident has bruising to the left side chest and shoulder from fall on 03/15/17. Resident not wanting to move her left arm. Resident stating she has pain to her left arm/shoulder and back. Call to (R #2's provider program) - spoke to (name of employee) notified of resident with bruising and pain from fall on 03/15/17, also notified (name of employee) that calls were placed Thursday 03/16/16. (Name of employee) stated she would talk to the doctor. Awaiting return call. Continues to have bruising and pain to the left shoulder. S. Record review of the progress note dated 03/21/17 indicated that a chest x-ray, shoulder series of the left shoulder and humerus (the long bone in the upper arm) of the left arm were completed for R #2. T. Record review of the progress note dated 03/21/17 revealed the following: (R #2's provider program) driver came approximately 12:30 pm and stated that he was here to pick up resident. CNA assisted resident in getting dressed and up in wheelchair. Resident upset and began crying, did not want to go to R #2's Adult Day Program. Call to (R #2's provider program) about resident being upset. U. Record review of the progress note dated 03/21/17 indicated that a representative from the x-ray provider stating that they have tried unsuccessfully to contact (R #2's provider program) regarding results of x-ray. CED was notified. V. On 04/24/17 at 1:57 pm, during interview, LPN #4 stated that CNA #5 was new to the facility and was from an employment agency, and did not know the residents at all. She also stated that CNA #5 had no training on using the equipment (sit to stand device) and that the transfer of R #2 was always a 2 person assist. She stated that CNA #5 did receive training on the equipment and care plan after the incident with R #2. W. Record review of the Owner's operation and Maintenance Manual for Relian 440, Sit to Stand device, indicated the following: Note: Although (Name of Company) recommends that two assistants be used for all lifting preparation, transferring from and transferring procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual. X. Record Review of the facility's policy Abuse Prohibition, revision date of 04/07/17, indicated the following: (Name of Corporation) will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Center will implement an abuse prohibition program through the following: 1. Screening of potential hires; 2. Training of employees (both new employees and ongoing training for all employees); 3. Prevention of occurrences; 4. Identification of possible incidents and allegations which need investigation; 5. Investigation of incidents and allegations; 6. Protection of patients during investigations; and 7. Reporting of incidents, investigations, and Center response to the results of their investigations .Neglect: is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on record review and interview, the facility failed to implement policies and procedures to prevent Neglect for 2 (R #s 1 and 2) of 2 (R #s 1 and 2) residents reviewed for neglect. This deficient practice resulted in R #1 sustaining a urinary tract infection [MEDICAL CONDITION] and R #2 sustaining a fracture to the left distal clavicle (collarbone) after a fall, followed by a delay in treatment. The findings are: Findings for Resident #1: A. Record review of the R #1's Discharge Summary from a local hospital dated 01/15/17 indicated, Brief HPI (History of Present Illness)/Hospital Course [AGE] year old woman with history of UTIs presented with septic shock due to UTI . B. Record review of R #1's History and Physical dated 01/24/17, revealed the following: .She was sent out to ED (Emergency Department) on 01/15/17 with chest pain. She was found to [MEDICAL CONDITION] (a systemic [MEDICAL CONDITION] response to an infection) due to UTI .The attending physician reports [DIAGNOSES REDACTED]. C. Record review of the Care Plan meeting notes dated 03/16/17, indicated the following people were in attendance: Staff member from activities, dietary, nursing, social services, (member from the insurance health care group), R #1 and her POA (power of attorney). The following was discussed, .(Name of R #1) and her POA are concerned of not receiving showers as scheduled. It was reported that the resident had not received a shower since Friday, 03/10/17. R #1's shower schedule was every Monday, Wednesday and Friday. The nursing staff reported that R #1 was scheduled to be bathed on 03/17/17. D. On 04/17/17 at 3:40 pm, during interview, the Long Term Care Coordinator (member from the insurance health care group), stated that during the Care Plan Meeting dated 03/16/17, it was discussed as to why were the residents not receiving as many showers? The answer from the nursing staff member was due to the facility being short staffed. E. Record review of R #1's ADL (Activities of Daily Living) records for the months of December 2016 through April 18, 2017, revealed the following: 1. December - there were 9 missed or not documented shower opportunities out of 13 scheduled shower days, 2. January - there were 5 missed or not documented shower opportunities out of 13 scheduled shower days, 3. February - there were 5 missed or not documented shower opportunities out of 12 scheduled shower days, 4. March - there were 6 missed shower or not documented opportunities out of 14 scheduled shower days, 5. April - as of 04/18/17, there were 3 missed or not documented shower opportunities out of 7 scheduled shower days. F. Record review of the facility's shower schedule for the 200 unit residents, indicates that R #1 should have received a shower every Monday, Wednesday and Friday. G. On 04/18/17 at 3:15 pm, during an interview, the Long Term Care (LTC) Unit Manager confirmed that showers were not being documented like they should be. He stated that a nurse can initiate the shower schedule in PCC (Point Click Care), then that would trigger on the treatment administration record (TAR), that showers for these particular residents would be on Monday, Wednesday and Friday. The LTC Unit Manager did feel that the showers were being given to the residents, but the showers were not being documented. H. Record review of the Resident Council Meeting dated 03/17/17 revealed the following: .shortage of staff for dressing, showers, etc . I. Record review of the facility's policy titled Activities of Daily Living (ADLs), dated 11/28/16, indicated the following: Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Activities of daily living (ADLs) include: Hygiene - bathing, dressing grooming, and oral care; Mobility - transfer and ambulation, including walking; Elimination - toileting; Dining - eating, including meals and snacks; .ADL care is documented every shift by the nursing assistant on an ADL flow record or in PointClickCare (PCC) ADL Point of Care (POC). The ADL Flow record will be reviewed at morning meetings . Findings for R #2: J. Record review of R #2's progress note dated 03/16/17 revealed the following: A change of condition has been noted. The symptoms include Falls: 03/15/2017 at 8:40 pm. Change reported to Primary Care Clinician: 03/16/17 3:55 am; Orders obtained include: first aide to skin tears to right arm . K. Record review of R #2's progress note dated 03/16/17 revealed the following: Report from night nurse (name of nurse) stating that resident had a fall last night. CNA (certified nursing assistant) reports that resident yelled out when she was attempting to put shirt on resident this morning. Resident this morning complaining of bilateral upper extremity pain. Call to (R #2's provider program) - left message for provider. L. On 04/18/17 at 2:30 pm, during interview, LPN (licensed practical nurse) #2 stated that during shift report from LPN #4 on 03/16/17, R #2 had a change in condition by experiencing a fall. During the night shift R #2 did not voice any complaints of pain. LPN #2 stated that during her shift, that the CNA who dressed R #2 the next morning, stated that R #2 yelled in pain while being dressed. LPN #2 stated that she had placed two calls to R #2's provider's program regarding pain and treatment. She stated she did not receive a call back from R #2's provider's program. No orders for pain or treatment were obtained. M. On 04/18/17 at 2:16 pm, during interview, the Center Executive Director (CED) stated that a HFL&C (Health Facility Licensing & Certification) Incident Report, was sent to the State on 03/16/17. The State does not have any documentation about this incident which occurred on 03/15/17 at 8:40 pm. She stated that there were several [MEDICATION NAME] sent to the Department of Health intake department and she was not sure what happened to the original reportable on this incident. She was not able to locate the original and was told to do a hand-written report, which was sent on 04/07/17. Which was 21 days after the incident. N. Record review of the progress notes dated 03/18/17 revealed the following: This is a follow-up not from the accident/incident/fall in past 72 hours that occurred on 03/16/17 (sic). Status of condition: improved. Resting in bed. Cooperative with medications. No signs and symptoms of pain. Dressings intact to right arm. Assessed for pain and new injuries status [REDACTED]. O. Record review of the progress notes dated 03/19/17 revealed the following: Resident with fall on 03/15/17 at night, large bruise noted to residents left scapula area measures approx. 4.5 x 6 inches and smaller one on left shoulder measuring 1 x 2 inches. Resident denied any pain to bruised area. P. Record review of the progress notes dated 03/21/17 written by LPN #2, revealed the following: This is a follow-up note from the accident/incident/fall in past 72 hours that occurred on 03/15/17. Status of condition: no change. Resident has bruising to the left side chest and shoulder from fall on 03/15/17. Resident not wanting to move her left arm. Resident stating she has pain to her left arm/shoulder and back. Call to (name of R #2's provider's program) - spoke to (name of employee) notified of resident with bruising and pain from fall on 03/15/17. Also notified (name of employee) that calls were placed Thursday 03/16/16. (Name of employee) stated she would talk to the doctor. Awaiting return call. Continues to have bruising and pain to the left shoulder. Q. Record review of progress note dated 03/21/17 indicated that a chest x-ray, shoulder series of the left shoulder and humerus (the long bone in the upper arm) of the left arm were completed for R #2. R. Record review of progress note dated 03/21/17 indicated that a representative from the x-ray provider stated that they have tried unsuccessfully to contact (name of R #2's provider's program) regarding results of x-ray. CED was notified. S. On 04/24/17 at 1:57 pm, during interview, LPN #4 stated that CNA #5 was new to the facility and was from an employment agency, and did not know the residents at all. She also stated that CNA #5 had no training on using the equipment (sit to stand device) and that the transfer of R #2 was always a 2 person assist. T. Record review of the Owner's Operation and Maintenance Manual for Relian 440, Sit to Stand device, indicated the following: Note: Although (Company Name) recommends that two assistants be used for all lifting preparation, transferring from and transferring procedures . U. Record Review of the facility's policy Abuse Prohibition, revision date of 04/07/17 indicated the following: (Name of Corporation) will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Center will implement an abuse prohibition program through the following: 1. Screening of potential hires; 2. Training of employees (both new employees and ongoing training for all employees); 3. Prevention of occurrences; 4. Identification of possible incidents and allegations which need investigation; 5. Investigation of incidents and allegations; 6. Protection of patients during investigations; and 7. Reporting of incidents, investigations, and Center response to the results of their investigations . Neglect: is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on record review and interview, the facility failed to establish and maintain an Infection Control Program designed to prevent the development and transmission of infection as evidence by: 1. Failing to ensure staff competency when performing peri-care (washing the genitals and anal area to prevent infections) for 2 residents (R #s 31 and 32) observed for peri-care. 2. Failing to ensure agency staff were following facility policy and procedures with peri-care and urinary catheter care. 3. Failing to ensure the PDS (Practical Development Specialist)/NPE (Nurse Practice Educator) was knowledgeable of facility policies and procedures as well as their scope of practice. 4. Failing to trend and address 25 residents (R #s 5-30), identified on the Infection Control Tracking sheets, documented as having house/facility acquired Urinary Tract Infections (UTIs) and by not developing an action plan to prevent UTI's in the future. These deficient practices have caused 25 residents to acquire UTIs due to staff failing to perform sanitary peri-care. This directly affected resident care outcomes by not addressing the facility acquired UTIs, not identifying the cause of the UTI and not developing measures to prevent future infections from occurring. The findings are: A. Review of the facility's policy titled Infection Prevention and Control Program (IPCP), dated 11/28/16 revealed the following: The IPCP is a comprehensive process that addresses preventing, identifying, reporting, investigating and controlling infections and communicable diseases for patients, staff . and other individuals providing services under a contractual agreement. The IPCP policy also indicated the following major program activities; *Process Surveillance- to review infection prevention and control practices directly related to patient care . *Prevention of infection which includes staff and patient education focusing on risk of infection and practices to decrease risk. *Reporting of Incidents Identified .monitor procedures for proper infection prevention and control technique .perform surveillance to monitor the rate of healthcare acquired infection .analyze and develop action plan to address. B. Review of the facility's policy titled, Peri Care, dated 12/01/06 revealed the following: .cleanse perineum (area between the penis or the vaginal opening and the rectum) with soap, water .or perineal cleanser by wiping the front of the perineum toward the rectum. C. Review of the facility's policy titled, Catheter: Indwelling Urinary - Care of, dated 01/02/14 indicates: Male: Wash area around catheter insertion site and then wash from the tip of the penis down to the body including the scrotum and underneath the scrotum .cleanse the catheter .washing away from the insertion site and manipulating the catheter as little as possible. D. On 04/19/17 at 10:53 am, during observation, Certified Nursing Assistant (CNA) #3 performed peri care on Resident #31, who also had a urinary catheter (a small sterile tube inserted through the penis and into the bladder). During the procedure, CNA #3 was observed demonstrating deficient practice by cleaning and wiping the catheter tubing in the wrong direction going towards the penis instead of away from the insertion area several times further contaminating the area. E. On 04/19/17 at 1:43 pm, during observation, CNA #4 performed peri care on R #32, who demonstrated deficient practice while cleaning the inside of the residents genitalia area, and wiping only on the outside with the cleaning wipes. F. On 04/19/17 at 11:29 am, during interview, the Center Executive Director (CED) stated that the facility has not had a full time IPCP since January 2017. The CED also stated the Long Term Care Unit Manager (LPN) #1 was one of the designated IPCPs and had completed the infection control tracking sheet for the month of March . and another IPCP reviewed the IPCP data from February. The Infection Control (IC) data tracking sheets for UTIs from 12/01/16 to 03/31/17 were reviewed with the Center Executive Director which revealed the following; UTIs December 2016 = 11, January 2017 = 15, February 2017 = 12 and March 2017 = 14 UTIs totaling, 52 UTIs over a four month period. During this interview the facility Center Executive Director was unable to provide any documentation that would indicate the UTIs had been addressed and/or investigated as to the cause or that an action plan had been developed. G. On 04/19/17 at 11:52 am, during interview, LPN #1 stated that the total number of UTIs reported over the above four month period also included residents that were admitted with UTIs. LPN #1 then presented a separate list of facility acquired UTIs for the same four month period which equaled 30 of the 52 originally noted on the IC data sheets. H. Review of the Medication Administration Records (MARs) and Physician order [REDACTED].#5 through R #30) identified as developing facility acquired UTIs were all treated with antibiotics and noted to have physician orders [REDACTED]. I. On 04/20/17 at 8:38 am, during interview, Registered Nurse (RN)/PDS (Practical Development Specialist)/Nurse Educator #1 stated that she was new to this role, and had been in her current position for three weeks after completing training. RN #1 then stated that she had just provided an in-service on peri care with the agency CNAs working that day. RN #1 was then asked if she actually watched the four CNAs perform peri- care, RN #1 stated, No, then added, yesterday when she did the competency training she just sat down with the CNAs and reviewed the check list and asked them if they had any questions. RN #1 also stated that she went over the policy (meaning peri-care policy) with them (the four CNAs), because she was not familiar with the (Name of Corporation) policy yet or if there was one for peri care. RN #1 was then asked, if by reviewing a competency check list, this meant that staff members were competent and RN #1 stated, No .I didn't think I could go into a residents room to watch because of patient privacy. J. On 04/20/17 at 9:21 am, during interview LPN #3, IPCP stated, since March of this year (2017) she had been helping out with several buildings (meaning in their health care system) as well as this facility. LPN #3 then stated that when she was here in March (2017) she performed IC rounds in the facility and completed the IC audit tool sheets then got pulled to another building, but had requested the CED and the Center Executive Director of Nursing (CEDN) to follow up on her findings. LPN #3 also stated, when she was in the facility in March (2017) she started a new binder for tracking and trending infections because she could not understand the prior documentation . she completed her report and gave it to the CED to review in monthly QA (Quality Assurance) committee meetings. LPN #3 added, that if she had known these numbers (referring to the total number of facility acquired UTIs over the above 4 month period) she would have started an investigation and taken appropriate measures to identify the cause of these high numbers. The IC data collection binder was reviewed from October 2016 through March 2017 which revealed no documented evidence that the facility was trending their infection rates. K. On 04/20/17 at 11:39 am, during interview, the CED presented the QA/COR (Clinical Outcomes Report) documents for December 2016 through March 2017 which revealed a total number of facility acquired UTIs reported was 7 compared to the 30 as reported by LPN #1. When asked to explain the discrepancy, the Corporate Clinical Consultant (who was also present during the interview) stated, the IPCPs utilize a tool to identify a UTI but the resident must meet both parts of the criteria to be counted as a UTI. The first part of the criteria refers to the resident showing signs and symptoms of a UTI. The second part of the criteria indicates the physician has to order a urine test and/or culture. If a physician fails to order a urinalysis (urine lab study) or a urine culture the resident would automatically not meet the requirement and therefore not be counted as having a documented UTI, resulting in skewed data reporting and a failure to address the facility's acquired UTIs. L. On 04/20/17 at 9:44 am, during interview, the Medical Director stated that his criteria for diagnosing a UTI would include if a resident displayed specific symptoms and were terribly sick he would order a culture and was unaware of the discrepancy in the number of facility acquired UTIs. The Medical Director then stated, he believes other contracted physicians may be contributing to this issue because they will sometimes just treat residents without obtaining the necessary lab studies and planned to speak with them on this issue.

Based on record review and interview, the facility failed to provide an environment for residents that was free from hazards for 1 (R #2) of 2 (R #s 2 and 4) residents reviewed for falls. This deficient practice resulted in R #2 sustaining injuries from a fall in which the sit to stand device was not used properly by an employment agency staff member. The findings are: A. Record review of the Complaint Narrative Investigation Report (5 day) dated 03/21/17, indicated the following: Rsd (resident) (#2) was lowered to the floor by CNA (Certified Nursing Aide) #5 on 03/15/17, while trying to transfer her from the toilet at 8:40 pm. CNA #5 had the Sara lift (a sit to stand device to assist the resident from a sitting position to a standing position) in front of (the) resident. When she grabbed hold of the arms to stand herself up, she started slipping. CNA (#5) reported he lowered her down by letting her slide down his leg. CNA (#5) notified his nurse, Licensed Practical Nurse (LPN) #4 assessed the resident. Upon assessment, 2 skin tears noted to her right arm and first aid was administered. Range of motion and neuro (neurological) checks are within normal limits for resident. B. On 04/18/17 at 2:16 pm, during interview, the Center Executive Director (CED) stated that CNA #5 lowered the resident (R#2) to the floor, so there was no actual fall. C. Record review of the written statement from CNA #5, titled Incident Report dated 03/15/17, revealed the following: I was helping a woman (R#2) to the bathroom, I got the sit to stand and started to put on the straps. When she got hold of the bars and tried to stand that is when I got her and put her against my body so that she would not fall. I hit the restroom call light box, no one came to help. I let the resident down to the floor by sliding her down my body and legs. I made sure she was OK and went for help. I found the nurse right outside the door. She came with me, back into the room and into the bathroom to see what had happened. That's when I was informed about her care plan, so the nurse went to get help and she got two other CNAs. We put a blanket on the floor and the nurse and I rolled the resident back and forth, then got the blanket under her. Then all of us picked her up and moved her to the bed. When I started to clean her up and get her ready for bed. I was working on 200 hall and the nurse was back but don't remember her name . D. Record review of R #2's Care Plan dated 11/15/16, indicated the following: (Name of R #2) is at risk for falls due to: cognitive loss, lack of safety awareness, impaired mobility. Interventions included: Place call light within reach while in bed or close proximity to the bed. Maintain a clutter-free environment in the resident's room and consistent furniture arrangement; When resident is in bed, place all necessary personal items within reach and Monitor for and assist toileting needs. (Name of R #2) requires assistance/is dependent for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Recent hospitalization resulting in fatigue, activity intolerance, increased confusion and ADL decline. Interventions included: Provide resident/patient with extensive assist of 2 for bed mobility; Provide resident/patient with extensive assist of 2 for transfers using a pivot. E. Record review of Lift Transfer Reposition Assessment for R#2 dated 03/10/17 indicated the following: Focus: Resident/Patient requires assistance/is dependant for ADL care in (specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) Interventions: Provide resident/patient with extensive assist of 2 for bed mobility; Intervention: Provide resident/patient with extensive assist of 2 for transfer using a pivot (specify: walker, roll walker, quad cane, straight cane, pivot transfer, slide board, etc.). F. On 04/21/17 at 10:45 am, during interview, CNA #6 on the 200 unit, stated that when using a Sara lift/sit to stand it should take 2 staff members. G. On 04/21/17 at 10:50 am, during interview, CNA #7 on the 300 unit, stated it always takes 2 staff to use the sit to stand. H. On 04/21/17 at 10:55 am, during interview, CNA # 8 on the 400 unit, stated that it always takes 2 staff to utilize the sit to stand equipment with residents. I. Record review of the Owners Manual of the Mechanical Lift/Sit to Stand, designated by the CED revealed the following: Lifting Preparation .recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures .

Based on observation, record review and interview the facility failed to follow the plan of care by not following physician orders [REDACTED]. Resident #45 did not receive her [MEDICATION NAME] for 3 days. She had to be taken to the emergency room at a local hospital with a possible blood clot. In addition, Resident #45 was not supplied oxygen, as ordered by the physician, which resulted in an oxygen saturation level of 88%. This deficient practice was likely to cause harm for 4 of the residents (17, 45, 160 and 166) on blood thinners and oxygen therapy. The findings are: A. Review of Resident #45's medical record revealed the following information: 1. The Physicians Progress Notes, dated 01/27/11, indicated the resident had a [DIAGNOSES REDACTED]. 2. Long Term Care Physician's admission orders [REDACTED]. 3. The February 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The order had not been transcribed to the MAR upon admission. 4. The Nurses Notes, dated 02/03/11, indicated the nurse was unable to get a palpable radial pulse in the residents right arm. 5. A Physicians Telephone order, dated 02/03/11, indicated that the resident was to return to the emergency department via ambulance for evaluation of the right upper extremity. B. On 03/10/11 at 2:25 pm, during an interview with the Minimum Date Set (MDS)Coordinator, she stated that the long term care admission orders [REDACTED]. MARs were hand written in by the charge nurse/admitting nurse. She verified that the admission orders [REDACTED]. At that time, Charge Nurse #1 was unable to get a pulse. The resident did not want to go to the hospital. But it was explained to her that there was no palpable radial pulse in her right arm. The physician was notified at that time. The family convinced the patient that she needed to go to the hospital. C. On 03/10/11 at 6:00 pm, during an interview was conducted with Family Member #1, who is also the resident's power of attorney. She stated that she was disappointed about the missed medications and that her family member had to be taken back to the hospital in the very cold weather. She stated that the resident "risked getting sick from the cold as well as having another blood clot." D. Review of Resident #45's March 2011 physician's orders [REDACTED]. The oxygen was ordered on [DATE] at the time of her re-admission following an emergency department evaluation. E. On 03/11/11 at 10:20 am, during observation, the resident had a nasal cannula in place connected to an empty portable oxygen container. Her hands were bluish in color. F. On 03/11/11 at 10:25 am, during an interview, the resident stated that she uses the oxygen because the physician said she needed it and "It will make me feel better." G. On 03/11/11 at 10:30 am, during an interview, Registered Nurse #2 verified the portable oxygen container was empty. She then obtained the residents oxygen saturation with a result of 88%. She stated that filling the oxygen containers was the responsibility of the Certified Nursing Assistants.