Every finding on record at The Rio at Mission Trails

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records:The facility failed to document on Resident #1's Psychotropic Medication Consent a medication dosage increase to the residents Lithium medication.These failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings included:Record review of Resident #1's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with other behavioral disturbance (a general term for a group of conditions that cause a gradual decline in memory, thinking, reasoning, language, and the ability to perform every day activities), schizoaffective disorder (a mental health with symptoms that may include hallucinations, delusions, disorganized thinking or speech, and reduced emotional expression or social withdrawal) bipolar type (symptoms include mania, and depression), and anxiety disorder (a mental health condition in which a person experiences excessive fear, worry, or nervousness that is persistent, difficult to control, and interferes with daily life).Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills, had been diagnosed with anxiety disorder, and schizophrenia and was treated with antianxiety medication.Record review of Resident #1's Order Summary Report dated 7/31/26 reflected the following:- Lithium Carbonate Oral Capsule 600 mg, give 1 capsule by mouth one time a day related to schizoaffective disorder, bipolar type with order date 2/25/25 and hold date 7/27/26- Lithium Carbonate Oral Capsule 600 mg, give 600 mg by mouth two times a day for mood stabilization with order date 6/15/26 and discontinued on 7/27/26Record review of Resident #1's MAR dated 8/3/26 for June 2026 reflected the resident was scheduled to receive Lithium 600 mg from 6/1/26 and discontinued on 6/15/26. Resident #1's MAR for June 2026 reflected the resident was scheduled to receive Lithium 600 mg twice a day beginning 6/17/26 and discontinued on 7/27/26.Record review of Resident #1's Psychotropic Medication Consent with effective date 6/17/26 and electronically signed by the ADON on 6/17/26 at 12:00 p.m. reflected with all new orders for psychoactive medication, review with resident and representative and or responsible party, the reason, expected benefit(s), side effects and course of treatment. Check appropriate response below. Record review of Resident #1's Psychotropic Medication consent reflected the date of the order was for 6/17/26, and the consent was generated for Lithium, and the question on the form 3. Is this order a dosage increase? was marked No.During an interview on 8/4/26 at 11:53 a.m., the ADON stated she routinely reviewed medication order lists and noticed Resident #1 had a new order for Lithium and was aware the resident had been treated with Lithium, but the dosage had been increased. The ADON stated a new Psychotropic Medication Consent was generated by her because of the Lithium increase. ADON stated she made contact with the family representative to report the dosage increase to the Lithium medication and obtained verbal consent. The ADON stated, after reviewing Resident #1's Psychotropic Medication Consent form that she had accidently marked No on the section that asked if the order was for a dosage increase. The ADON stated she was not sure if the documentation on the Psychotropic Medication Consent form would make the consent invalid and stated, if I had caught it, I would have corrected it.During an interview on 8/4/26 at 1:36 p.m., the DON stated she, the nurses, and the ADON were responsible for obtaining consents for medication changes related to psychotropic medications. The DON stated the ADON made a documentation error on Resident #1's Psychotropic Medication Consent and that the consent was considered a legal document. The DON stated the documentation error on the consent would make it assume [Resident #1's] family representative did not know the dosage was changed on the lithium.Record review of the facility document titled Documentation, undated reflected in part, .Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file.It has legal requirements regarding accuracy and completeness, legibility and timing.The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on interview and record review, the facility failed to establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights for 1 (Resident #1) of 1 residents that either the resident or their responsible party had a complaint or concern related to the facility reviewed for grievances. The facility failed to implement a grievance process to address resident and responsible party concerns or complaints when Resident #1's next of kin brought complaints to the facility staff that were not addressed as grievances. This failure could place the residents at risk for a decreased quality of life and care within their living environment, and/or not having their needs met.Findings included: Record review of Resident #1's admission Record, dated 06/23/2026, revealed a [AGE] year-old male that admitted to the facility 05/28/2026 with diagnosis that included Type 2 Diabetes Mellitus with Ketoacidosis (can affect individuals with type 2 diabetes-particularly during severe infections, extreme stress, or when insulin therapy is interrupted); Acute Kidney Failure (a sudden loss of kidney function that develops within hours or days); Metabolic Encephalopathy (a general term for global brain dysfunction caused by chemical imbalances in the body, rather than a primary physical brain injury); and Chronic Kidney Disease (where your kidneys are damaged and cannot filter blood properly). Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated cognition intact. Record review of Resident #1's Care Plan, dated 05/29/2026, revealed monitoring of Endocrine system related to cancer and kidney disease and failure, monitoring related to a pacemaker, monitoring for renal failure related to kidney disease, and monitoring of signs and symptoms of complications related to diabetes mellitus. Record review of Resident #1's Order Summary Report, dated 06/23/2026, revealed orders for Humalog KiwkPen 100UNIT/ml inject per sliding scale: if 150-200+ 2 units; 201-250+ 4 units; 251-300+ 6 units; 301-350+ 8 units; 351-400+ 10 units; 401+ administer 10 units and notify MD, subcutaneously before meals and at bedtime. Order Summary Report also revealed Lantus SoloStar Pen-Injector 100UNIT/ml inject 20 units subcutaneously at bedtime. During an interview on 06/23/2026 at 11:13 am, Resident #1's next of kin revealed that she shared multiple complaints with the facility regarding everything from showers to medications. Resident #1's Next of Kin revealed that she expressed to the ADMIN that Resident #1 was not receiving his medications correctly as well as the bed linen being dirty. During an interview on 06/23/2026 at 1:56 pm, the ADMIN revealed that Resident #1's Next of Kin made frequent complaints about everything under the sun and was a frequent complainer and that it would be difficult to document everything. The ADMIN revealed that if it was something easy to address right away, they did not fill out a grievance form. The ADMIN also stated they only file Formal Grievances in PCC. The ADMIN explained that a Formal Grievance was where the word Grievance was used. The ADMIN said they could not say how the facility proved that a complaint was addressed or how issues were tracked and trended. The ADMIN stated that they visited residents often during their 'Champion Rounds' in the mornings and managers shared that info at stand-up. During an interview on 06/23/2026 at 2:04 pm near the dining room, two of the four unknown residents stated that they did not know how to file a grievance. One of four unknown residents stated they would notify the SW. All four residents said they felt that if they used verbiage along the lines of issue, complaint or concern they expected the facility to handle and address the issues and give them some type of resolution, with updates along the way. None of the four residents claim that the word Grievance would have been used by them when reporting issues. During an interview on 06/23/2026 at 2:18 pm, the ADMIN, DON and SW revealed that if staff goes to the SW about a grievance, she entered it into PCC. The DON revealed she sent texts to ADMIN and SW when a resident claimed they have a grievance. The ADMIN, DON and SW stated that if a concern was voiced, they discussed it at stand-up with the team and then they clarified that the follow-up to ensure that the concern was addressed and followed up again at stand-down. During an interview on 06/23/2026 at 2:41 pm, the ADMIN revealed that the facility did not have a policy for their stand-up and stand-down to explain how the meeting was set-up, how issues were addressed and how follow-up was determined. The ADMIN did not have an answer for how oversight within the facility or from outside entities were accomplished without documented addressment of concerns or complaints. Record review of Grievances submitted to the Social Worker and documented in PCC, dated 06/23/2026, revealed three grievances from 05/01/2026 through 06/23/2026. Grievance 1 was 06/19/2026; Grievance 2 was 06/10/2026; and Grievance 3 was on 05/12/2026. Record review of the facility policy titled, Grievance Policy, DATED 11/21/2016, revealed the facility must make prompt efforts to resolve any grievances the resident may have. Policy also reflected that the facility was to keep record of grievance results for a period of no less than three years from issuance of the grievance decision.

Based on interviews and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 5 residents reviewed for medical records. The facility failed to ensure that Resident #1's insulin documentation was accurately recorded in the electronic medical record. This failure could place residents at risk for errors in care and treatment. Findings included: Record review of Resident #1's admission Record, dated 06/23/2026, revealed a [AGE] year-old male, admitted [DATE], with diagnoses that included Type 2 Diabetes Mellitus with Ketoacidosis (can affect individuals with type 2 diabetes-particularly during severe infections, extreme stress, or when insulin therapy is interrupted); Acute Kidney Failure (a sudden loss of kidney function that develops within hours or days); Metabolic Encephalopathy (a general term for global brain dysfunction caused by chemical imbalances in the body, rather than a primary physical brain injury); and Chronic Kidney Disease (where your kidneys are damaged and cannot filter blood properly). Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated cognition intact. Record review of Resident #1's Care Plan, dated 05/29/2026, revealed monitoring of Endocrine system related to cancer and kidney disease and failure, monitoring related to a pacemaker, monitoring for renal failure related to kidney disease, and monitoring of signs and symptoms of complications related to diabetes mellitus. Record review of Resident #1's Order Summary Report, dated 06/23/2026, revealed orders for Humalog KwikPen 100UNIT/ml inject per sliding scale: if 150-200+ 2 units; 201-250+ 4 units; 251-300+ 6 units; 301-350+ 8 units; 351-400+ 10 units; 401+ administer 10 units and notify MD, subcutaneously (under the skin) before meals and at bedtime. Order Summary Report also revealed Lantus SoloStar Pen-Injector 100UNIT/ml inject 20 units subcutaneously at bedtime. Record review of Resident #1's Weights and Vitals Record, dated 06/23/2026, revealed that Resident #1's blood sugar checks on 06/08/2026 was done at 7:44 am, 4:34 pm, 4:38pm, 8:09pm and 8:10 pm. Blood sugar check documentation on 06/05/2026 was done at 11:37 am, 11:39 am, 5:34 pm, 9:37 pm, and again at 9:37 pm. Blood sugar check documentation on 06/04/2026 was done at 11:30am, again at 11:30 am, 5:38 pm, 8:11 pm, and 8:12 pm. Blood sugar check documentation on 05/31/2026 was done at 12:33 am, 12:36 am, 3:09 pm, again at 3:09 pm, 5:19 pm, and 8:43 pm. Blood sugar check documentation on 05/30/2026 was done at 9:51 am, 11:17 am, and 5:00pm. During an interview on 06/23/2026 at 1:45 pm, LVN A stated that the process he used for insulin administration was that he took the residents blood sugar, returned to computer to document the blood sugar, the electronic medical record told him how many units to give, he drew up the insulin, administered it to the resident and then returned to computer to document the location of the injection. LVN A stated that the electronic medical record transferred the blood sugar level from the medication administration page to the weights and vitals page automatically when entered and signed and that he never checked the blood sugar and administered the insulin without documenting it in electronic medical record because the blood sugar was always changing. LVN A also stated that proper procedure was to document when tasks were being completed. LVN A also stated Resident #1 gets insulin on his shift before breakfast, before lunch, and before dinner. During an interview on 06/23/2026 at 2:18 pm, the ADMIN and DON stated that the expectation for insulin administration was to check the sugar, check the resident's orders for amount to administer, and after administering insulin return to document location. The ADMIN and DON both stated that insulin should never be administered without following order if stated to check blood sugar first and that administration should be documented when completed, not later during the shift or after the shift. During an interview on 06/23/2026 at 3:10 pm, the ADMIN stated the negative impact for not documenting medications on time could be that residents did not receive the appropriate medications or at the appropriate time. During an interview on 06/23/2026 at 4:15 pm, LVN A stated that he was unsure why the blood sugars for Resident #1 were not documented at appropriate times. LVN A stated he must have gotten busy and did not make it back to document it right away. LVN A stated that he would never administer insulin by checking the blood sugar first and not seeing the dose needed. LVN A stated that Resident #1's order stated that his blood sugar was to be checked and insulin administered if needed before breakfast, before lunch, before dinner and before bed. Record review of the facility policy titled, Medication Administration and General Guidelines, dated March 2025, revealed, Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and Adheres to the 6 Rights of Medication Administration: Right Time, Right Documentation. Record review of the facility policy titled, Documentation, dated March 2025, revealed information was to be documented in the resident's record correctly and timely as It has legal requirements regarding accuracy and completeness, legibility and timing. Record review also revealed that Documentation also occurs in the clinical software, electronic medical record, Point Click Care (PCC).

Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 4 of 5 residents (Residents #1, #2, #3, and #4) reviewed for medical records. 1. The facility failed to ensure Resident #1's medication administration report did not contain blanks. 2. The facility failed to ensure Resident #2's medication administration report did not contain blanks. 3. The facility failed to ensure Resident #3's medication administration report did not contain blanks. 4. The facility failed to ensure Resident #4's medication administration report did not contain blanks. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records. The findings included: 1. Record review of Resident #1's admission record, dated 5/6/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness or partial paralysis affecting the right side of the body following a stroke), chronic obstructive pulmonary disease (chronic lung disease causing airflow limitation and breathing difficulty), acute respiratory failure with hypoxia (inadequate oxygen levels requiring respiratory support), unspecified protein-calorie malnutrition (poor nutritional status which may impair healing and increase risk for infection), aphasia following cerebral infarction (difficulty communicating following a stroke), dysphasia following cerebral infarction (difficulty swallowing following a stroke increasing risk for aspiration and complications), neuromuscular dysfunction of bladder (impaired bladder function related to nerve dysfunction), tracheostomy status (presence of a surgically created airway opening in the neck), gastrostomy status (presence of a feeding tube inserted into the stomach), and chronic kidney disease stage 3 (moderate decrease in kidney function). Record review of Resident #1's annual MDS assessment, dated 4/28/26 revealed the resident's cognition was severely impaired for daily decision making, with a BIMS score of 3. Record review of Resident #1's care plan revealed the resident had a care planned pressure ulcer identified as Stage 4 to sacrum, initiated 11/10/25 and revised on 04/30/26. The care plan goal stated the resident's pressure ulcer would show signs of healing and remain free from infection through the review date. Interventions included to Administer medications as ordered. Monitor/document for side effects and effectiveness, Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN, Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD, Educate the resident/family/caregivers as to causes of skin breakdown, and Follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #1's May 2026 electronic MAR revealed an order for wound care: sacrum- cleanse with wound cleanser and pat dry. Apply methylene blue foam to wound bed. Apply border gauze, one time a day every Monday, Wednesday, and Friday for stage 4 pressure injury. The order contained blank on 5/4/26. Further review of the MAR revealed the scheduled treatment was left blank with no coding, initials, or documentation to indicate whether the wound care was administered, refused, held, or for the daily order. 2. Record review of Resident #2's admission record, dated 5/6/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stage 4 pressure ulcer of sacral region, unspecified dementia with other behavioral disturbance, type 2 diabetes mellitus without complications, unspecified protein-calorie malnutrition, acute respiratory failure with hypoxia, systemic lupus erythematosus, neuromuscular dysfunction of bladder, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness, pneumonia due to inhalation of food and vomit, gastrostomy status, and oral phase dysphagia. Record review of Resident #2's other type MDS assessment, dated 4/15/26 revealed the resident's cognition was severely impaired for daily decision making, and a BIMS score could not be obtained. Record review of Resident #2's care plan, initiated 2/16/26 and revised 3/17/26, revealed the resident had pressure ulcers to the sacrum stage IV, left heel unstageable, and right heel unstageable. The care plan revealed The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included Do not massage over bony prominences and use mild cleansers for peri-care/washing, Ensure heels are floated with the use of pillows, and The resident requires the use of an air mattress. Record review of Resident #2's April 2026 electronic MAR revealed an order for wound care: left heel - cleanse with NS/WC. pat dry. apply skin prep and leave open to air one time a day for unstageable pressure injury. The order contained blanks on 4/3/26, 4/11/26, and 4/12/26. The MAR also revealed the order was placed on hold from 4/16/26 at 6:43 a.m. through 4/19/26 at 6:43 a.m. and again from 4/19/26 at 5:16 p.m. through 4/22/26 at 5:15 p.m. Record review of the same MAR revealed:- an order for wound care: right heel - cleanse with NS/WC. pat dry. apply medihoney and cover with dry dressing Mon/Wed/Fri and PRN soiling one time a day every Mon, Wed, Fri for pressure injury unstageable-an order for wound care: sacrum - cleanse with wound cleanser. pat dry. apply medihoney, calcium alginate and bordered gauze one time a day every Mon, Wed, Fri for stage 4 pressure injury.Both orders contained a blank entry on 4/3/26. Further review of the MAR revealed the scheduled treatment entries were left blank with no coding, initials, or documentation to indicate whether the treatments were completed, refused, held, or unavailable. 3. Record review of Resident #3's admission record, dated 5/7/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stage 4 pressure ulcer of sacral region, osteomyelitis of vertebra, sacral and sacrococcygeal region, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, emphysema, unspecified severe protein-calorie malnutrition, epilepsy, chronic pain syndrome, muscle weakness, hemiplegia affecting left nondominant side, neuromuscular dysfunction of bladder, tracheostomy status, and gastrostomy status. Record review of Resident #3's admission MDS assessment, dated 3/9/26 revealed the resident's cognition was severely impaired for daily decision making, and a BIMS score could not be obtained. The MDS further revealed she had 1 stage 4 pressure ulcer and received care intervention with a pressure reducing device for bed, pressure ulcer care, applications of dressings, and application of ointments or medications. Record review of Resident #3's April 2026 electronic MAR revealed an order for fluid filled blister (blue) to left heel: cleanse with normal saline, pat dry, paint with betadine, leave OTA every shift for wound care. The order contained blanks on 4/9/26 and 4/14/26. Further review of the MAR revealed the scheduled treatment entries were left blank with no coding, initials, or documentation to indicate whether the treatment was completed, refused, held, or unavailable. 4. Record review of Resident #4's admission record, dated 5/7/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stage 4 pressure ulcer of unspecified site, acute and chronic respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, tracheostomy status, gastrostomy status, paraplegia, dysphagia following cerebral infarction, acute kidney failure with tubular necrosis, neuromuscular dysfunction of bladder, acquired absence of kidney, anoxic brain damage, anemia, and gastro-esophageal reflux disease without esophagitis. Record review of Resident #4's other type MDS assessment, dated 5/5/26 revealed the resident's cognition was severely impaired for daily decision making, and a BIMS score could not be obtained. Record review of Resident #4's care plan, initiated 4/30/25 and revised 3/16/26, revealed the resident had pressure ulcers including stage 4 to left sacrum (buttock/gluteal fold near anus), stage 4 to left ischial, stage 4 to left outer ankle, stage 4 to left shoulder, and stage 4 to right ischium. The care plan revealed [Resident #4] pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included Administer medications as ordered. Monitor/document for side effects and effectiveness, Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN, Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the resident MD, Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, Follow facility policies/protocols for the prevention/treatment of skin breakdown, and Notify nurse immediately of any new areas of skin breakdown: Open area, Redness, Blisters, Bruises, discoloration noted during bath or daily care. Record review of Resident #4's April 2026 electronic MAR revealed orders for:- wound care: sacrum - cleanse with wound cleanser. pat dry. apply medihoney, calcium alginate, and bordered foam one time a day for stage 4 pressure injury,- wound care: left shoulder - cleanse with wound cleanser. pat dry. apply medihoney, calcium alginate, and dry dressing one time a day for stage 4 pressure injury,- wound care: right ischium - cleanse with wound cleanser. pat dry. apply medihoney, calcium alginate and bordered foam one time a day for stage 4 pressure injury,- wound care: left lateral ankle - cleanse with wound cleanser. pat dry. apply medihoney, calcium alginate, and bordered gauze one time a day for stage 4 pressure injury.The orders contained blanks on 4/10/26, 4/22/26, and 4/25/26. The MAR also revealed the orders were placed on hold from 4/14/26 at 7:31 p.m. through 4/17/26 at 1:28 p.m.Further review of the MAR revealed the scheduled treatment entries were left blank with no coding, initials, or documentation to indicate whether the treatments were completed, refused, held, or unavailable. Record review of Residents #1's, #2's, #3's, and #4's skin assessments dated from 3/30/26 through 5/4/26 revealed the residents' wounds had not worsened and all wounds showed a decrease in size during the review period. During an interview on 5/6/26 at 5:31 p.m., LVN C stated he had worked the morning shift from 6:00 a.m. to 6:00 p.m. for the last year. LVN C stated wound care had been a bit of a fiasco and there had been multiple changes in the wound care nurse position. He stated he had filled in at times when there was not a designated wound care nurse. LVN C stated there had been occasions where the facility had a wound care nurse and then all of a sudden they did not, and staff were not informed or aware they were responsible for completing the wound care treatments that day. He stated wound care nurse coverage had been sporadic. LVN C stated he could not say for sure whether wound care treatments associated with blank entries on the MARs had been completed or not completed and stated it was possible the treatments had been done but not documented. LVN C stated there had been times he forgot to document treatments after being called away by other staff and someone later identified the blank entry and had him correct or document it, but due to multiple staffing and management changes that had not really occurred recently. LVN C stated he had been scheduled and responsible for Resident #2's wound care on 4/3/26 and could not state why there had been a blank entry or recall whether the treatment had been completed. LVN C stated failure to provide wound care regularly per physician orders could have led to potential bacteria buildup in the wound. LVN C stated Resident #2 had a colostomy and Foley catheter and may not have required as much incontinent care as other residents, making it possible a dressing may not have been noticed as unchanged for several days. During an interview on 5/6/26 at 4:55 p.m., the DON stated there had been new nurses working on some of the hallways and she did not like seeing blanks on residents' MARs. The DON stated blank entries could have occurred when nurses completed a treatment and then became distracted by residents requesting assistance or other tasks before documenting the treatment. The DON stated staff may have completed the wound care but forgot to document it and acknowledged if it doesn't get documented, it didn't happen. The DON stated if wound care had been completed but not documented, staff could have reviewed the dressing and date on the bandage to determine the treatment had been completed. The DON stated if wound care had not been completed as ordered, the resident could have been at risk for possible infection. Record review of facility policy titled Documentation,, no date, revealed documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident.legal requirements regarding accuracy and completeness, legibility and timing.the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.the facility will ensure that information is comprehensive and timely and properly signed.document completed assessments in a timely manner and per policy.complete documentation as needed in a timely manner.each entry will be dated and timed.each entry will be signed with proper signature and title.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #1) reviewed for infection control: The facility failed to ensure LVN A maintained proper hand hygiene during wound care for Resident #1 during a wound care observation. This failure could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #1's admission record, dated 5/6/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness or partial paralysis affecting the right side of the body following a stroke), chronic obstructive pulmonary disease (chronic lung disease causing airflow limitation and breathing difficulty), acute respiratory failure with hypoxia (inadequate oxygen levels requiring respiratory support), unspecified protein-calorie malnutrition (poor nutritional status which may impair healing and increase risk for infection), aphasia following cerebral infarction (difficulty communicating following a stroke), dysphasia following cerebral infarction (difficulty swallowing following a stroke increasing risk for aspiration and complications), neuromuscular dysfunction of bladder (impaired bladder function related to nerve dysfunction), tracheostomy status (presence of a surgically created airway opening in the neck), gastrostomy status (presence of a feeding tube inserted into the stomach), and chronic kidney disease stage 3 (moderate decrease in kidney function). Record review of Resident #1's annual MDS assessment, dated 4/28/26 revealed the resident's cognition was severely impaired for daily decision making, with a BIMS score of 3. Record review of Resident #1's care plan revealed the resident had a care planned pressure ulcer identified as Stage 4 to sacrum, initiated 11/10/25 and revised on 04/30/26. The care plan goal stated the resident's pressure ulcer would show signs of healing and remain free from infection through the review date. Interventions included to Administer medications as ordered. Monitor/document for side effects and effectiveness, Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN, Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD, Educate the resident/family/caregivers as to causes of skin breakdown, and Follow facility policies/protocols for the prevention/treatment of skin breakdown. During an observation on 5/6/26 at 3:27 p.m., LVN A prepared to provide wound care to Resident #1. Resident #1 was lying in bed and did not respond when spoken to. LVN A washed his hands in the bathroom in the resident's room. LVN A then needed to replace his gown. After putting on a new gown, LVN A put on new gloves, pulled the resident's curtain over with his gloved hand, handed LVN B the bed remote with his gloved hand, removed the resident's blankets, turned the resident to her left side, grabbed a paper tape measure, and began measuring the resident's wound to her sacrum area. LVN A's gloves touched the wound bed while he measured the wound with the paper tape. LVN A then stated he needed a trashcan, removed his gloves, went to the bathroom and washed his hands, returned to the resident's bedside, moved the resident's curtain with his bare hand, grabbed new gloves, and put them on. With the same gloves, LVN A then grabbed wet gauze and cleaned the resident's wound bed. LVN A then removed his gloves and washed his hands in the resident's bathroom. LVN A then returned to the bedside, moved the resident's curtain with his bare hand, put on new gloves, grabbed foam dressing, cut it to size, placed it back on the clean field, grabbed dry gauze, wiped the wound bed, then left to wash his hands again. LVN A returned after washing his hands and used his arm to move the resident's curtain. LVN A placed the foam in the resident's wound bed and covered the wound and foam with an island dressing. LVN A dated the dressing. LVN A and LVN B then secured the same brief back onto the resident. The brief had visible blood from the wound on it and pieces of skin from the resident. During an interview on 5/6/26 at 4:00 p.m., LVN A stated you cannot touch objects that are not clean and then touch a resident's wound. LVN A stated he guessed medically it would be considered cross-contamination even if gloves were changed and the wound was cleaned. LVN A stated he did not remember touching the curtain during wound care; however, if he had touched the curtain and then touched the wound or wound care supplies, it would have been cross-contamination that could cause infection. When asked why the resident's brief was not changed and the same brief was reapplied after wound care, LVN A stated the aides usually changed the brief after care was provided. During an interview on 5/6/26 at 4:03 p.m., the Director of Nursing (DON) stated if staff touched the curtain or bedroom remote during wound care, it could have caused cross-contamination because staff did not know what contaminants could have been present on those surfaces. The DON stated hand sanitizer was available and should have been used in between glove changes during wound care. The DON stated cross-contamination during wound care could have placed the resident at risk for possible infection. The DON also stated the nurses could have changed and should have changed the resident's brief during care to ensure a clean brief was applied. Record review of the facility's undated Infection Control Policy & Procedure Manual, policy number AD 03-8.0, no date, revealed Hand Hygiene, hand hygiene continues to be the primary means of preventing the transmission of infection.some situations that require hand hygiene: before and after direct resident contact.before and after performing any invasive procedure.before and after changing a dressing.after contact with a resident's mucous membranes and body fluids or excretions.after handling soiled or used linens, dressings, bedpans, catheters and urinals.after removing gloves or aprons.consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.gloves were worn to provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin.to reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures.to reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite can transmit these microorganisms to another resident.gloves must be changed between resident contacts, and hands washed after gloves are removed.wearing gloves does not replace the need for hand washing.failure to change gloves between resident contacts is an infection control hazard.adequate disinfection of bedside equipment and environmental surfaces (e.g. bed rails, bedside tables, carts, commodes, doorknobs, faucet handles).for pathogens.that can survive as a fomite for prolonged periods of time.equipment that is visibly soiled with blood or body fluids will be cleaned immediately with an approved disinfectant.

Based on interviews and records review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs for 1 of 3 residents (Resident #1) reviewed for care planning. The facility failed to ensure Resident #1's comprehensive care plan included the resident's need for oral suction. This failure could result in residents not receiving the intended care. Findings included:Record review of Resident #1's admission Record dated 4/16/2026 reflected a [AGE] year-old female admitted to the facility on [DATE], with relevant diagnoses that included dysphagia (the inability to swallow normally). Record review of Resident #1's quarterly MDS submitted 2/27/2026 reflected a BIMS score of 0 due to the resident's inability to be understood. Section 06110 (Special Treatments, Procedures, and Programs) of the MDS did not indicate Resident #1 required suctioning on admission, while a resident, or at discharge. Record review of Resident #1's Care Plan Report printed 4/16/2026 did not reveal interventions related to oral suctioning. Record review of Resident #1's Order Summary Report dated 4/16/2026 reflected a physician's order for NPO diet NPO texture, NPO consistency [sic] dated 2/13/2026.Resident #1 was unable to participate in an interview attempted on 4/16/2026 due to cognitive and functional decline. In an interview on 4/16/2026 at 1:05 PM, LVN B said Resident #1 required occasional oral suctioning. He was unsure if Resident #1 had a physician's order or care planning for the suctioning. He said he knew Resident #1 required the treatment occasionally because he had been working with her for a while and there was suctioning equipment in her room, which indicated it was needed. In an interview on 4/16/2026 at 2:32 PM, RN A said he had performed oral suctioning on Resident #1 during the shift on 4/14/2026. He said Resident #1 occasionally required oral suctioning due to her medical history. In an interview with MDS on 4/17/2026 at 10:10 AM, she said Resident #1's care plan did not include the need for suctioning because there was not a physician's order for suction. She said she created that area of the care plan based on physician's orders. She said the suctioning treatment should be included in the care plan to ensure Resident #1 received the treatment as needed. In an interview with the DON on 4/16/2026 at 1:57 PM, she said she had just started the position of DON and was unaware Resident #1 required occasional oral suctioning. She said this intervention should be in the care plan to ensure proper care. Record review of the facility policy titled Comprehensive Care Planning (undated) reflected the following:Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interview and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for respiratory care.The facility failed to ensure Resident #1 had a signed, physician's order for oral suctioning.This failure could result in residents not receiving intended care. Findings included:Record review of Resident #1's admission Record dated 4/16/2026 reflected a [AGE] year-old female admitted to the facility on [DATE], with relevant diagnoses that included dysphagia (the inability to swallow normally). Record review of Resident #1's quarterly MDS submitted 2/27/2026 reflected a BIMS score of 0 due to the resident's inability to be understood. Section 06110 (Special Treatments, Procedures, and Programs) of the MDS did not indicate Resident #1 required suctioning on admission, while a resident, or at discharge. Record review of Resident #1's Care Plan Report printed 4/16/2026 did not reveal interventions related to oral suctioning. Record review of Resident #1's Order Summary Report dated 4/16/2026 reflected a physician's order for NPO diet NPO texture, NPO consistency [sic] dated 2/13/2026. Further review of the report revealed there was no order for suction. Resident #1 was unable to participate in an interview attempted on 4/16/2026 due to cognitive and functional decline. In an interview on 4/16/2026 at 1:05 PM, LVN B said Resident #1 required occasional oral suctioning. He was unsure if Resident #1 had a physician's order or care planning for the suctioning. He said he knew Resident #1 required the treatment occasionally because he had been working with her for a while and there was suctioning equipment in her room, which indicated it was needed. In an interview on 4/16/2026 at 2:32 PM, RN A said he had performed oral suctioning on Resident #1 during the shift on 4/14/2026. He said Resident #1 occasionally required oral suctioning due to her medical history. He was unsure if there was a physician's order for suctioning. In an interview on 4/16/2026 at 1:57 PM, the DON said she recently become the DON for the facility, and she was unaware Resident #1 required occasional oral suctioning. She said Resident #1 should have had a physician's order for suctioning. Record review of the facility policy titled Airway Suctioning (undated) reflected the following:Suctioning is prescribed for residents unable to clear the airway by coughing .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1) reviewed for care plans in that: Resident #1's comprehensive person-centered care plan did not address interventions due to the diagnosis of osteopenia (a condition of low bone mineral density, weakening bones). This failure could place residents at risk of not receiving appropriate treatment and services.The findings were: Record review of Resident #1's face sheet, dated 4/7/26, revealed an admission date of 2/4/2026 with diagnoses that included: Depression (persistent feeling of sadness and loss of interest), Arthritis (bone disease causing inflammation, pain, stiffness, and swelling in joints), and Diabetes (disorder when the body cannot use its insulin effectively). Record review of Resident 1's admission MDS assessment, dated 1/26/2026, revealed Resident #1's BIMS score was 3, which indicated severe impairment. Record review of Resident #1's care plan, last review/revision date 2/10/2026, did not reveal a care plan for osteopenia. Record review of Resident #1's hospital clinical paperwork, dated 1/25/26, revealed the resident had a diagnosis of osteopenia prior to admission to the nursing facility. During an interview with Resident #1's responsible party on 4/7/2026 at 8:30 AM revealed, all nursing staff should know [Resident #1's] diagnosis of osteopenia to help care for her needs, During an interview on 04/7/26 at 10:09 a.m., the DON stated the MDS Coordinator, or any nurse, was responsible for updating the care plans. The DON stated the comprehensive person-centered care plan was essential because it identified the types of care and services residents were supposed to receive. She does not know why it was not done for Resident #1 but would look into it. During an interview on 04/07/26 at 10:58 a.m., the MDS Coordinator stated she was responsible for developing and revising the comprehensive person-centered care plan. The MDS Coordinator stated the comprehensive person-centered care plan was important because it contained information on how to care for Resident #1 and identified the types of services the resident needed. She did not know why it was not completed, but thinks it was overlooked and would start auditing care plans. Record review of the facility's policy and procedure titled, Comprehensive care planning, undated revealed in part, .Policy Statement .An individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas .b. Incorporate risk factors associated with identified problems .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .d. at least quarterly .

Based on interview and record review the facility failed to implement a grievance policy that included ensuring that all grievances shared in resident council were transcribed to grievance forms and submitted to the Grievance Official for 6 out of 6 residents that were present for Resident Council at any given time and complained month to month anonymously. The facility failed to address resident grievances mentioned in the resident council through the appropriate processes. This failure could place the residents at risk for a decreased quality of life and care within their living environment, and/or not having their needs met. The findings included:Record reviews of the Resident Council minutes from 03/2025-02/2026 revealed that every month a complaint of staff on their personal cells phones while providing care or while standing in resident common areas were documented by Activity Director. Record review of the facility's Grievance logs, dated 03/2025-02/2026, revealed no grievance forms related staff cell phone usage. Interview with residents in the Resident Council meeting on 03/24/2026 at 2:14 pm, revealed 6 residents who wanted to maintain anonymity participated. The resident stated they notified staff of their concerns regarding cell phone usage and that it may improve for a short time but was still always a concern. The residents stated that the staff started putting earphones in their ears, so it was not obvious that they were on the phone.Interview with the Activity Director on 03/25/2026 at 11:20 am revealed that she did not complete a grievance form for concerns shared during the Resident Council. The Activity Director stated that she brought the minutes into stand-up and they discussed what was mentioned in the council meeting. The surveyor asked how they made sure that they addressed the residents' concerns if they were not filling out the grievance forms. The Activity Director stated that the Administrator followed up on the items discussed. The Activity Director stated that she knew they had addressed it because she remembered signing In-services regarding cell phones.Interview with the Administrator on 03/25/2026 at 1:30pm revealed that facility had addressed the issues brought up in Resident Council and that he was sure that there were in-services regarding cell phone usage. Administrator provided in-services that spanned over a year and not one in-service produced specifically mentioned cell phone usage.The surveyor requested a policy from the facility related to the resident council on 03/24/2026 at 3:45 pm and 03/25/2026 at 12:45 pm as well as 5:15 pm. A policy was not provided.Record review of facility's in-services for 03/2025-02/2026 revealed no in-service regarding cell phone usage specifically. Record review of facility Grievance Policy, DATED 11/21/2016, revealed that the facility must make prompt efforts to resolve any grievances the resident may have. Policy also reflected that the facility was to keep record of grievance results for a period of no less than three years from issuance of the grievance decision. Record review of Resident Council policy could not be accomplished as policy was never presented to surveyors. Surveyor asked for policy on 03/24/2026 at 3:45 pm and 03/25/2026 at 12:45pm and 5:15pm. A policy was not provided.

Based on interview and record review, the facility failed to use the services of a registered nurse of at least 8 consecutive hours a day, 7 days a week for 9 of 59 days reviewed (2/17/2026, 2/21/2026, 2/23/2026, 2/24/2026, 2/26/2026, 3/3/2026, 3/7/2026, 3/12/2026, 3/21/2026) reviewed for RN coverage as well as having a designated Director of Nursing from 02/14/2026 through 3/24/2026.The facility failed to ensure they had an RN charge nurse on duty on 2/17/2026.2/21/2026, 2/23/2026, 2/24/2026, 2/26/2026, 3/3/2026, 3/7/2026, 3/12/2026, 3/21/2026.The facility failed to ensure that an RN served as a designated Director of Nursing from 2/14/2026 through 3/24/2026.This failures could place the residents at risk of missed nursing assessments, interventions, care and treatment.Findings include:Record review of the February 2026 overall RN hours reflected less than 8 hours worked by an RN on 2/17/2026 4 hours by one RN and 5 hours by another- not consecutive, 2/21/2026 7.8 hours by one RN and 7.7 by another RN- not consecutive, 2/23/2026 one RN 7.6 hours, 2/24/2026 one RN 6.8 hours and another RN 6.3 hours- Not consecutive, 2/26/2026 one RN 2 hours.Record review of the March 2026 overall RN hours reflected less than 8 hours worked by an RN on 3/3/2026 one RN for 2 hours, 3/7/2026 on RN for 2 hours, 3/12/2026 one RN for 2 hours, 3/21/2026 one RN for 7.5 hours and another RN for 2.1 hours- not consecutive.Record reviews of timecard punches for days showing less than 8 hours of RN coverage revealed 11 of 59 days reviewed did not have 8 consecutive hours of RN coverage.During an interview on 3/24/2026 at 11:38 am, the Administrator revealed that the facility had not had a designated DON since the previous DON left on 2/13/2026. The Administrator also stated that they had a corporate nurse come in 1-2 times a week. The Administrator went on to state that the new DON would be starting that week. During an interview on 3/23/2026 at 1:35 pm, RN I stated that he was unaware of who his supervisor was since there was not a designated DON at the moment. RN I stated that he was unsure who to report to and he also stated that he did not know who the corporate RN was. During an interview on 3/25/2026 at 11:30 am, the Human Resources Coordinator (HRC) stated that the last DON worked 2/13/2026 and they were onboarding a new DON. The HRC stated that a corporate nurse was coming into the facility to assist but they did not clock in and out while in building to verify which days they were there and which days they were not.

Based on observation, interview and record review the facility failed to ensure that a medication error rate was not 5 percent or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which involved 2 of 6 residents (Residents #47 and #75) and 3 of 4 staff (LVN B, and LVN C) reviewed for medication administration reviewed for medications errors. LVN F administered Resident #47's Injectable insulin without first priming the pen-injector.LVN L failed to administer Resident #75's insulin. These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.The findings include: 1, A record review of Resident #47's admission record dated 3/25/2026 revealed an admission date of 2/19/2025 with diagnoses which included type II diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar levels). A record review of Resident #47's quarterly MDS assessment dated [DATE] revealed Resident #47 was a [AGE] year-old male admitted for long term care with supports for insulin injection therapies. Resident #47 was assessed with a BIMS score of 12 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #47's physician's orders revealed the physician prescribed for Resident #47 to receive insulin aspart via an injection before meals per a sliding scale according to his blood sugar level, Insulin Aspart (with Niacinamide)) Inject as per sliding scale: if 150 - 199 = 2 units ; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; . During an observation and interview on 3/25/2026 at 4:38 PM revealed LVN F assessed Resident #47's blood sugar level as 342 and prepared and administered 8 units of insulin aspart to Resident #47 without first priming the injector pen. LVN F stated he had administered Resident #47's insulin without first priming the insulin injector pen. LVN F stated he was vaguely familiar with priming insulin syringes but was not certain if the practice applied to insulin injection pens. LVN F stated the practice of not priming insulin injections could be that residents would not receive the dose as prescribed by the physician. 2. A record review of Resident #75's admission record dated 3/25/2026 revealed an admission date of 3/14/2026 with a diagnosis of diabetes type II. A record review of Resident #75's admission MDS assessment dated [DATE] revealed Resident #75 was a [AGE] year-old female admitted for long term ADL care. A record review of Resident #75's physician's orders revealed the physician prescribed for Resident #75 to receive an injection of Lantus (a long-acting, man-made insulin used once daily to control high blood sugar in adults with type 2 diabetes) insulin glargine solution 100 units / ml, inject 20 units subcutaneously twice a day, mornings and evenings. During an observation and interview on 3/24/2026 at 7:23 AM revealed LVN L had assessed Resident #75 with a blood sugar of 61 and decided not to administer Resident #75's prescribed insulin glargine because LVN L believed she had standing orders from the Medical Director to hold insulin glargine when a person's blood sugar levels were below 70. LVN L stated she was taught this by LVN C. During an interview on 3/25/2026 at 4:00 PM the Regional Clinical RN stated the policy, training, and professional standard was for nursing staff to administer medications per the physicians' orders and to follow the drug manufactures instructions for using their medication administration devices e.g., insulin injection pens which should be primed prior to administering the injection and to administer long acting insulin regardless of current blood sugar levels if the physician's orders did not specify parameters. The Regional Clinical RN stated if the nurse had a professional concern to withhold a medication the nurse should assess the resident and give a report to the physician. The Regional Clinical Nurse stated there were no standing orders to hold long-acting glargine insulin. The Regional Clinical Nurse stated the potential negative outcome could be residents would not receive their intended effects from their medication. A record review of the facility's undated policy Medication Administration and General Guidelines revealed, Medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices and only by persons legally authorized to do so. procedure: . Medications are administered at the time they are prepared medications are not pre poured. This person then records the administration on the residence medication administration record at the time the medication is given at the end of each medication passed the person administering the medication reviews the medication administration record to ascertain that all necessary doses were administered and documented . If a dose of regularly scheduled medication is withheld, refused, forgiven at other than the scheduled time, the physician must be notified.

Based on interviews and record reviews, the facility failed to ensure residents were free from significant medication administration errors for 5 of 12 Residents (Residents #2, #40, #60, #68, and #78) reviewed for medication administration of medications with parameters. -The facility failed to ensure nursing staff administered blood pressure medications to Residents #2, #40, #60, #68, and #78 per their prescribed orders. This failure could place residents at risk of not receiving the intended therapeutic effects of their prescribed medications. The findings include: A record review of Resident #2's admission record dated 3/23/2026 revealed an admission date of 11/3/2025 and a discharge date of 11/9/2025 with a diagnosis of hypertension (high blood pressure.) A record review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for long term care and supports for his tracheostomy. A record review of Resident #2's physician's orders revealed on 11/4/2025 at 5:51 pm the physician prescribed for Resident #2 to receive hydralazine (a vasodilator medication used to lower high blood pressure by relaxing blood vessels) 25mg as needed for high blood pressure episodes, give 1 tablet via g-tube [a medical device inserted through the abdominal wall directly into the stomach to provide nutrition, fluids, and medication when oral intake is insufficient] every 6 hours as needed for SBP [systolic blood pressure, the top number in a blood pressure reading, measuring the force of blood against artery walls when the heart contracts] greater than 160 and/or heart rate greater than 90. A record review of Resident #2's November 2025 medication administration record (MAR) revealed:- On the evening of 11/4/2025 LVN C assessed Resident #2 with a heart rate of 94, greater than 90, and had not administered Resident #2's hydralazine as prescribed by the physician.- On the Morning of 11/6/2025 LVN M assessed Resident #2 with a SBP of 165, greater than 160, and had not administered Resident #2's hydralazine as prescribed by the physician.- On the evening of 11/6/2025 LVN N assessed Resident #2 with a SBP of 165, greater than 160, and had not administered Resident #2's hydralazine as prescribed by the physician.- On the evening of 11/7/2025 LVN N assessed Resident #2 with a SBP of 177, greater than 160, heart rate of 112, greater than 90 and had not administered Resident #2's hydralazine as prescribed by the physician.- On the morning of 11/8/2025 LVN A assessed Resident #2 with a SBP of 177, greater than 160, a heart rate of 112, greater than 90 and had not administered Resident #2's hydralazine as prescribed by the physician.- On the evening of 11/8/2025 LVN A assessed Resident #2 with a heart rate of 92, greater than 90, and had not administered Resident #2's hydralazine as prescribed by the physician. A record review of Resident #40's admission record dated 3/23/2026 revealed an admission date of 12/17/2025 with a diagnosis of spina bifida (a common neural tube birth defect where the spine and spinal cord do not form properly, leaving an opening in the backbone. It ranges from mild to severe, often causing physical and neurological challenges like leg paralysis or bladder issues, typically requiring lifelong care, treatments, and surgery.) A record review of Resident #40's quarterly MDS assessment dated [DATE] revealed Resident #40 was a [AGE] year-old female admitted for long term care with ADL's and supports for her tracheostomy and ventilator. Resident #40 was assessed with a BIMS score of 12 out of a possible 15 which indicated mild cognitive impairment. A record review of Resident #40's physician's orders revealed on 8/14/2025 the physician prescribed for Resident #40 to receive midodrine (a medication used to treat low blood pressure, particularly orthostatic hypotension, by constricting blood vessels to raise blood pressure) 10mg, hold for blood pressure greater than 110. A record review of Resident #40's March 2026 medication administration record revealed:- On 3/1/2026 at 11:30 AM LVN A assessed Resident #40 with a SBP of 141, greater than 110, and administered Resident #40's midodrine contrary to the physicians' orders. - On 3/1/2026 at 5:00 PM LVN A assessed Resident #40 with a SBP of 120, greater than 110, and administered Resident #40's midodrine contrary to the physicians' orders. - On 3/2/2026 at 11:30 AM LVN B assessed Resident #40 with a SBP of 107, less than 110, and had not administered Resident #40's midodrine per the physicians' orders. - On 3/5/2026 at 5:00 PM LVN C assessed Resident #40 with a SBP of 108, less than 110, and had not administered Resident #40's midodrine per the physicians' orders. - On 3/7/2026 at 5:00 PM LVN A assessed Resident #40 with a SBP of 128, greater than 110, and administered Resident #40's midodrine contrary to the physicians' orders. - On 3/22/2026 at 11:30 AM LVN A assessed Resident #40 with a SBP of 136, greater than 110, and administered Resident #40's midodrine contrary to the physicians' orders. A record review of Resident #60's admission record dated 3/25/2026 revealed an admission date of 6/16/2025 with a diagnosis of hypertension (high blood pressure.) A record review of Resident #60's quarterly MDS assessment dated [DATE] revealed Resident #60 was a [AGE] year-old female admitted for long term care with supports for ADL and high blood pressure. Resident #60 was assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. A record review of Resident #60's physician's orders dated 3/25/2026, revealed on 11/21/2025 the physician prescribed for Resident #60 to receive hydralazine 10mg every 6 hours as needed for high blood pressure, give IF SBP is greater than 170. A record review of Resident #60's March 2026 medication administration record revealed:- On the morning of 3/3/2026 MA O recorded Resident #60's SBP as 178, greater than 170, and had not administered Resident #60's hydralazine as prescribed by the physician. - On the morning of 3/19/2026 MA O recorded Resident #60's SBP as 173, greater than 170, and had not administered Resident #60's hydralazine as prescribed by the physician. A record review of Resident #68's admission record dated 3/25/2026 revealed an admission date of 7/20/2025 with a diagnosis of hypertension (high blood pressure.) A record review of Resident #68's quarterly MDS assessment dated [DATE] revealed Resident #68 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 15 out of a possible 15 which indicated intact cognition. A record review of resident #68's physician's orders revealed on 12/19/2025 the physician prescribed for Resident #68 to receive hydralazine 25mg via her gastronomy tube, give 1 tablet via g-tube every 8 hours as needed for SBP greater than 160. A record review of Resident #68's March 2026 medication Administration record revealed:- On the morning of 3/11/2026 LVN L assessed Resident #68 with a SBP of 162, greater than 160, and had not administered Resident #68's hydralazine per the physician's orders. - On the evening of 3/11/2026 LVN L assessed Resident #68 with a SBP of 162, greater than 160, and had not administered Resident #68's hydralazine per the physician's orders. - On the morning of 3/19/2026 LVN L assessed Resident #68 with a SBP of 164, greater than 160, and had not administered Resident #68's hydralazine per the physician's orders. A record review of Resident #78's admission record dated 3/25/2026 revealed an admission date of 3/27/2025 with a diagnosis of hypertension (high blood pressure.) A record review of Resident #78's quarterly MDS assessment dated [DATE] revealed Resident #78 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 3 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #78's physician's orders dated 3/25/2026 revealed on 7/21/2025 the physician prescribed for Resident #78 to receive hydralazine 25mg as needed for high blood pressure, give 1 tablet by mouth every 6 hours as needed for high blood pressure greater than 170. A record review of Resident #78's March 2026 medication administration record revealed:- On the morning of 3/2/2026 MA P documented a SBP for Resident #78 as 173, greater than 170, and had not administered resident #78's hydralazine per the physician's orders.- On the morning of 3/3/2026 MA P documented a SBP for Resident #78 as 173, greater than 170, and had not administered resident #78's hydralazine per the physician's orders. During an interview on 3/25/20026 at 3:50 PM the Medical Director stated his expectation was for nursing staff to follow physicians' orders and if needed to call the physician and clarify the orders. During a joint interview on 3/25/2025 at 4:20 PM the Administrator and the Regional Clinical RN stated the policy, training, and the expectation was for nursing staff to administer medications by following physicians' orders and if needed to report to physicians and obtain order clarifications. A record review of the facility's undated policy Medication Administration and General Guidelines revealed, Medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices and only by persons legally authorized to do so. procedure: . Medications are administered at the time they are prepared medications are not pre poured. This person then records the administration on the residence medication administration record at the time the medication is given at the end of each medication passed the person administering the medication reviews the medication administration record to ascertain that all necessary doses were administered and documented . If a dose of regularly scheduled medication is withheld, refused, forgiven at other than the scheduled time, the physician must be notified.

Based upon staff interview, review of medical records, and review of the policy, the facility failed to ensure each resident is screened for a Mental Disorder (MD) or Intellectual Disability (ID) prior to admission of 2 residents in the sample of 6 (Resident #4 and Resident #50) reviewed for Preadmission Screening and Resident Review (PASRR).The facility failed to ensure Resident #4 had an accurate PASRR Level 1 (PL1) Screening for mental disorder or intellectual disability prior to admission. The facility failed to ensure that Resident #50 had an accurate PASRR Level 1 Screening which indicated a diagnosis of mental illness. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. The findings include: 1. Review of Resident #4's admission record, dated 03/25/2026, reflected a [AGE] year-old male. He was admitted on [DATE] and re-admitted on [DATE]. Review of Resident #4's diagnosis report dated 03/24/2026, reflected diagnoses which included schizophrenia, bipolar disorder, and vascular dementia. Review of Resident #4's quarterly Minimum Data Set (MDS) dated [DATE], reflected the resident had a BIMS score of 14, which indicated he was cognitively intact. The resident was mobile via wheelchair, required assistance with transfers, incontinence care, and opening food items. Resident #4's active diagnoses included bipolar disorder and schizophrenia, and he was taking antianxiety and antidepressant medications. Review of Resident #4's initial PASRR Level I (PL1) dated 04/25/2019 reflected a positive determination that there was evidence or an indicator this was an individual that had a mental Illness. A second PL1 Screening dated 04/26/2019 reflected a negative determination that there was no evidence or an indicator this was an individual that had a mental illness. A change of ownership prompted a PL1 Screening dated 08/24/2022 reflected a negative determination that there was no evidence or an indicator this was an individual that had a mental illness. The medical record did not contain PL1 Screening using the revised June 2023 pre-admission screening form. The medical record did not contain a PASRR level II evaluation prior to admission to the facility. Review of Resident #4's current care plan dated 03/19/2026 documented that the resident had an impaired cognitive function/dementia or impaired thought processes [related to] BIPOLAR DISORDER, UNSPECIFIED, VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE, SCHIZOPHRENIA, UNSPECIFIED. During an interview on 03/24/2026 at 6:08 p.m., the MDS LVN revealed that she submitted the CHOW PL1 on 8/24/2022 for Resident #4 and said dementia was his primary diagnoses and they do have evidence from a doctor that dementia is the primary diagnosis so his PL1 was negative and a PE was not required. She said she was trained to code Section C C0100. Mental Illness with No indicating there was no evidence or an indicator this was an individual that had a mental illness if the individual's primary diagnosis was dementia. The MDS LVN said she understood that if a PE was not completed on a resident the facility would not know if they would have qualified for PASRR services and it could be a concern for their care as the individual with a mental illness could receive additional mental health services. She said she was aware that Resident #4 was an individual with a mental illness, but his primary diagnosis was dementia, therefore requiring her to code question C0100. Mental Illness with No. The MDS LVN reviewed the former PL1 screening form, and it did not reflect if there was evidence that dementia was the primary diagnosis for Resident #4 as what was revised with the June 2023 Version 4.0 form. During an interview on 03/24/2026 6:54 p.m., the Regional MDS Nurse revealed that Resident #4's primary diagnosis was dementia, and they do have evidence from a doctor that dementia is the primary diagnosis and the mental illness diagnosis is secondary, therefore a PL1 would not be required. He said he has worked with PASRR for more than 20 years and knows how it works and said to the MDS LVN not to worry if there is a citation for non-compliance as it would not be an issue and would not pass enforcement. He said PASRR PL1 was completed for Resident #4 at admission and it was negative for PE. He said the former MDS LVN was good at her job and completed the screening correctly and was trained to omit the mental illness if dementia was a primary diagnosis. The Regional MDS Nurse said that the referring entity marked the initial 04/25/2019 PL1 incorrectly and coded that there is evidence or an indicator that Resident #4 had a mental illness but made the correction on the 04/26/2019 PL1 and coded there is no evidence or indicator that Resident #4 had a mental illness, despite a diagnosis of schizophrenia and bipolar disorder. The Regional MDS Nurse said he is aware the PASRR Level 1 Screening form was revised in June 2023; however, he did not believe Resident #4 required a new PL1 to reflect there is evidence that dementia is the primary diagnosis for this individual. He said the initial PL1 was sufficient to meet the pre-admission screening criteria. He said he understands the importance of providing residents with mental health services if they are evaluated and found eligible for services. During an interview on 03/25/2026 at 6:30 p.m., the Administrator said he was not well versed in PASRR but said he is working with his staff to ensure pre-admission screenings are completed for every resident admitted to the facility. He said he is working with the staff to ensure they are accurately screening residents as inaccurate screenings can be a concern with the services provided to a resident. 2. Record review of Resident #50's face sheet, dated 03/24/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included Schizophrenia (chronic, severe brain disorder affecting >1% of the population, causing hallucinations, delusions, and disorganized thinking), Huntington's Disease (fatal, inherited neurodegenerative disorder caused by a faulty dominant gene that causes progressive breakdown of nerve cells in the brain), Depression (common, serious mood disorder characterized by persistent sadness, loss of interest, fatigue and sleep/appetite changes), Anxiety (common, intense, and persistent fear or worry that interferes with daily life), Hydrocephalus (an accumulation of cerebrospinal fluid (CSF) within the brain's ventricles, causing increased pressure , tissue damage, and potential long-term developmental issues),and Altered Mental Status (broad term for any, often sudden, change in brain function, including confusion, decreased alertness, agitation, or hallucinations). Record review of Resident #50's admission MDS, dated [DATE], revealed diagnoses which included schizophrenia and a BIMS level of 02. Record review of Resident #50's care plan, dated 03/22/2026, revealed the resident took an anti-psychotic medication for schizophrenia. The care plan also reflected that Resident # 50 took an anti-anxiety medication for anxiety, an anti-depressant for depression, and had impaired cognitive function or impaired thought processes related to Huntington's disease. Record review of Resident #50's admission paperwork from the referring facility, dated 02/15/2026, revealed a list of diagnoses and medical history to include schizophrenia. Record review of Resident #50's Level 1 PASRR screening that was completed by the referring entity, completed on 02/23/2026, indicated in section C0100 that there was no evidence of this individual having a mental illness. Record review of Resident #50's clinical chart, dated 03/24/2026, revealed under the Miscellaneous Chart tab, where uploaded clinical documentation from outside entities is saved, that there was not a secondary Level 1 PASRR assessment by the facility to confirm that the resident's Level 1 PASRR was accurately marked as negative despite the diagnosis in the clinical assessment data received by the facility from the referring entity. [NAME] review of a PASRR facility policy dated 03/06/2019 revealed facility stance of reviewing the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. During an interview on 03/24/2026 at 10:37 am the MDS LVN stated that Resident #50's PL1 was marked negative and that she did not double check the PL1 against what the hospital sent to verify accuracy. The MDS LVN was unsure of the protocol verifying the accuracy of the PL1 that the referring entity filled out. The surveyor asked the MDS LVN if there was a reason why, despite having an approved diagnosis for a positive PL1 Resident #50 may have been marked negative in section C0100 and the MDS LVN replied that a primary diagnosis of dementia cancels out the mental illness diagnosis. The surveyor asked the MDS LVN what Resident #50's primary diagnosis was and MDS LVN revealed that the primary diagnosis for Resident #50 was Huntington's Disease. The surveyor asked the MDS LVN if Huntington's Disease would affect the PL1 outcome and MDS LVN revealed that it should not. During an interview with the MDS LVN on 03/24/2026 at 2:35 pm it was revealed that the facility submitted a positive PL1 for Resident #50 into the database and was awaiting the Local Authority to schedule a day and time for a PASRR Evaluation for Resident #50. The MDS LVN felt that since it had not a full 30 days after admission into the facility Resident #50 not having the positive PL1 should not be a problem. The surveyor asked the MDS LVN if a policy for the facility had the 30 days listed as the window of time to provide a correct PL1 for any resident admitting to the facility. The MDS LVN stated that she would have to verify the facility policy for PL1's. During an interview with the Regional MDS Nurse on 03/24/2026 at 09:08 am, the Regional MDS Nurse stated that Resident #50's PL'1 is to be entered into the system as it was written by the referring entity. The Regional MDS Nurse stated that MDS LVN completed their job correctly. The surveyor asked the Regional MDS Nurse when does the facility verify the correctness of the PL1 submitted to the facility and the Regional MDS Nurse stated that the facility would do a correction when a new qualifying diagnosis was presented or diagnosed. The surveyor asked the Regional MDS Nurse what happens if the referring entity's paperwork lists the qualifying diagnosis and was submitted to the facility before Resident #50's admission for review for admission to facility. The Regional MDS Nurse stated that they just enter what referring entity marks. The surveyor mentioned that the PASRR policy for the facility reflected that the facility will enter the PL1 Screening Form exactly as written except for corrections to identifying data and that the facility is required to review the submitted PL1 for accuracy per their policy. The Regional MDS Nurse stated that they would need to review the facility policy due to not being sure about 'correcting' the referring entities submitted PL1. Review of the facility document, Documentation undated reflected: Goal 1. The facility will maintain complete and accurate documentation for each resident. Procedure 2. Review documents to determine need for follow-up monitoring. Review of PASRR Level 1 (PL1) Screening Form, June 2023, Version 4.0 reflected: Section C. C0090. Primary Diagnosis of Dementia.Is there evidence that dementia is the primary diagnosis for this individual? C0100. Mental Illness. Is there evidence or an indicator this is an individual that has a Mental Illness? C0200. Intellectual Disability. Is there evidence or an indicator this is an individual that has an intellectual Disability? C0300. Developmental Disability. Is there evidence or an indicator that this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability? Review of PASRR Level 1 Screening, July, 2021, V.3 form reflected: Section C C0100. Mental Illness. Is there evidence or an indicator this is an individual that has a Mental Illness? C0200. Intellectual Disability. Is there evidence or an indicator this is an individual that has an intellectual Disability? C0300. Developmental Disability.Is there evidence or an indicator that this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability? Review of the facility document, PASRR Level 1 Screen Policy and Procedure dated 3-6-2019 reflected: PASRR Program has 3 Goals: 1. To identify individuals with Ml, ID, or DD/RC.3. The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations.

Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 2 of 8 residents (Residents #51 and #94) reviewed for administration and documentation of medications. On 3/24/2026 at 7:34 AM LVN C said she had administered Resident #51's medications but had not documented the administration.On 3/24/2026 at 7:34 AM LVN C said she had administered Resident #94's medications but had not documented the administration. These failures could place residents at risk for not receiving the therapeutic effects of their medications.The findings include: A record review of Resident #51's admission record dated 3/24/2026 revealed an admission date of 1/24/2026 with diagnoses which included chronic obstructive disease (a progressive, incurable lung disease-primarily caused by smoking-that obstructs airflow, causing severe breathing difficulties, persistent cough, and fatigue), Tracheostomy (a surgical procedure that creates an opening in the neck and directly into the trachea (windpipe) to create a secure, alternative airway), and a gastronomy tube (a medical device surgically inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications.) A record review of Resident #51's quarterly MDS assessment dated [DATE] revealed resident #51 was a [AGE] year-old female admitted for long term care related to her needs for a tracheotomy supported by a ventilator (This setup provides long-term, secure breathing support for patients unable to breathe adequately on their own due to chronic conditions, neuromuscular disorders, or severe injuries.) Resident #51 was assessed with unclear speech complicated by the tracheostomy and a BIMS score of 6 which indicated severe cognitive impairment. A record review of Resident #51's care plan dated 3/25/2026 revealed, The resident has congestive heart failure . Give cardiac medications as ordered . The resident has emphysema COPD chronic obstructive pulmonary disease . Give aerosol or bronchodilators as ordered . The resident has hypertension . give antihypertensive medications as ordered. The resident is on enhanced barrier precautions . gloves and gowns should be donned (to put on PPE) if any of the following activities are to occur: . Enteral feeding (tube feeding or enteral nutrition, is a method of delivering nutrients directly into the stomach or small intestine when a person cannot eat enough by mouth) care . tracheostomy care . high level contact . chronic pain syndrome osteoarthritis of the knee bilateral (both knees) . The resident uses anti-anxiety medications . administer anti-anxiety medications as prescribed by the physician. A record review of Resident #51's physicians' orders dated 3/25/2026 revealed Resident #51 was prescribed to receive the following medications, by her gastronomy tube, every morning:Cyanocobalamin 1000mgFurosemide 20mgEmpagliflozin 10mgMultivitaminPantoprazole 40 mgSpironolactone 25mgThiamine 100mgAspirin 81mgBuspirone 10mgMetoprolol 25mgQuetiapine 25mgCalcium carbonate 500mg A record review of Resident #94's admission record dated 3/25/2026 revealed an admission date of 3/9/2025 with diagnoses which included spastic quadriplegic cerebral palsy (a group of permanent movement disorders appearing in early childhood, caused by abnormal brain development or damage to the developing brain the most severe form of cerebral palsy, resulting from brain injury before, during, or shortly after birth), tracheostomy and gastronomy tube. A record review of Resident #94's quarterly MDS assessment dated [DATE] revealed resident #94 was a [AGE] year-old male admitted for long term care related to her needs for a tracheotomy supported by a ventilator (This setup provides long-term, secure breathing support for patients unable to breathe adequately on their own due to chronic conditions, neuromuscular disorders, or severe injuries.) Resident #94 was assessed with unclear speech complicated by the tracheostomy and a BIMS score of 99 which indicated Resident #94 could not complete the interview. A record review of Resident #94's care plan dated 3/25/2026 revealed, (Resident #94) has seizure disorder . Give medications as ordered . Resident #94 has Multiple sclerosis . give medications as ordered . Is fungal related skin condition . give medications as ordered . is on enhanced barrier precautions . gloves and gowns should be donned if any of the following activities are to occur: . Enteral feeding care . tracheostomy care . high level contact . A record review of Resident #94's physicians' orders dated 3/25/2026 revealed Resident #94 was prescribed to receive the following medications, by her gastronomy tube, every morning:Carbamazepine 100mg/ml give 10mlCholecalciferol 100 unitsFamotidine 40mgAscorbic acid 500mgClonazepam 1mgUTI stat 30mlLactulose 20g/ml give 30mlOxybutynin 5mg-And apply to face - Triamcinolone acetonide cream. During an observation and interview on 3/24/2026 at 7:34 AM revealed LVN C was at the end of the 400-hall at her medication cart documenting on her computer. LVN C stated she had arrived for work this morning at 6:00 AM, received report from the previous nurse, and had assumed resident care. LVN C stated she was assigned to care for 10 residents from room [ROOM NUMBER] to room [ROOM NUMBER] which included Resident #51 and Resident #94. LVN C stated she was finished with her morning medication administration. LVN C stated she had administered medications via gastronomy tubes to all 10 residents within an hour and a half. LVN C stated she was currently documenting her medication administration on residents' medication administration records. LVN C stated she had yet to document Residents #51 and #94. LVN C stated she had already assessed Resident #51's blood sugar, and administered her medications which included:FurosemideEmpagliflozinAspirinCalcium carbonatePantoprazoleAnd vitamins.LVN C stated she had assessed Resident #91's blood sugar and had administered Resident #94 medications via his gastronomy tube and had not yet documented the medication administration in Resident #94's medication administration record. LVN C stated Resident #94's medications included:ClonazepamOxybutyninFamotidineVitamin cCarbamazepineVitamin dUTI stat LVN C stated she had documented her medication administration for all of her 10 residents and stated the procedure was accepted by professional standards. LVN C stated she was fast and usually completed all her medication administration which included donning and doffing PPE, assessing residents for blood sugar levels, applying topical creams, flushing indwelling urinary catheters, and administering gastronomy tube medications in an hour and a half. During an interview on 3/25/2026 at 4:00 PM the Regional Clinical RN stated the policy, training, and professional standard for medication administration was for all nurses to follow physicians' orders and administer medications and treatments and then to immediately document the medication administration for each individual resident. The Regional Clinical RN stated the practice of signing for all residents after multiple medication administrations could be the residents may not receive the therapeutic effects of their prescribed medications. A record review of the facility's undated policy Medication Administration and General Guidelines revealed, Medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices and only by persons legally authorized to do so. procedure: . Medications are administered at the time they are prepared medications are not pre poured. This person then records the administration on the residence medication administration record at the time the medication is given at the end of each medication passed the person administering the medication reviews the medication administration record to ascertain that all necessary doses were administered and documented . If a dose of regularly scheduled medication is withheld, refused, forgiven at other than the scheduled time, the physician must be notified.

Based on observations and interviews the facility failed to ensure all drugs and biologicals were locked in compartments under proper temperature controls and permitted only authorized personnel to have access to the keys, for 1 of 6 medication carts (the 400-hall medication cart) reviewed for security. LVN A left the 400-hall medication cart unsupervised, unattended, and unlocked for more than 9 minutes. This failure could place residents at risk for misappropriation of property and or not receiving the therapeutic effects of their medications.The findings include: During an observation on 3/22/2025 at 9:35 AM revealed the 400-hall medication cart stationed at the end of the 400-hall. The 400-hall was occupied by more than 14 residents. The medication cart was unattended, unsupervised, and unlocked and the drawers were facing out towards the hall. During an observation and interview on 3/22/2026 at 9:44 AM revealed LVN A returned with PPE supplies and recognized she had left her cart unlocked and proceeded to lock the cart. LVN A stated she went to the 200-hall supply room to retrieve PPE supplies and could not see her cart from the 200-hall. LVN A stated she left her cart unlocked and knew she should have locked her cart. LVN A stated medications, such as high blood pressure, insulins and others, could have been taken out of the cart by not locking the cart. During a joint interview on 3/25/2026 at 4:24 PM the Administrator and the Regional Clinical RN stated the policy, training, and expectations were for all nursing staff to secure their medication carts when not in use and whenever the nurse needed to be away from the cart. The Regional Clinic RN stated the potential negative outcome could be the loss of secured medications. A record review of the facility's undated Medication Administration and General Guidelines policy revealed, Medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices and only by persons legally authorized to do so. procedure: . when administering as needed medications at times other than medication pass, the dose may be prepared in the medication cart storage area and taken to the residence bedside, leaving the cart locked and secured.

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 resident in the sample of 6 (Resident #4) reviewed for clinical records. The facility failed to ensure Resident #4's schizophrenia and bipolar disorder diagnosis was accurately documented in his medical diagnosis list and MDS Assessment. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.The findings include:Review of Resident #4's admission record, dated 03/25/2026, reflected a [AGE] year-old male. He was admitted on [DATE] and re-admitted on [DATE].Review of Resident #4's diagnosis report dated 03/24/2026, reflected diagnoses which included schizophrenia, bipolar disorder, and vascular dementia. Further review of Resident #4's diagnosis report reflected 08/18/2018 bipolar disorder and Schizophrenia, unspecified onset, 04/25/2019, move-in dx [history] vascular dementia onset 9/23/2022, and primary of unspecified dementia, onset 09/23/2022. Review of Resident #4's quarterly Minimum Data Set (MDS) dated [DATE], reflected the resident had a BIMS score of 14, which indicated he was cognitively intact. Resident #4's active diagnoses included bipolar disorder and schizophrenia, and he was taking antianxiety, antidepressant, diuretic, and opioid medications.Review of Resident #4's current care plan dated 03/19/2026 revealed that the resident had an impaired cognitive function/dementia or impaired thought processes [related to] BIPOLAR DISORDER, UNSPECIFIED, VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE, SCHIZOPHRENIA, UNSPECIFIED. Further review of Resident #4's care plan revealed it did not include PASRR services. Review of Resident #4's initial PASRR Level I (PL1) dated 04/25/2019 reflected a positive determination that there was evidence or an indicator this is an individual that has a mental Illness. A second PL1 Screening dated 04/26/2019 reflected a negative determination that there was no evidence or an indicator this is an individual that has a mental illness. A change of ownership prompted PL1 Screening dated 08/24/2022 reflected a negative determination that there was no evidence or an indicator this is an individual that has a mental illness. The medical record did not contain PL1 Screening using the revised June 2023 pre-admission screening form. The medical record did not contain a PASRR level II evaluation prior to admission to the facility.During an interview on 03/24/2026 6:54 p.m., the Regional MDS Nurse revealed that in January of 2023 the facility underwent a transition and was required to have a thorough assessment for schizophrenia conducted by the Local Authority (LA) before it could be a valid diagnosis. He said once Resident #4's schizophrenia diagnosis was validated by the LA the diagnosis report was updated to include the valid diagnosis. He added that Resident #4's medical diagnosis report was inaccurate for a brief period (August 2024 - December 2025) but had since been corrected with the quarterly Minimum Data Set (MDS) dated [DATE] The Regional MDS Nurse said it was important for medical records to reflect accurate information including diagnosis to provide the best possible care for each resident.During an interview on 03/25/2026 at 6:30 p.m., the Administrator said he was working with the staff to ensure they were accurately documenting medical records as inaccurate records could cause concerns with the services provided to a resident. Review of the facility document, Documentation undated reflected: Documentation is the recording of all infom1ation, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident repo1ts, and summary sheets (daily, weekly, monthly, discharge). Goal 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview and record review the facility failed to ensure that each resident room marked as available for new residents was adequately equipped to allow new residents to call for staff assistance through a communication system that would relay the call directly to a staff member or centralized staff work area for one room (215) of four observed that had a welcome sign and future resident listed outside of room.The facility failed on 3/22/2026 to ensure that the call light system was properly working for potential new resident rooms for room [ROOM NUMBER]. The call light box was hanging from the wall.This failure could place new residents at risk of not having a means of directly contacting staff in an emergency or when they needed support for daily living.Findings included:During an observation on 3/22/2026 at 10:23 am on the 200 hall revealed that the call light for room [ROOM NUMBER] was activated, as evidenced by the light flashing outside of the room door in the hallway. The surveyor did not hear the call light ringing at the nurse's station. The surveyor walked to nurses station and approached the nurse call light panel behind the nurses station to locate room [ROOM NUMBER] on the panel. The surveyor observed no light on the panel for room [ROOM NUMBER], as well as no ringing sound. A light for another room on 100 hall lit up and the panel began to ring. During an interview on 3/22/2026 at 10:25 am with LVN C, LVN C stated the nurse call light panel lit up and rang when a resident pushed their call light. The surveyor asked LVN C if the panel acknowledged that the call light in room [ROOM NUMBER] was activated. LVN C looked at the nurse call light panel and stated that the panel was not activated for that room. The surveyor asked LVN C why the light above the door to room [ROOM NUMBER] was lit and flashing if the call panel indicated that the call light was not activated. LVN C revealed that she did not have an answer.During an observation on 3/22/2026 at 10:26 am at the nurses station the surveyor witnessed LVN C leave the nurses station and walk to the200 hall. The surveyor observed that another LVN, LVN B, had started walking down the 200 hall when the surveyor was asking LVN C about the call light panel. At 10:30 am LVN B was exiting room [ROOM NUMBER] and called to LVN C that the room was empty and housekeeping was in there and had activated the light but now could not turn it off. LVN C proceeded to initiate a work order for the call light, expressing thankfulness that teh room was empty.During an observation on 3/22/2026 at 10:31 am the surveyor entered room [ROOM NUMBER] and observed the call light box hanging from the wall, connected by the wires only. Both call lights were plugged into the call light box. During an interview on 3/22/2026 at 10:32 am with Housekeeper K, Housekeeper K stated that she did clean the 200 hall. Housekeeper K stated that she was also responsible for cleaning the empty rooms, however housekeeper K had not entered room [ROOM NUMBER] on 3/22/2026 as of yet. When asked Housekeeper K stated that she was unaware that the light was going off as she had not heard the ringing to prompt her to look up at doorways.Interview on 3/22/2026 at 12:45 am with the Administrator revealed that the beds listed on Bed Classification report showed available beds.Record review of the 3740, Bed Classification form dated 3/22/2026 revealed that room [ROOM NUMBER], both bed A and bed B, were reported on form as ready for move-in.

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the status of the residents for 1of 9 residents (Residents #1) reviewed for resident assessments. The facility failed to ensure Resident #1's diet was accurately reflected on her significant change MDS assessment, dated 02/17/2025. This failure could place residents at risk of missed or inaccurate care.The findings included: Record review of Resident #1's electronic face sheet dated 03/16/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: acute (comes on quickly) and chronic (long-term problem) respiratory failure with hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function), neuromuscular dysfunction of bladder(when a person lacks bladder control due to brain, spinal cord or nerve problems), insomnia (inability to sleep), morbid obesity (a body mass index of 35 or higher with related health conditions), type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), bipolar disorder (a mental health condition that causes extreme mood swings), tracheostomy status (a surgically created hole, in the windpipe, also known as the trachea to allow air to pass, and help with breathing) and polyphagia (a feeling of extreme, insatiable hunger). Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was on a mechanically altered diet. Her cognitive status was intact, and she was dependent on staff for assistance with ADLs. Record review of Resident #1's comprehensive care plan dated 03/03/2025 reflected Focus, diet order, regular diet, regular texture and regular consistency. Record review of Resident #1's Active Orders as of: 03/16/2026 reflected Regular diet, regular texture, regular consistency per hospice, start date 12/02/2025. Observation on 03/18/2026 1:00 p.m., Resident #1 was lying in bed being assisted with eating her lunch. She was provided with regular food, regular texture with regular consistency. Record review of Resident #1's meal ticket on 03/18/2026 reflected Regular diet, regular texture and regular consistency. During an interview on 03/18/2026 at 1:05 p.m., Resident #1 responded she was on a regular diet and had been since she was first admitted . During an interview on 03/19/2026 at 1:30 p.m., MDS A stated she missed the CPAP, which should have been noted under non-invasive mechanical ventilator. MDS B said she did not know how she missed it and was accountable for the accuracy of the MDS. She stated an inaccurate MDS could result in missed care for a resident. During an interview on 03/19/2026 at 2:50 p.m., MDS A stated Resident #1's significant change MDS assessment dated [DATE] needed to reflect she received a regular diet, and it did not. She stated she did not know how the regular diet was missed. During an interview on 03/19/2026 at 3:00 p.m., the ADON stated staff assisted Resident #1 continually with feeding. She stated the resident orders food from outside, and her family brings in food. She stated Resident #1 was on a regular diet and that the MDS accuracy was important to show what the residents needed for care and inaccuracy could lead to missed care. During an interview on 03/19/2026 at 4:00 p.m., the ADM stated MDS accuracy was important and it showed the care a resident required. Record review of the facility policy and procedure titled Minimum Data Set Policy for MDS assessment Data Accuracy (undated) reflected The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental and psychosocial well-being. 1. The assessment accurately reflects the resident's status. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Residents #2) reviewed for infection control, in that: The facility failed to ensure LVN B removed soiled gloves, sanitized hands, and put on clean gloves after cleaning feces from the anal area of Resident #2 and before placing a clean incontinent brief on the resident. These failures could place residents at-risk for infection due to improper care practices.The findings included: Record review of Resident #2's face sheet, dated 03/18/2026, revealed a [AGE] year-old female, admitted on [DATE]. Her diagnoses included: pneumonia (inflammation of the lungs, usually caused by an infection), methicillin resistant staphylococcus aureus infection (a group of staph bacteria that are resistant to common antibiotics), pressure ulcer of sacral region, stage 4 (the most severe form of pressure injury involving full-thickness loss with exposed muscle and bone), type 2 diabetes mellitus (chronic disease characterized by high levels of sugar in the blood), tracheostomy (surgical opening in the wind pipe to assist in air exchange and breathing), gastrostomy (surgical opening and tube to the stomach to assist with intake of fluids, medicines, enteral feeding) and neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems). Record review of Resident #2's 5-day scheduled MDS assessment, dated 02/12/2026, revealed the resident rarely understood she could rarely be understood. She was not a candidate for a BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. She had a stage 4 pressure ulcer. Record review of Resident #2's care plan dated 03/17/2026, revealed Focus, has bowel incontinence, Interventions, provide peri care after each incontinent episode.Observation on 03/19/2026 at 10:30 a.m., LVN B performed incontinent care for Resident #2. LVN B wiped feces from Resident #2's anal area and threw the wipe in the trash. She continued to move the dirty brief further under the resident in preparation for inserting a clean brief. LVN B took a clean brief and placed it under Resident #2's clean buttocks without discarding her soiled gloves, sanitizing her hands, and putting on clean gloves. She continued to complete Resident #2's incontinent care. During an interview on 03/19/2026 at 10:45 a.m. LVN B stated she should have removed her soiled gloves, sanitized her hands, and put on clean gloves prior to placing a clean brief under Resident #2. She stated she had infection control training and performed treatments for facility residents. She stated she did not know why she did not remove her soiled gloves. During an interview with the ADON on 03/19/2026 at 3:00 p.m., she stated the nurse should have changed her gloves after cleaning Resident #2's anal area to prevent cross contamination of other items. She stated infection control training was provided and staff's skills were checked annually. She stated the DON was ultimately accountable for the nursing care in the facility. Record review of LVN B's Nurse Proficiency Audit dated 08/2023, reflected she satisfactorily passed her proficiency of Infection Control, proper hand washing, prevents cross contamination and universal precautions. Record review of the facility policy and procedure titled Perineal Care dated 05/11/2022 reflected gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area, doff gloves and perform hand hygiene. Record review of the facility policy and procedure titled Hand Hygiene (undated) reflected you may use alcohol-based hand cleaner or soap/water for the following: after contact with a resident's mucous membranes, body fluids or excretions.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse neglect for 1 of 11 Residents (Resident #1) whose records were reviewed for abuse and neglect. 1. Resident #1 told RT A she yelled at her on 03/01/2025 when Resident #1 wanted a larger cup of ice. RT A wrote the allegation was made by Resident #1 in Resident#1's progress notes without reporting the allegation to the Administrator that RT A had yelled at Resident #1. 2. The ADM reported the allegation of Resident Abuse on 03/03/2025, 2 days later to the State Agency when RT A's progress note for Resident #1 was reviewed. The noncompliance was identified as PNC. The noncompliance began on 03/01/2025 and ended on 03/03/2025. The facility had corrected the noncompliance before the survey began. These failures could affect residents who reside at the facility and result in allegations of abuse not investigated immediately and harm to the resident. The findings included: Review of the facility policy, Abuse/Neglect revised 3/29/18, read: The facility will provide and promote the protection of resident rights. It is everyone's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, abuse and situations that may constitute abuse or neglect to any resident in the facility. 3. Facility employees must report all allegations: abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designees will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. a. If the allegations involve abuse or result in serious bodily injury, the report must be made within 2 hours of the allegation. Record Review of Resident #1's electronic face sheet dated 04/09/2025 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute and chronic respiratory failure with hypoxia (inadequate gas exchange by the respiratory system resulting in low oxygen levels), depression (mood disorder that causes a persistent feeling of sadness and loss), anxiety (an emotion characterized by an unpleasant state of inner turmoil), myopathy (disease of the muscles that connect to the bones) and dysphagia (difficulty in swallowing food or liquid). Record Review of Resident #1's Admission MDS assessment dated [DATE] reflected she was sometimes understood and sometimes understands. She scored a 99 on her BIMS which signified the interview could not be completed related to refusal to answer or nonsensical responses. She was dependent for care. Resident's diet was NPO, and she received enteral nutrition. She had a tracheostomy with invasive mechanical ventilation. Record review of Resident #1's comprehensive care plan revised dated 03/01/2025 reflected Focus, may have ice chips per MD orders, Intervention, supervise resident while consuming ice chips. Record review of Resident #1's Active Orders as of: 03/01/2025 reflected Pt may have ice chips in three-fourths of a cup once a shift upon request. Pt must be elevated in an upright position with her cuff deflated with RT supervision at bedside Phone Active 03/01/2025. Record review of RT A's progress note dated 03/1/2025 at 01:15 pm reflected. 3/1/2025 13:15 Activity Note Note Text: The resident accused me of yelling at her, which I did not do. I explained that i have never raised my voice at any of my patient before. I also clarified that because I am wearing a face mask, I naturally speak a little louder than usual. The resident stated, I'm not deaf and claimed that what I said was inappropriate, by saying what i said was Bull shit.She also requested a larger cup of ice. I informed her that I am unable to provide a larger cup and I could not stay in the room longer than 10 minutes, as I am the only RT on the floor now. She responded by saying that was also bullshit and insisted that I did have time to stay longer.SA B was present. The resident then asked if one of them could stay in the room because she felt I was going to yell at her again. SA B stayed in the room with me while I provided the ice to the patient from 12:43 pm - 1:15 pm Observation on 04/08/2025 at 09:15 am of Resident #1 lying on an air mattress in bed revealed she received mechanical ventilation via an oxygen concentrator with tubing connected to her tracheostomy. Interactions between Resident #1 and staff was positive. Interview on 04/08/2025 at 09:22 am with Resident #1, she denied abuse, yelling or issues with staff. She whispered her care was good at the facility and staff treated her well. Interview on 04/08/2025 at 04:42 pm with RT A revealed that she went to provide Resident #1 ice as ordered and Resident #1 requested a bigger cup of ice On 3/1/2025. She stated she wore a mask because Resident #1 was on enhanced barrier precautions. RT A stated she told Resident #1 she would need to check the physician orders and she stated she spoke louder wearing the mask. She stated Resident #1 said You do not have to yell at me, I am not deaf. She stated Resident #1 apologized to her later in the day for being rude. She denied yelling. She stated she reported to her supervisor that Resident #1 was not happy, but she did not think to report the incident to the Administrator who was the abuse and neglect coordinator, but she did annotate the quote from Resident #1 in her progress notes. She stated she had training on abuse and neglect. Interview on 04/09/2025 at 10:50 am with RT D, RT A's supervisor, he stated RT A called him and told him Resident #1 was not happy about the ice. He stated she did not mention anything about Resident #1's allegations. He stated RT staff were trained on abuse and neglect. Interview on 04/10/2025 at 02:57 pm with SA B revealed she was present in Resident #1's room when RT A provided her the ice chips, and she did not witness RT A yelling or being inappropriate. Interview on 04/10/2025 at 5:33 pm with the DON revealed when the administrative team reviewed the notes from the weekend, they immediately started to investigate the incident and train 100 percent of the staff on abuse and when to report, to whom and provided the ADM's phone number. Interview on 04/10/2025 at 5:53 pm with the ADM revealed Administrator reviewed the abuse and neglect protocol. Seven components. Training important and reporting immediately. Accountable for care at the facility. They provided the in-service to 100% staff after they found RT A's note. They do a meeting and review progress notes and found that communication The Administrator said they do champion rounds and monitor for abuse and neglect. Accountable for the care in the facility. Record review of RT A's in-service attendance record dated 01/12/2025 reflected she received training on abuse/neglect and reporting. The facility course of action prior to surveyor entrance included: Record review of the facility PIR dated 03/03/2025 reflected an investigation into the incident between Resident #1 and RT A was investigated and reported immediately to HHSC. Record review of the Administrator's PIR dated 03/03/2025 revealed: All required notifications were made which included the Medical Director, Responsible Party, Physician, QA Ad Hoc Committee and HHSC. Record review of RT A's personnel folder reflected no issues of concern. Record review dated 04/10/2025- 118 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Abuse/Neglect and Reporting. STAFF INTERVIEWS ON TRAINING: 04/10/2025 from 2:57 PM to 5:33 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts. On 04/10/2025 at total of 6 LVN's (E, F, G, H, I and J), 4 CNA's (K, L, M and N), 1 CMA (O), 1 SA (B) 1 PT (C) and 2 RTs (A and D), 2 RN's, (DON, ADON) were interviewed on reporting, abuse, and neglect. They were trained to report to the ADM, provided a phone number and instructed to report immediately or within 2 hours. They were instructed on the diverse types of abuse. The noncompliance was identified as PNC. The noncompliance began on 03/01/2025 and ended on 03/03/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for 1 of 5 Residents (Residents #1) reviewed for neglect. During a capping trial on [DATE], Resident #1 was not monitored, and no staff were physically present in her room. Resident #1 became unresponsive and had to be transported to the ER for treatment. The facility did not have a policy/procedure in place for capping trials at the time of the incident. Resident #1 died at the hospital on [DATE]. This failure resulted in an IJ on [DATE] at 5:00 PM. While the IJ was removed on [DATE] at 3:45 PM., the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that was not immediate jeopardy with a scope of isolated due to facility's need to evaluate the effectiveness of their plan of removal. This failure could place tracheostomy residents recommended for a capping trail at risk for exacerbation of condition up to and including death. The findings included: Resident #1's face sheet, undated, revealed the resident was a [AGE] year-old admitted on [DATE], readmitted [DATE], transferred to hospital [DATE], and deceased [DATE]. Diagnoses included: stroke, cerebral aneurism (blood vessel weakness in the brain), diabetes, DVT (deep vein thrombosis) (blood clots in deep vein), HTN (hypertension), quadriplegic, and seizures. Further review revealed the resident's RP was listed as a family member, and the resident's Code Status was Full Code. Record review of Resident#1's admission note, dated [DATE] and [DATE], reflected the resident was admitted to the facility with a tracheostomy on both occasions. Record review of Resident #1's admissions MDS, dated [DATE], reflected the resident was unable to answer questions in cognition, and had upper and lower extremity impairments due to a diagnosis of stroke. Record review of Resident #1's Care Plan, dated [DATE], reflected: resident had a tracheostomy related to respiratory failure. Interventions included tracheostomy care Q shift and Capping trials 30 mins_1 hour BID as tolerated . Monitor respiratory rate, depth and quality . Record review of Resident #1's physician's order, dated ,d+[DATE], reflected orders to administer capping trials for 30 minutes up to 1 hour twice per day on the day shift starting [DATE] and ending [DATE]; and use of nasal cannula at 3L/ minute during capping trials. Record review of Resident #1's Pulmonologist note, dated [DATE] at 11:30 AM, reflected, resident tolerated the second capping trial on [DATE] well and was on a T piece for oxygen. Record review of Resident #1's RT note, dated [DATE] at 11:36 AM authored by RT A, reflected: the resident was placed on a red cap trial with a heart rate of 84 and an oxygen saturation of 97%; and the resident was noted not to be in distress. Record review of Resident #1's RT note, dated [DATE] at 11:59 AM authored by RT A, reflected: RT A checked on the resident at 11:59 AM and the resident's oxygen saturation was at 97 % and heart rated at 84. Resident received 3 L/minute of O2 from nasal cannula. Record review of Resident #1's RT note dated [DATE] at 12:38 PM authored by RT A, reflected: resident was found unresponsive with no pulse felt. CPR was started by the RT A and a Nurse (name not documented) and EMS called and Resident #1 was transferred to the ER. Record review of Resident#1's capping sheet for capping trial #1 ([DATE]) and capping trial # 2 ([DATE]) reflected vitals were normal and the first capping lapse time was 30 minutes; and the second capping #2 time was recorded as 30 minutes. The trach and capping trial sheet reflected that the resident's [RP] was present at bedside. The third capping on [DATE] started at 11:36 AM for one hour of capping and the sheet reflected that RT A saw the resident at 11:59 AM; stop time was not recorded. Record review of Resident #1's Code Blue Record, dated [DATE] at 12:44 PM, reflected the code was initiated at 12:38 PM. The Code Blue Record read: History of Code: RT [A] noted Resident unresponsive and no pulse .Pulse detected @ 62 BPM after 2 rounds. EMS arrived and transported resident to [local ER] . Record review of Resident #1's EMS Run Report, dated [DATE] at 12:41 PM (Incident # 0209529) , read: .According to staff she was last [seen] with a pulse 39 mins prior and no shocks were delivered .After a round of epi, bicarb and calcium [heart medications] was delivered .Pulses were confirmed at a ratee of 60 .En route the pulse was lost .and one more dose of epi (heart medication) was applied . Resident #1's ER report, dated [DATE], revealed, admitted for cardiac arrest; history of trach. The ER report read, She is a nursing home resident with approximately 30 minutes of unresponsiveness prior to EMS arrival. She did require CPR with ROSC (return of spontaneous circulation) obtained in the ER [another heart attack in the ER] . remains unresponsive. Record review of Resident #1's Hospital initial assessment note read: OOH (out of hospital) arrest ,d+[DATE] .ABI (brain injury); mri (scan) anoxic ischemia [tissue dead due to lack of O2] .C diff colitis .[history of brain bleed [DATE]] .AKI (acute kidney injury), likely secondary to hypoperfusion during arrest (lack of blood flow) .chronic respiratory failure s/p (status post) trach .HTN (hypertension) .DM (diabetes). During an interview on [DATE] at 1:14 PM, the DON stated on [DATE] the family came in to speak to the administrator and alleged the resident [Resident #1] was deceased and needed to pick up her belongings. The DON stated, the family felt that the death was suspicious. The DON stated, the administrator informed her that he would make a self-report to HHS of a suspicious death. The DON stated that the resident coded on [DATE] and was resuscitated and sent to the ER for further evaluation. The DON stated the administrator contacted the family on [DATE] and was informed the resident was still alive. The DON stated the resident had a history of pleural infusion (issues with excess fluid in the lungs), HTN, and history of CVA; and chronic stage 3 kidney disease. The DON stated, the resident was on a trach because the resident had respiratory failure after her stroke at home, prior to admissions. The resident arrived at admissions with a trach and a ventilator. The DON stated the resident was weaned off the ventilator around [DATE]. The DON stated the resident was kept on the trach for respiratory reasons. The DON stated an in-service was initiated on ANE on [DATE] was still on-going on [DATE]. The DON stated that there were 18 residents with a trach in the respiratory hall (Hall 400). During a telephone interview on [DATE] at 1:18 PM, the Medical Examiner stated the cause of death involving Resident #1 was still under investigation. During an interview on [DATE] at 3:50 PM, The DON stated no staff was present for Resident #1's initial capping trials for 100% of the time. The DON stated there was no requirement for staff to be present during trach capping trials; and Resident #1 did not start a trial until a full evaluation by the Pulmonologist. The DON stated the capping trials did not contribute to the cardiac arrest. The DON stated the initial trials were done daily, one trial per day; the first and second trials started [DATE] in AM shift (12 AM-12 PM) and no staff were physically present during the trial time span of the first and second trials. The DON stated on the third trial on [DATE] started at 11:36 AM the RT discovered resident unresponsive at 12:30 PM. The DON stated that the resident breathing was assessed at 11:59 PM; O2 was at 97 % (normal) and pulse was at 84 (normal). The DON stated based on the timeline the RT [A] entered at 12:38 PM and found the resident unresponsive; with no pulse and code was called. The DON stated there was no policy on capping trials except to follow physician orders. The DON stated the physician's orders did not specify that a staff member had to be present during the time resident was breathing independently. The DON stated no one was required to be present during the time of monitoring. The DON stated the resident's co-morbidities caused the cardiac arrest during the third capping trial. The DON stated the Pulmonologist was working with Resident #1 and felt it was safe to initiate capping trials. During an interview [DATE] at 9:21 AM, RT Director stated, Resident #1 was doing well after the removal of the ventilator. Resident had hemoglobin issues; needed transfusions. The RT Director stated Resident #1 was stable and capping trials started; [DATE] for two trials. The RT Director stated on the third trial an oximeter [non-audible] placed on Resident #1. The RT Director stated, the oximeter would not alert or alarm if the resident had a cardiac rest. The RT Director stated, at the time of the third trial there was no system in place to monitor the heart rate. The RT Director stated the trial started, and the RT specialist [RT A] checked on the resident within a time frame of 30 minutes. The RT Director stated the resident had underlying issues that included HTN, stroke, anemia, and kidney issues. The RT Director there was no one physically present for one-on-one monitoring during any trial for Resident #1. The RT Director stated existing policy only called for spot checks and no documentation was required for the spot checks. The RT Director did not provide a response as to whether a resident like Resident #1 with co-morbidities needed a physical presence when cap trials were done. The RT Director stated in-service training for the RT staff was started on [DATE] [at time of surveyor's entrance] on trach care and capping procedures. The RT Director stated Resident #1 could not uncap on her own. The RT Director stated that the facility did not have a written policy on capping because capping was based on clinical standards. During a telephone interview on [DATE] at 9:54 AM, RT A stated she was the RT for the 3rd capping trial for Resident #1. RT A stated before the trail started, she checked Resident #1's O2 sats, trach care, breathing treatment, and mental status. RT A stated, she placed an oximeter [non audible] on the resident that read for saturation and heart rate. RT A stated that the oximeter would not alarm if the resident had a cardiac arrest. RT A stated that the resident had previous underlying issues. RT A stated Resident #1's the third capping trial started at 11:16 AM and she returned at 11:59 AM to check on the resident and the resident was not in distress. RT A stated she returned at 12:36 PM and the resident was unresponsive; the resident was pale, not responding to sternal rubbing and calling her name; then the RT called for help; CPR started at 12:38 PM, EMS arrived, and the resident was resuscitated. The RT stated. I did not stay with the resident because she had no previous issues with capping. RT A stated she did not stay with Resident #1 because she had to attend to other residents. Interview on [DATE] at 12:05 PM with the Medical Director revealed Resident #1 suffered a cardiac arrest during the third capping trial on [DATE]. During interview on [DATE] at 1:25 PM with the Pulmonologist stated Resident #1 was a suitable candidate for capping trials because the resident was off the ventilator and had no congestion. The Pulmonologist stated observation during capping only required the RT to view the resident for a few minutes. The Pulmonologist said the RT could leave after the resident was not in distress and return later for further assessment of independent breathing. The Pulmonologist stated the facility had no equipment for monitoring present in Resident #1's room when the capping trial was conducted. The Pulmonologist stated Resident #1's cardiac arrest could not have been predicted, but no alert system or monitoring equipment were present to alert RT staff who were not physically present in the room when Resident #1 coded. During an interview on [DATE] at 4:04 PM, LVN B stated on [DATE] she saw Resident #1 at 12:10 PM and the resident was not in distress. LVN B stated she saw a red cap on the resident's trach and the resident was breathing with the nasal canula receiving ,d+[DATE] liters/ minute. LVN B stated, the resident looked normal. LVN B stated she did not document the observation of Resident #1 during the initial capping trial. During telephone interview on [DATE] at 10:50 AM, RT G stated he initiated the first capping trial for Resident #1 on [DATE] for 30 minutes and remained with the resident 100% of the time. RT G stated the resident tolerated the 30 minutes of capping and revealed no signs of distress. RT G stated he was not aware of any facility policy on capping. RT G stated his policy was to remain with the resident throughout the trail to ensure the resident did not suffer any distress. During telephone interview on [DATE] at 11:00 AM, RT C stated she initiated capping trial for Resident #1 on [DATE] at 1:30 PM and the resident's RP was present. RT C stated she remained the entire time with the resident and the RP during the trial scheduled for 30 minutes. RT C recalled the second capping trial was halted between ,d+[DATE] minutes because the resident became exhausted. RT C stated she was not aware of any facility policy on capping. Record review of Resident #1's Trach Capping Flow Sheet dated [DATE] read: .Resident coughed. RT [RT C] had resident complete alphabet then ended trial. [family member] of resident @ bedside . During telephone interview on [DATE] at 4:35 PM, the family member stated the family member and the [RP] at admission were told by the RT Director that a staff member would be physically present when capping trials were attempted. The family member stated at a second meeting before the capping trials started the RT Director again assured the family that a staff member would be present all the time during the initial capping trials. The family member stated the family told the RT Director that the family was concerned about the resident's condition and her inability to communicate during an emergency. During telephone interview on [DATE] at 5:02 PM, Resident #1's RP stated he recalled when Resident #1 was admitted to the facility the Rehab Director assured him and the family that during the initial capping trials that staff would be present all the time. The RP stated that at a second CP meeting, unknown date, the RT Director was present and assured the family that staff would be present all the time during the initial capping trials. The RP stated he was happy about the staff being present during the initial capping trial because the resident could not pull the call light and could not cry out for help. The RP stated he was physically present with the [RT C] all the time on the second capping trial. The RP recalled he repeated the alphabet to the capped resident, and she was able to mimic some sounds. The RP stated the second capping trial lasted about ,d+[DATE] minutes and it was scheduled for 30 minutes. The RP stated he was not sure why the second capping trial did not last for 30 minutes. The RP stated that he was not invited to the third capping trial on [DATE]. Resident #1's RP stated, if I had known that [the resident] was going to be left alone, I would not allow the third trial. The RP stated his expectation was for staff to be physically present 100% of the time during the third capping trial and not just spot checking and monitoring. The RP stated he saw Resident #1 on [DATE] and she was alert and smiling. The RP stated he visited Resident #1 regularly for the past seven months. The RP stated that she (Resident #1) was left by herself [[DATE]] .I was assured that staff would be present all the time . During an interview on [DATE] at 9:18 AM, the ICU RN D stated the hospital clinical notes authored by MD E for Resident #1's record reflected the resident was admitted to ICU on [DATE] with no vasopressors (medications used to raise blood pressure in the emergency room ) and intubated and placed on a ventilator. RN D stated the resident was anoxic per the MD note (without oxygen in the brain) and coded. RN D stated with family's approval resident was made an in hospital DNR. RN D stated, the resident deceased on [DATE]. During second interview on [DATE] at 1:12 PM, the Pulmonologist stated Resident #1 was a suitable candidate for capping trials. The Pulmonologist stated her expectation was at the first capping trail staff needed to be present the entire time of the capping; on the second trial of capping the family was present the entire time. The Pulmonologist stated given that Resident #1 experienced a cardiac arrest on the third trial, Yes staff should have been present all the time. The Pulmonologist stated Yes the facility needed a policy on capping. During an interview on [DATE] at 1:17 PM, RT F stated she was trained on capping procedures in school and had been an RT for five years. RT F stated capping trials were dependent on the resident's condition and being off the ventilator. RT F stated the initial trials ranged from ,d+[DATE] minutes. RT F stated monitoring involved checking on the resident and it could be continuous or sporadic for the initial trials. RT F stated on the first capping it required 100% presence of staff in the room; trial 2 and 3 were dependent on how well the resident did in trial one. RT F stated there was no policy or protocol on capping, and one should be present for resident safety. During an interview an interview on [DATE] at 1:50 PM, the Administrator stated he met with Resident #1's family on [DATE] and was informed by the family that the resident was deceased . The Administrator stated that standards of care dictated the initial capping trials for Resident #1. The Administrator stated the facility's investigation of the incident on [DATE] was still in progress. During an interview on [DATE] at 1:55 PM, the RT Director denied he ever made a commitment to Resident #1's family and RP that staff would be present during the entire time of the capping trials. The RT Director stated at admissions the family and RP were informed they had an open invitation to attend capping trials. The RT Director stated there was no requirement that he call the RP to initiate a capping trial. During interview on [DATE] at 2:30 PM, the DON stated the timeline was as follows: 11:30 AM - Pulmonologist assessed the resident and no contra indications against the third capping trial on [DATE]. 11:36 AM - RT [A] capped the resident. 11:59 AM - RT [A] re-assessed the resident. 12:15 PM - LVN [B] made rounds and observed the resident. The resident was not in distress. 12:38 PM - RT [A] found the resident unresponsive; code called, and CPR started. 12:41 PM - EMS arrived. 12:44 PM - EMS transported resident to ER. In an interview and observation on [DATE] at 11:34 AM, RT C revealed a battery-operated audible pulse oximeter was kept on the Respiratory Therapist cart and the facility had this audible pulse oximeter for about three months. In an interview on [DATE] from 11:14 AM to 11:35 AM, the Respiratory Therapy Director stated he provided the in-service training to the RTs of the revised capping trial policy either in person or via phone or text message. The Respiratory Therapy Director stated the facility has had the plug-in audible pulse oximeter for about a week or two. Record review of facility's policy titled Tracheostomy Care Procedures dated [DATE] revealed Tracheostomy care will be performed per physician's orders. Record review of facility's policy titled Capping Trial for Tracheostomy Patients dated Revised 2023 [from an unknown author and not signed by the Facility's QAPI leadership team] was presented to the Surveyor on [DATE] at 4:45 PM while template vetting discussion was in progress. Record review of the facility's policy titled Abuse/Neglect, dated revised [DATE], read: .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of facility's in-service on the topic of Notify MD of any Respiratory Change of condition and Follow Physician's Orders was started on [DATE] [day of the surveyor's entrance]. Of 16 RT employees 13 RTs had attended the training for a completion rate of 81%. On the topic of Monitoring During Capping Trials started [DATE], 13 RTs had attended the training for a completion rate of 81%. The Capping training read: RT will monitor and perform O2 saturation checks and pulse checks at least every 30 minutes during capping trials. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 5:00 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10:03 a.m. on [DATE] and reflected the following: February 21, 2025 [Facility] Re: F600 NEGLECT Interventions: On [DATE] All medical records of residents with a trach were audited by the DON/ADON/RT supervisor to ensure that an order for capping trails was followed as ordered by the physician. The audit completed on [DATE] revealed no current residents are being trialed on capping of tracheostomies. On [DATE] Procedure for capping trials was developed and implemented. On [DATE] all Respiratory Therapist were/will be in-serviced by the DON, RT supervisor regarding: o Following physician orders will include monitoring to be documented by the respiratory therapist. o The respiratory therapist will remain at bedside to assess the resident for 10 minutes at the beginning of the capping trial and document assessment to include pulse, oxygen saturation, respiration and lung sounds o Respiratory Therapist will remain on the unit while capping trial is being conducted until determined by physician monitoring is no longer required o Use of an audible pulse oximeter during capping trial time will be indicated in the physician orders for monitoring purposes based on resident individual needs. o The audible pulse oximeter will be audible from other rooms on the unit. o Respiratory Therapist will respond to audible pulse oximeter alarm and assess resident needs if indicated. o Nursing staff will be in-serviced on [DATE] to the capping trial process and available to respiratory therapist if any change of condition occurs by the DON/designee. o Respiratory Therapist will monitor the resident every 30min during capping trail for any change of condition. o Monitoring of tracheotomy capping trial residents will be done by Respiratory Therapist o Monitoring oxygen saturation, respirations and pulse during capping trails o Notifying the physician and family of any change in condition during capping trials. On [DATE] all facility staff were in serviced by the DON, ADON/designee related to Abuse and Neglect. All new hired Respiratory Therapist and nurses as well as any agency therapist/nurses that maybe utilized will receive the in-services upon hire. Any respiratory therapist and nurse that has not received the in-services will complete prior to start of shift. The DON and Respiratory Therapist will ensure that all respiratory therapist and nurses receive in-services, and the Administrator will validate completion of in-services. Monitoring: At least 5 times per week for 4 weeks then 2 times a week for 4 weeks then as needed as capping trials orders occur, orders will be reviewed by the DON/designee to ensure that capping trial orders are complete. The DON / RT supervisor will interview at least 3 Respiratory Therapist per week for 4 weeks then 2 times a week for 4 weeks and questions will include: o How frequently do you monitor residents on capping trials? o What vitals are to be monitored during capping trials? o When do you notify the physician and family? o For capping trials whose orders are to be followed? The DON/ADON/RT supervisor will review resident's records (vital signs, progress notes) of capping trials at least 5 times per week for 4weeks then 2 times a week for 2 weeks then as needed to monitor the residents for any changes of condition during the capping trial. And ensure that the physician/family was notified of resident changes in condition. The administrator will monitor and review the findings of the DON/ADON/RT supervisor during morning and stand down meeting at least 5 times per week for 4weeks then 2 times a week for 2 weeks then as needed. Findings will be reviewed by the QAPI committee and changes will be made as needed. Verification of Plan of Removal: In an interview on [DATE] at 11:09 AM, the DON stated there were no residents who were on a ventilator who had an order for capping trials. In an interview on [DATE] at 11:09 AM, the DON stated they had revised their policy on capping trial for residents on a ventilator and provided a copy of the newly revised policy. In an observation and interview on [DATE] at 11:34 AM, RT C revealed a battery-operated audible pulse oximeter was kept on the Respiratory Therapist cart and RT C stated the facility had this audible pulse oximeter for about three months. In an interview and observation at [DATE] at 11:38 AM, the RT Director stated the facility has a continuous audible pulse oximeter that could be plugged in. The Administrator brought the plug-in audible pulse oximeter and took it into a room nearby where the Surveyor H was standing, and the surveyor was able to hear from the hallway the alarm sound from the plug-in audible pulse oximeter. Interviews on [DATE] from 11:24 AM to 5:00 PM and on [DATE] from 8:28 AM to 10:00 AM with 5 Respiratory Therapist (4 worked day shift [6 AM-6 PM], and 1 worked night shift [6 PM - 6 AM]), and 7 LVNs (6 worked day shift, and 1 worked night shift), and 1 RN who worked the night shift revealed they had been in-serviced on the best practice of following the physician orders, the RTs will notify the physician if orders need clarification, clarified orders would be put into the resident's clinical record, the physician would be notified of any change of condition in the resident's respiratory status and any new orders received would be implemented; and the Rt would monitor and perform pulse oximeter blood oxygen saturation checks at least every 30 minutes during capping trials. Also, Interviews on [DATE] from 11:24 AM to 5:00 PM and on [DATE] from 8:28 AM to 11:00 AM with 5 Respiratory Therapist (4 worked day shift [6 AM-6 PM], and 1 worked night shift [6 PM - 6 AM]), 7 LVNs (6 worked day shift, and 1 worked night shift), 1 RN (who worked the night shift), 3 CNAs (who worked day shift), 2 housekeepers, 1 Cook, 2 Dietary Aides and the FSS (Food Service Supervisor) revealed they had been in-serviced on abuse and neglect. Interview with the Medical Director on [DATE] from 4:38 PM to 4:43 PM revealed he attended the Ad hoc (un-planned) QAPI (Quality Assurance/Performance Improvement) meeting by phone that was held with the DON, Administrator and Respiratory Therapy Director; and the POR (plan of removal) for capping trials on residents was discussed. In an interview on [DATE] from 11:14 AM to 11:35 AM, the Respiratory Therapy Director stated he provided the in-service training to the RTs of the revised capping trial policy either in person or via phone or text message. The Respiratory Therapy Director stated the facility has had the plug-in audible pulse oximeter for about a week or two. The Respiratory Therapy Director stated the residents who had ventilators orders were reviewed and there were no residents who had orders for capping trials. The Respiratory Therapy Director stated the policy for Capping Trial was revised to include the use of an audible continuous pulse oximeter, to be with the resident the first 10 minutes of the trial and to check on the resident every 20 minutes after that. Further, the Respiratory Therapy Director stated he would train the new RT staff using a mannequin on how the capping trial process would be done in the facility before they started to work on the floor. The Respiratory Therapy Director stated he attended the Ad hoc QAPI meeting with the DON, Administrator, and the Medical Director to discuss the facility's POR plan. Lastly, the Respiratory Therapy Director stated he would be randomly interviewing three RTs the questions on the monitoring form each week. In an interview on [DATE] from 11:42 AM to 11:58 AM, the DON stated the facility made a video for the nurses to watch of what the Capping Trial policy involved, and it showed the Respiratory Therapy Director doing a capping trial on a mannequin so the nurses would know what was involved and what their role was during the capping trial. [Surveyor H observed portions of the video] The DON stated the training video was sent to the nurses and then they came in and signed the in-service training sheet. The DON stated she had reviewed the orders of residents who had a tracheostomy and were on a vent and there were no residents with an order for capping trial. The DON stated the facility revised their old policy on Capping Trials and added an audible pulse oximeter, which would alarm if the resident had a change in their condition, would be used during the capping trial to the policy and added the RT would stay with the resident for the first 10 minutes of the trial. Also, the DON stated staff were provided a copy of the abuse policy and were informed of the types of abuse, who the abuse coordinator was, and how to find the abuse coordinators phone number. Further, the DON stated newly hired nurses would be shown the video they made of the facility's capping trial procedure during their orientation before they started to work on the floor. The DON stated she had ensured all the nurses had received the training by having the nurses come into the facility to verify they had received the training. Moreover, the DON stated weekly audits would be done, she would review the resident's orders daily for any new orders for capping trials and it would be discussed in the morning meetings. The DON stated she and the RT director would be interviewing three RTs per week to make sure they were aware of the revised capping trial process. In an interview on [DATE] from 12:04 PM to 12:16 PM, the Administrator stated the DON in-serviced the nurses on the facility's revised Capping Trial policy and the Respiratory Therapy Director in-serviced the RTs on the revised policy. The Administrator stated an audit of residents' charts was done which revealed there were no residents in the facility who were on capping trials. The Administrator stated the facility's policy for Capping Trials was revised to include the use of an audible pulse oximeter during the capping trial. Also, the Administrator stated the facility had a group abuse training that was presented by the DON on [DATE] for staff present in the facility and other staff came into the facility and signed the in-service sheet after they had reviewed the abuse policy. In addition, the Administrator stated the newly hired nurses and RTs would have the revised Capping Trial policy reviewed with them before they started to provide care to residents. The Administrator stated he made sure all the nurses and RTs had received the in-service training on the revised policy when he reviewed the in-service signature page. The Administrator stated an Ad Hoc QAPI meeting was held with the Medical Director, DON, RT Director, and the ADON and the facility's plan to remove the immediacy was reviewed. The Administrator stated results of the facility's monitoring with use of the monitoring tools they developed of the POR would be reviewed at the monthly QAPI meetings. Lastly, the Administrator stated he would use the monit[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 5 Residents (Residents #1) reviewed for respiratory care. During a capping trial on [DATE], Resident #1 was not monitored, and no staff were physically present in her room. Resident #1 became unresponsive and had to be transported to the ER for treatment. The facility did not have a policy/procedure in place for capping trials at the time of the incident. Resident #1 died at the hospital on [DATE]. This failure resulted in an IJ on [DATE] at 5:00 PM. While the IJ was removed on [DATE] at 3:45 PM., the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that was not immediate jeopardy with a scope of isolated due to facility's need to evaluate the effectiveness of their plan of removal. This failure could place tracheostomy residents recommended for a capping trail at risk for exacerbation of condition up to and including death. The findings included: Resident #1's face sheet, undated, revealed the resident was a [AGE] year-old admitted on [DATE], readmitted [DATE], transferred to hospital [DATE], and deceased [DATE]. Diagnoses included: stroke, cerebral aneurism (blood vessel weakness in the brain), diabetes, DVT (deep vein thrombosis) (blood clots in deep vein), HTN (hypertension), quadriplegic, and seizures. Further review revealed the resident's RP was listed as a family member, and the resident's Code Status was Full Code. Record review of Resident#1's admission note, dated [DATE] and [DATE], reflected the resident was admitted to the facility with a tracheostomy on both occasions. Record review of Resident #1's admissions MDS, dated [DATE], reflected the resident was unable to answer questions in cognition, and had upper and lower extremity impairments due to a diagnosis of stroke. Record review of Resident #1's Care Plan, dated [DATE], reflected: resident had a tracheostomy related to respiratory failure. Interventions included tracheostomy care Q shift and Capping trials 30 mins_1 hour BID as tolerated . Monitor respiratory rate, depth and quality . Record review of Resident #1's physician's order, dated ,d+[DATE], reflected orders to administer capping trials for 30 minutes up to 1 hour twice per day on the day shift starting [DATE] and ending [DATE]; and use of nasal cannula at 3L/ minute during capping trials. Record review of Resident #1's Pulmonologist note, dated [DATE] at 11:30 AM, reflected, resident tolerated the second capping trial on [DATE] well and was on a T piece for oxygen. Record review of Resident #1's RT note, dated [DATE] at 11:36 AM authored by RT A, reflected: the resident was placed on a red cap trial with a heart rate of 84 and an oxygen saturation of 97%; and the resident was noted not to be in distress. Record review of Resident #1's RT note, dated [DATE] at 11:59 AM authored by RT A, reflected: RT A checked on the resident at 11:59 AM and the resident's oxygen saturation was at 97 % and heart rated at 84. Resident received 3 L/minute of O2 from nasal cannula. Record review of Resident #1's RT note dated [DATE] at 12:38 PM authored by RT A, reflected: resident was found unresponsive with no pulse felt. CPR was started by the RT A and a Nurse (name not documented) and EMS called and Resident #1 was transferred to the ER. Record review of Resident#1's capping sheet for capping trial #1 ([DATE]) and capping trial # 2 ([DATE]) reflected vitals were normal and the first capping lapse time was 30 minutes; and the second capping #2 time was recorded as 30 minutes. The trach and capping trial sheet reflected that the resident's [RP] was present at bedside. The third capping on [DATE] started at 11:36 AM for one hour of capping and the sheet reflected that RT A saw the resident at 11:59 AM; stop time was not recorded. Record review of Resident #1's Code Blue Record, dated [DATE] at 12:44 PM, reflected the code was initiated at 12:38 PM. The Code Blue Record read: History of Code: RT [A] noted Resident unresponsive and no pulse .Pulse detected @ 62 BPM after 2 rounds. EMS arrived and transported resident to [local ER] . Record review of Resident #1's EMS Run Report, dated [DATE] at 12:41 PM (Incident # 0209529) , read: .According to staff she was last [seen] with a pulse 39 mins prior and no shocks were delivered .After a round of epi, bicarb and calcium [heart medications] was delivered .Pulses were confirmed at a ratee of 60 .En route the pulse was lost .and one more dose of epi (heart medication) was applied . Resident #1's ER report, dated [DATE], revealed, admitted for cardiac arrest; history of trach. The ER report read, She is a nursing home resident with approximately 30 minutes of unresponsiveness prior to EMS arrival. She did require CPR with ROSC (return of spontaneous circulation) obtained in the ER [another heart attack in the ER] . remains unresponsive. Record review of Resident #1's Hospital initial assessment note read: OOH (out of hospital) arrest ,d+[DATE] .ABI (brain injury); mri (scan) anoxic ischemia [tissue dead due to lack of O2] .C diff colitis .[history of brain bleed [DATE]] .AKI (acute kidney injury), likely secondary to hypoperfusion during arrest (lack of blood flow) .chronic respiratory failure s/p (status post) trach .HTN (hypertension) .DM (diabetes). During an interview on [DATE] at 1:14 PM, the DON stated on [DATE] the family came in to speak to the administrator and alleged the resident [Resident #1] was deceased and needed to pick up her belongings. The DON stated, the family felt that the death was suspicious. The DON stated, the administrator informed her that he would make a self-report to HHS of a suspicious death. The DON stated that the resident coded on [DATE] and was resuscitated and sent to the ER for further evaluation. The DON stated the administrator contacted the family on [DATE] and was informed the resident was still alive. The DON stated the resident had a history of pleural infusion (issues with excess fluid in the lungs), HTN, and history of CVA; and chronic stage 3 kidney disease. The DON stated, the resident was on a trach because the resident had respiratory failure after her stroke at home, prior to admissions. The resident arrived at admissions with a trach and a ventilator. The DON stated the resident was weaned off the ventilator around [DATE]. The DON stated the resident was kept on the trach for respiratory reasons. The DON stated an in-service was initiated on ANE on [DATE] was still on-going on [DATE]. The DON stated that there were 18 residents with a trach in the respiratory hall (Hall 400). During a telephone interview on [DATE] at 1:18 PM, the Medical Examiner stated the cause of death involving Resident #1 was still under investigation. During an interview on [DATE] at 3:50 PM, The DON stated no staff was present for Resident #1's initial capping trials for 100% of the time. The DON stated there was no requirement for staff to be present during trach capping trials; and Resident #1 did not start a trial until a full evaluation by the Pulmonologist. The DON stated the capping trials did not contribute to the cardiac arrest. The DON stated the initial trials were done daily, one trial per day; the first and second trials started [DATE] in AM shift (12 AM-12 PM) and no staff were physically present during the trial time span of the first and second trials. The DON stated on the third trial on [DATE] started at 11:36 AM the RT discovered resident unresponsive at 12:30 PM. The DON stated that the resident breathing was assessed at 11:59 PM; O2 was at 97 % (normal) and pulse was at 84 (normal). The DON stated based on the timeline the RT [A] entered at 12:38 PM and found the resident unresponsive; with no pulse and code was called. The DON stated there was no policy on capping trials except to follow physician orders. The DON stated the physician's orders did not specify that a staff member had to be present during the time resident was breathing independently. The DON stated no one was required to be present during the time of monitoring. The DON stated the resident's co-morbidities caused the cardiac arrest during the third capping trial. The DON stated the Pulmonologist was working with Resident #1 and felt it was safe to initiate capping trials. During an interview [DATE] at 9:21 AM, RT Director stated, Resident #1 was doing well after the removal of the ventilator. Resident had hemoglobin issues; needed transfusions. The RT Director stated Resident #1 was stable and capping trials started; [DATE] for two trials. The RT Director stated on the third trial an oximeter [non-audible] placed on Resident #1. The RT Director stated, the oximeter would not alert or alarm if the resident had a cardiac rest. The RT Director stated, at the time of the third trial there was no system in place to monitor the heart rate. The RT Director stated the trial started, and the RT specialist [RT A] checked on the resident within a time frame of 30 minutes. The RT Director stated the resident had underlying issues that included HTN, stroke, anemia, and kidney issues. The RT Director there was no one physically present for one-on-one monitoring during any trial for Resident #1. The RT Director stated existing policy only called for spot checks and no documentation was required for the spot checks. The RT Director did not provide a response as to whether a resident like Resident #1 with co-morbidities needed a physical presence when cap trials were done. The RT Director stated in-service training for the RT staff was started on [DATE] [at time of surveyor's entrance] on trach care and capping procedures. The RT Director stated Resident #1 could not uncap on her own. The RT Director stated that the facility did not have a written policy on capping because capping was based on clinical standards. During a telephone interview on [DATE] at 9:54 AM, RT A stated she was the RT for the 3rd capping trial for Resident #1. RT A stated before the trail started, she checked Resident #1's O2 sats, trach care, breathing treatment, and mental status. RT A stated, she placed an oximeter [non audible] on the resident that read for saturation and heart rate. RT A stated that the oximeter would not alarm if the resident had a cardiac arrest. RT A stated that the resident had previous underlying issues. RT A stated Resident #1's the third capping trial started at 11:16 AM and she returned at 11:59 AM to check on the resident and the resident was not in distress. RT A stated she returned at 12:36 PM and the resident was unresponsive; the resident was pale, not responding to sternal rubbing and calling her name; then the RT called for help; CPR started at 12:38 PM, EMS arrived, and the resident was resuscitated. The RT stated. I did not stay with the resident because she had no previous issues with capping. RT A stated she did not stay with Resident #1 because she had to attend to other residents. Interview on [DATE] at 12:05 PM with the Medical Director revealed Resident #1 suffered a cardiac arrest during the third capping trial on [DATE]. During interview on [DATE] at 1:25 PM with the Pulmonologist stated Resident #1 was a suitable candidate for capping trials because the resident was off the ventilator and had no congestion. The Pulmonologist stated observation during capping only required the RT to view the resident for a few minutes. The Pulmonologist said the RT could leave after the resident was not in distress and return later for further assessment of independent breathing. The Pulmonologist stated the facility had no equipment for monitoring present in Resident #1's room when the capping trial was conducted. The Pulmonologist stated Resident #1's cardiac arrest could not have been predicted, but no alert system or monitoring equipment were present to alert RT staff who were not physically present in the room when Resident #1 coded. During an interview on [DATE] at 4:04 PM, LVN B stated on [DATE] she saw Resident #1 at 12:10 PM and the resident was not in distress. LVN B stated she saw a red cap on the resident's trach and the resident was breathing with the nasal canula receiving ,d+[DATE] liters/ minute. LVN B stated, the resident looked normal. LVN B stated she did not document the observation of Resident #1 during the initial capping trial. During telephone interview on [DATE] at 10:50 AM, RT G stated he initiated the first capping trial for Resident #1 on [DATE] for 30 minutes and remained with the resident 100% of the time. RT G stated the resident tolerated the 30 minutes of capping and revealed no signs of distress. RT G stated he was not aware of any facility policy on capping. RT G stated his policy was to remain with the resident throughout the trail to ensure the resident did not suffer any distress. During telephone interview on [DATE] at 11:00 AM, RT C stated she initiated capping trial for Resident #1 on [DATE] at 1:30 PM and the resident's RP was present. RT C stated she remained the entire time with the resident and the RP during the trial scheduled for 30 minutes. RT C recalled the second capping trial was halted between ,d+[DATE] minutes because the resident became exhausted. RT C stated she was not aware of any facility policy on capping. Record review of Resident #1's Trach Capping Flow Sheet dated [DATE] read: .Resident coughed. RT [RT C] had resident complete alphabet then ended trial. [family member] of resident @ bedside . During telephone interview on [DATE] at 4:35 PM, the family member stated the family member and the [RP] at admission were told by the RT Director that a staff member would be physically present when capping trials were attempted. The family member stated at a second meeting before the capping trials started the RT Director again assured the family that a staff member would be present all the time during the initial capping trials. The family member stated the family told the RT Director that the family was concerned about the resident's condition and her inability to communicate during an emergency. During telephone interview on [DATE] at 5:02 PM, Resident #1's RP stated he recalled when Resident #1 was admitted to the facility the Rehab Director assured him and the family that during the initial capping trials that staff would be present all the time. The RP stated that at a second CP meeting, unknown date, the RT Director was present and assured the family that staff would be present all the time during the initial capping trials. The RP stated he was happy about the staff being present during the initial capping trial because the resident could not pull the call light and could not cry out for help. The RP stated he was physically present with the [RT C] all the time on the second capping trial. The RP recalled he repeated the alphabet to the capped resident, and she was able to mimic some sounds. The RP stated the second capping trial lasted about ,d+[DATE] minutes and it was scheduled for 30 minutes. The RP stated he was not sure why the second capping trial did not last for 30 minutes. The RP stated that he was not invited to the third capping trial on [DATE]. Resident #1's RP stated, if I had known that [the resident] was going to be left alone, I would not allow the third trial. The RP stated his expectation was for staff to be physically present 100% of the time during the third capping trial and not just spot checking and monitoring. The RP stated he saw Resident #1 on [DATE] and she was alert and smiling. The RP stated he visited Resident #1 regularly for the past seven months. The RP stated that she (Resident #1) was left by herself [[DATE]] .I was assured that staff would be present all the time . During an interview on [DATE] at 9:18 AM, the ICU RN D stated the hospital clinical notes authored by MD E for Resident #1's record reflected the resident was admitted to ICU on [DATE] with no vasopressors (medications used to raise blood pressure in the emergency room ) and intubated and placed on a ventilator. RN D stated the resident was anoxic per the MD note (without oxygen in the brain) and coded. RN D stated with family's approval resident was made an in hospital DNR. RN D stated, the resident deceased on [DATE]. During second interview on [DATE] at 1:12 PM, the Pulmonologist stated Resident #1 was a suitable candidate for capping trials. The Pulmonologist stated her expectation was at the first capping trail staff needed to be present the entire time of the capping; on the second trial of capping the family was present the entire time. The Pulmonologist stated given that Resident #1 experienced a cardiac arrest on the third trial, Yes staff should have been present all the time. The Pulmonologist stated Yes the facility needed a policy on capping. During an interview on [DATE] at 1:17 PM, RT F stated she was trained on capping procedures in school and had been an RT for five years. RT F stated capping trials were dependent on the resident's condition and being off the ventilator. RT F stated the initial trials ranged from ,d+[DATE] minutes. RT F stated monitoring involved checking on the resident and it could be continuous or sporadic for the initial trials. RT F stated on the first capping it required 100% presence of staff in the room; trial 2 and 3 were dependent on how well the resident did in trial one. RT F stated there was no policy or protocol on capping, and one should be present for resident safety. During an interview an interview on [DATE] at 1:50 PM, the Administrator stated he met with Resident #1's family on [DATE] and was informed by the family that the resident was deceased . The Administrator stated that standards of care dictated the initial capping trials for Resident #1. The Administrator stated the facility's investigation of the incident on [DATE] was still in progress. During an interview on [DATE] at 1:55 PM, the RT Director denied he ever made a commitment to Resident #1's family and RP that staff would be present during the entire time of the capping trials. The RT Director stated at admissions the family and RP were informed they had an open invitation to attend capping trials. The RT Director stated there was no requirement that he call the RP to initiate a capping trial. During interview on [DATE] at 2:30 PM, the DON stated the timeline was as follows: 11:30 AM - Pulmonologist assessed the resident and no contra indications against the third capping trial on [DATE]. 11:36 AM - RT [A] capped the resident. 11:59 AM - RT [A] re-assessed the resident. 12:15 PM - LVN [B] made rounds and observed the resident. The resident was not in distress. 12:38 PM - RT [A] found the resident unresponsive; code called, and CPR started. 12:41 PM - EMS arrived. 12:44 PM - EMS transported resident to ER. In an interview and observation on [DATE] at 11:34 AM, RT C revealed a battery-operated audible pulse oximeter was kept on the Respiratory Therapist cart and the facility had this audible pulse oximeter for about three months. In an interview on [DATE] from 11:14 AM to 11:35 AM, the Respiratory Therapy Director stated he provided the in-service training to the RTs of the revised capping trial policy either in person or via phone or text message. The Respiratory Therapy Director stated the facility has had the plug-in audible pulse oximeter for about a week or two. Record review of facility's policy titled Tracheostomy Care Procedures dated [DATE] revealed Tracheostomy care will be performed per physician's orders. Record review of facility's policy titled Capping Trial for Tracheostomy Patients dated Revised 2023 [from an unknown author and not signed by the Facility's QAPI leadership team] was presented to the Surveyor on [DATE] at 4:45 PM while template vetting discussion was in progress. Record review of the facility's policy titled Abuse/Neglect, dated revised [DATE], read: .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of facility's in-service on the topic of Notify MD of any Respiratory Change of condition and Follow Physician's Orders was started on [DATE] [day of the surveyor's entrance]. Of 16 RT employees 13 RTs had attended the training for a completion rate of 81%. On the topic of Monitoring During Capping Trials started [DATE], 13 RTs had attended the training for a completion rate of 81%. The Capping training read: RT will monitor and perform O2 saturation checks and pulse checks at least every 30 minutes during capping trials. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 5:00 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10:03 a.m. on [DATE] and reflected the following: February 21, 2025 [Facility] Re: [Citation Number] Interventions: On [DATE] All medical records of residents with a trach were audited by the DON/ADON/RT supervisor to ensure that an order for capping trails was followed as ordered by the physician. The audit completed on [DATE] revealed no current residents are being trialed on capping of tracheostomies. On [DATE] Procedure for capping trials was developed and implemented. On [DATE] all Respiratory Therapist were/will be in-serviced by the DON, RT supervisor regarding: o Following physician orders will include monitoring to be documented by the respiratory therapist. o The respiratory therapist will remain at bedside to assess the resident for 10 minutes at the beginning of the capping trial and document assessment to include pulse, oxygen saturation, respiration and lung sounds o Respiratory Therapist will remain on the unit while capping trial is being conducted until determined by physician monitoring is no longer required o Use of an audible pulse oximeter during capping trial time will be indicated in the physician orders for monitoring purposes based on resident individual needs. o The audible pulse oximeter will be audible from other rooms on the unit. o Respiratory Therapist will respond to audible pulse oximeter alarm and assess resident needs if indicated. o Nursing staff will be in-serviced on [DATE] to the capping trial process and available to respiratory therapist if any change of condition occurs by the DON/designee. o Respiratory Therapist will monitor the resident every 30min during capping trail for any change of condition. o Monitoring of tracheotomy capping trial residents will be done by Respiratory Therapist o Monitoring oxygen saturation, respirations and pulse during capping trails o Notifying the physician and family of any change in condition during capping trials. On [DATE] all facility staff were in serviced by the DON, ADON/designee related to Abuse and Neglect. All new hired Respiratory Therapist and nurses as well as any agency therapist/nurses that maybe utilized will receive the in-services upon hire. Any respiratory therapist and nurse that has not received the in-services will complete prior to start of shift. The DON and Respiratory Therapist will ensure that all respiratory therapist and nurses receive in-services, and the Administrator will validate completion of in-services. Monitoring: At least 5 times per week for 4 weeks then 2 times a week for 4 weeks then as needed as capping trials orders occur, orders will be reviewed by the DON/designee to ensure that capping trial orders are complete. The DON / RT supervisor will interview at least 3 Respiratory Therapist per week for 4 weeks then 2 times a week for 4 weeks and questions will include: o How frequently do you monitor residents on capping trials? o What vitals are to be monitored during capping trials? o When do you notify the physician and family? o For capping trials whose orders are to be followed? The DON/ADON/RT supervisor will review resident's records (vital signs, progress notes) of capping trials at least 5 times per week for 4weeks then 2 times a week for 2 weeks then as needed to monitor the residents for any changes of condition during the capping trial. And ensure that the physician/family was notified of resident changes in condition. The administrator will monitor and review the findings of the DON/ADON/RT supervisor during morning and stand down meeting at least 5 times per week for 4weeks then 2 times a week for 2 weeks then as needed. Findings will be reviewed by the QAPI committee and changes will be made as needed. Verification of Plan of Removal: In an interview on [DATE] at 11:09 AM, the DON stated there were no residents who were on a ventilator who had an order for capping trials. In an interview on [DATE] at 11:09 AM, the DON stated they had revised their policy on capping trial for residents on a ventilator and provided a copy of the newly revised policy. In an observation and interview on [DATE] at 11:34 AM, RT C revealed a battery-operated audible pulse oximeter was kept on the Respiratory Therapist cart and RT C stated the facility had this audible pulse oximeter for about three months. In an interview and observation at [DATE] at 11:38 AM, the RT Director stated the facility has a continuous audible pulse oximeter that could be plugged in. The Administrator brought the plug-in audible pulse oximeter and took it into a room nearby where the Surveyor H was standing, and the surveyor was able to hear from the hallway the alarm sound from the plug-in audible pulse oximeter. Interviews on [DATE] from 11:24 AM to 5:00 PM and on [DATE] from 8:28 AM to 10:00 AM with 5 Respiratory Therapist (4 worked day shift [6 AM-6 PM], and 1 worked night shift [6 PM - 6 AM]), and 7 LVNs (6 worked day shift, and 1 worked night shift), and 1 RN who worked the night shift revealed they had been in-serviced on the best practice of following the physician orders, the RTs will notify the physician if orders need clarification, clarified orders would be put into the resident's clinical record, the physician would be notified of any change of condition in the resident's respiratory status and any new orders received would be implemented; and the Rt would monitor and perform pulse oximeter blood oxygen saturation checks at least every 30 minutes during capping trials. Also, Interviews on [DATE] from 11:24 AM to 5:00 PM and on [DATE] from 8:28 AM to 11:00 AM with 5 Respiratory Therapist (4 worked day shift [6 AM-6 PM], and 1 worked night shift [6 PM - 6 AM]), 7 LVNs (6 worked day shift, and 1 worked night shift), 1 RN (who worked the night shift), 3 CNAs (who worked day shift), 2 housekeepers, 1 Cook, 2 Dietary Aides and the FSS (Food Service Supervisor) revealed they had been in-serviced on abuse and neglect. Interview with the Medical Director on [DATE] from 4:38 PM to 4:43 PM revealed he attended the Ad hoc (un-planned) QAPI (Quality Assurance/Performance Improvement) meeting by phone that was held with the DON, Administrator and Respiratory Therapy Director; and the POR (plan of removal) for capping trials on residents was discussed. In an interview on [DATE] from 11:14 AM to 11:35 AM, the Respiratory Therapy Director stated he provided the in-service training to the RTs of the revised capping trial policy either in person or via phone or text message. The Respiratory Therapy Director stated the facility has had the plug-in audible pulse oximeter for about a week or two. The Respiratory Therapy Director stated the residents who had ventilators orders were reviewed and there were no residents who had orders for capping trials. The Respiratory Therapy Director stated the policy for Capping Trial was revised to include the use of an audible continuous pulse oximeter, to be with the resident the first 10 minutes of the trial and to check on the resident every 20 minutes after that. Further, the Respiratory Therapy Director stated he would train the new RT staff using a mannequin on how the capping trial process would be done in the facility before they started to work on the floor. The Respiratory Therapy Director stated he attended the Ad hoc QAPI meeting with the DON, Administrator, and the Medical Director to discuss the facility's POR plan. Lastly, the Respiratory Therapy Director stated he would be randomly interviewing three RTs the questions on the monitoring form each week. In an interview on [DATE] from 11:42 AM to 11:58 AM, the DON stated the facility made a video for the nurses to watch of what the Capping Trial policy involved, and it showed the Respiratory Therapy Director doing a capping trial on a mannequin so the nurses would know what was involved and what their role was during the capping trial. [Surveyor H observed portions of the video] The DON stated the training video was sent to the nurses and then they came in and signed the in-service training sheet. The DON stated she had reviewed the orders of residents who had a tracheostomy and were on a vent and there were no residents with an order for capping trial. The DON stated the facility revised their old policy on Capping Trials and added an audible pulse oximeter, which would alarm if the resident had a change in their condition, would be used during the capping trial to the policy and added the RT would stay with the resident for the first 10 minutes of the trial. Also, the DON stated staff were provided a copy of the abuse policy and were informed of the types of abuse, who the abuse coordinator was, and how to find the abuse coordinators phone number. Further, the DON stated newly hired nurses would be shown the video they made of the facility's capping trial procedure during their orientation before they started to work on the floor. The DON stated she had ensured all the nurses had received the training by having the nurses come into the facility to verify they had received the training. Moreover, the DON stated weekly audits would be done, she would review the resident's orders daily for any new orders for capping trials and it would be discussed in the morning meetings. The DON stated she and the RT director would be interviewing three RTs per week to make sure they were aware of the revised capping trial process. In an interview on [DATE] from 12:04 PM to 12:16 PM, the Administrator stated the DON in-serviced the nurses on the facility's revised Capping Trial policy and the Respiratory Therapy Director in-serviced the RTs on the revised policy. The Administrator stated an audit of residents' charts was done which revealed there were no residents in the facility who were on capping trials. The Administrator stated the facility's policy for Capping Trials was revised to include the use of an audible pulse oximeter during the capping trial. Also, the Administrator stated the facility had a group abuse training that was presented by the DON on [DATE] for staff present in the facility and other staff came into the facility and signed the in-service sheet after they had reviewed the abuse policy. In addition, the Administrator stated the newly hired nurses and RTs would have the revised Capping Trial policy reviewed with them before they started to provide care to residents. The Administrator stated he made sure all the nurses and RTs had received the in-service training on the revised policy when he reviewed the in-service signature page. The Administrator stated an Ad Hoc QAPI meeting was held with the Medical Director, DON, RT Director, and the ADON and the facility's plan to remove the immediacy was revie[TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests for 3 of 7 residents (Resident #1, Resident #2 and Resident #5) reviewed for pest control, in that: The facility failed to ensure an effective pest control program was in place to keep flies out of resident rooms resulting in an infestation of maggots in Resident #1's left heel wound. On 05/30/2024 at 5:16 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 5/31/2024 at 8:32 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). The failure could place residents with wounds at risk for infection or infestations from pests. The findings included: 1. Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: anoxic brain damage (brain injury that cuts off oxygen to the brain) and type 2 diabetes mellitus (a condition resulting from insufficient production of insulin, causing high blood sugar). Record review of Resident #1's MDS assessment, dated 04/23/2024, revealed Resident #1 had short term and long-term memory problems and severe impairment for cognitive skills for daily decision making. The MDS revealed Resident #1 was dependent on staff for self-care and mobility. The MDS also revealed Resident #1 admitted to the facility with 2 unstageable pressure injuries presenting as deep tissue injuries. Record review of Resident #1's care plan, initiated 04/05/2024, revealed Resident #1, has impaired skin integrity at the time of admission AEB pressure ulcer/diabetic ulcer. Wounds listed on the care plan were: 1. Stage 4 to sacrum 2. DTI left heel 3. DTI right heel 4. Diabetic ulcer to left lateral leg. The goal of the care plan, revision date 04/30/2024 and target date 07/30/2024, stated the resident will have intact skin, free of redness, blisters or discoloration by/through review date. Record review of Resident #1's initial skin assessment, dated 04/06/2024, revealed Resident #1 had an abrasion to left lateral leg, DTI to left heel, DTI to right heel, and sacrum wound stage 4. Record review of Resident #1's weekly-ulcer assessment, dated 04/09/2024, revealed Resident #1 had a pressure ulcer on his left heel staged as a deep tissue injury measuring 4.5 cm in length and 3.7 cm in width. The assessment revealed the current wound treatment frequency was daily and was signed by the LVN Treatment Nurse. Record review of Resident #1's weekly-ulcer assessment, dated 05/21/2024, revealed Resident #1 had a pressure ulcer on his left heel staged as a deep tissue injury measuring 4.5 cm length and 3.7 cm width. The assessment revealed the current wound treatment frequency was daily and was signed by the LVN Treatment Nurse. Record review of Resident #1's May 2024 physician orders revealed Resident #1 had an order for, wound care-left heel-cleanse with wc or ns. Pat dry, apply betadine. Leave open to air. One time a day for DTI-necrotic tissue. Record review of Resident #1's May 2024 administration record revealed Resident #1 prescribed wound care order to his left heel was initialed as completed by the LVN Treatment Nurse between the hours of 6:0 0 a.m. and 6:00 p.m. on 05/23/2024. Record review of Resident #1's bathing log with a look back period of 14 days revealed Resident #1 was dependent for assistance for showers/bathing and received a shower/bath on 05/14/2024 at 8:23 a.m. 05/15/2024 at 9:59 a.m., 05/17/2024 at 1:32 p.m., 05/18/2024 at 9:33 a.m., 05/20/2024 at 8:34 a.m., 05/22/2024 at 1:02 p.m. and 05/23/2024 at 9:08 a.m. Record review of Resident #1's progress note, dated 05/24/2024 at 12:20 a.m., revealed a note stating Resident #1 was transferred to the hospital on 05/24/2024 at 1:00 a.m. related to high potassium of 6.75. Record review of Resident #1 EMS transport run document revealed EMS transport arrived at the facility on 05/24/2024 at 1:11:39 a.m. and were on scene at the facility for 35 minutes. EMS transport document revealed timed transport to the hospital began on 05/24/2024 at 1:46:05 a.m. Document revealed EMS transport arrived at the hospital at 2:07:35 a.m. and transferred the patient to the care of the emergency department at the hospital on 05/24/24 at 2:17:17 a.m. Record review of Resident #1's hospital physician emergency provider report, dated 05/24/2024 at 05:36 a.m., revealed the physician's initial greet time to the resident was 05/24/2024 at 02:15 a.m. and the physician noted stated, Skin: skin break down noted to b/l heels, left great toe, maggots noted in one of his skin ulcers. Record review of Resident #1's critical care consult notes, dated 05/24/2024, stated, extremities and back: several nonstagable wounds of the extremities, including ankle wounds s/p maggot removal by nursing. The note also stated, Resident #1 is a [AGE] year-old man admitted for a UTI, sepsis and acute on chronic renal disease with concern also for inadequate care at the nursing facility judging by the many wounds on his body, some with maggots. Under the assessment on this note it read, many pressure sores, heel wounds with maggots. Furthermore, the physician attestation findings and plan stated, patient is at risk for life threatening deterioration. Record review of Resident #1's vascular surgery consult notes, dated 05/24/2024 at 5:00 p.m., stated under diagnosis, assessment and plan: there are maggots and significant dry gangrene of the heel as well as toes as well as an area of the left shin. This will likely necessitate at least below-knee amputation. Record review of the company pest control contract, dated 01/05/2011, revealed a list of facilities receiving pest control services that included the facility. Record review of the pest control service statement, dated 04/01/2024, revealed, checked with maintenance director for any ongoing issues that needed to be addressed and no major issues going on at this time. Record review of pest control service statement, dated 04/20/2024, revealed, facility requested additional service. Maintenance Director showed me an office where a scorpion was killed. Treated the office with a liquid residual targeting scorpions as well as place glue boards for monitoring purposes. I was also informed on flies being throughout the facility. I did change out 2 fly glue boards as well as sprayed a fly bait around the fly lights and exit doors to help with fly pressure. Please be aware that having doors open constantly will cause flies to fly in. Record review of pest control service statement, dated 05/09/2024, revealed, checked in with maintenance director and administrator for any ongoing issues that needed to be addressed. I was informed on room [room number] for cockroach sightings as well as in room [room number]. Both rooms were treated with a liquid residual product while residents were out of the room. I was also informed on flies being throughout the facility. I went ahead and replaced the fly glue board in the kitchen and checked the remaining glue boards for any fly pressure. I treated along the doorways and around certain window frames with a pressurized fly bait to help with fly control. As I was treating the exterior perimeter of the facility, I also treated around main doorways to help with fly pressure. Please be aware that 3 of the 5 fly lights that the facility currently has are older models that don't work as well as the other 2. We will be sending a proposal for additional fly lights to be installed to further help with fly pressure. Please be aware that the more doors stay open the more flies and other pests will get into the facility. Record review of a facility in-service titled: pest control/insects, dated 05/21/2024 stated notify maintenance director if you observe any types of insects in the facility immediately'. The in-service training attendance roster contained 17 signatures. Record review of pest control service statement, dated 05/28/2024, revealed pest control was on site today to address fly issues around the facility. I started by inspecting common areas of the facility and saw very light activity of flies. I went ahead and used a liquid residual product on the walls of each hallway to help reduce fly pressure. This will ensure that if flies land on the wall the product will help eliminate the flies. A pressurized fly bait was also applied on the exterior perimeter near all entry ways to help reduce fly activity. Fly bait will help draw out flies from rooms also. Also fly light glue boards were changed out to help catch any fly activity. Please be aware the fly lights work best when there is no other light around. The blue light will help attract and catch flies on the glue boards. Observation during facility rounds, 05/29/2024 at 9:30 a.m., revealed 100 hall exit door propped open for approximately two minutes while residents were coming back inside from a smoke break. Fly light observed on the 100-hall wall approximately halfway up the hall. Observation of Resident #1's assigned room at the facility, 05/29/2024 at 11:00 a.m., revealed Resident #1's room was located next door to a facility exit door. The exit door had a sign on it that read Stop do not enter thru this door. Go thru front entrance only. Thank you, Administrator. Observation conducted in the conference room, 05/29/2024 at 11:30 a.m., revealed a live fly landing repeatedly on the conference room table. Observation of Resident #1's assigned room, 05/29/2024 at 6:15 p.m., revealed the window was closed and the window screen had a two-inch gap in the right side of the screen and the window. One live insect was crawling on the ground in the center of the room and two dead insects were observed on the room floor. Observation, 05/30/2024 at 11:17 a.m., revealed a live fly in the hallway of 400 hall. Observation, 05/30/2024 at 11:27 a.m., revealed a live fly in a resident room on the 400 hallway. Observation, 05/30/2024 at 11:30 a.m., revealed LVN C standing at the nurse's station with a fly swatter in her hand. Observation, 05/30/2024 at 12:50 p.m., revealed a live fly in the conference room. During an interview with an APS Case Worker, 05/28/2024 at 3:03 p.m., the APS Case Worker revealed she received an allegation of neglect from the hospital on 05/25/2024 due to Resident #1 admitting to the hospital with maggots in a wound. APS Case Worker stated she met with RN B at the hospital and was shown pictures of the maggots and the wound from when Resident #1 admitted to the hospital. During an interview with the facility DON, 05/28/2024 at 3:31 p.m., the DON stated flies were in the facility. The DON stated pest control was coming out twice a month, IV lights were in the hallway, an air curtain was ordered to place at the top of the door and vegetation had been reduced around the building. An interview with the Hospital RN ICU Unit Manager, 05/29/2024 at 12:53 p.m., revealed she arrived to the ICU unit on 05/24/24 at approximately 6:45 a.m. She said she went to Resident #1's room door and observed 2 RNs in the room transferring Resident #1 from a stretcher to a bed on the ICU. She said he was brought to the unit from the ER and was still wearing the multi podus boots on both heels that he arrived wearing. She said she observed the RN's remove his left heel boot and witnessed a bunch of maggots fall onto the bed from his heel, and they were crawling on the bed. An interview with Hospital RN A, 05/29/2024 at 2:58 p.m., revealed Resident #1 arrived to the ICU at approximately 7:00 a.m. RN A stated she transferred Resident #1 with another RN from the stretcher to the ICU bed. She said he had on, preventative boots, on both feet and that they were not the boots they use at the hospital. RN A stated when she began to take his boot off his left foot, maggots began falling out of his heel. RN A stated she completed a couple of saline flushes to get the maggots out of the wound, dressed the wound with a mepilex dressing and entered an order for a wound care consult. RN A's description of the maggots were, alive, crawling and moving, and that she counted at least 20 of them in his heel. RN A stated the RN Wound Care nurse came in and assessed Resident #1 in the afternoon around approximately 1:00 p.m. and the RN Wound Care Nurse told RN A that she was having to, really go deep into the wound and flush them out because there were a lot of them. An interview Hospital RN B, 05/29/2024 at 3:20 p.m., revealed she was working on the ICU floor the morning Resident #1 arrived at the ICU unit around approximately 6:45 a.m. RN B said she assisted RN A with transferring Resident #1 to the ICU bed and was present when RN A removed Resident #1's boot from his left heel. RN B said she witnessed maggots fall out of the boot and crawl out of the left heel wound on Resident #1. RN B said they flushed the wound several times, dressed it and made a referral to wound care. RN B said she only noticed maggots on and inside of Resident #1's left heel and said, he looked so neglected and his wounds did not look like they were being cared for. An interview with the facility LVN Treatment Nurse, 05/29/2024 at 4:15 p.m., revealed LVN Treatment Nurse was responsible for performing wound care Monday - Friday and the Charge Nurses or LVN D perform wound care on the weekend. LVN Treatment Nurse stated he completed the weekly ulcer assessments on residents with wounds. LVN Treatment Nurse revealed he performed the prescribed treatment to Resident #1's left heel on the morning of 05/23/2024. LVN Treatment Nurse revealed Resident #1 had adhered eschar to the left heel and that it had, been that way for a long time. He further revealed on the morning of 05/23/2024 the left heel appeared by touch to be soft or, boggy, in the center of the DTI. LVN Treatment Nurse stated Resident #1 had on multi podus boots, he removed the boot, visualized the wound and followed the prescribed orders. LVN Treatment Nurse was asked how flies may have infested the wound and he said he did not know and believed the wound had adhered tissue. During an interview with CNA A, 05/29/2024 at 5:02 p.m., revealed CNA A provided a shower to Resident #1 on 05/23/24. She said LVN Treatment Nurse came to the room and removed residents dressing, CNA A gave Resident #1 a shower and washed the wounds with soap and water and then LVN Treatment Nurse redressed his wounds. CNA A stated she did not see any open areas on Resident #1's left heel. During an interview with CNA B, 05/29/2024 at 5:20 p.m., revealed CNA B provided a shower to Resident #1 on 05/22/2024. CNA B stated LVN Treatment Nurse removed Resident #1's dressings before the shower, she completed the shower and then LVN Treatment Nurse redressed Resident #1's wounds. CNA B stated she did not see any open areas on Resident #1's left heel. During an interview with LVN B, 05/30/2024 at 10:08 a.m., revealed LVN B was the Charge Nurse assigned to Resident #1 during the overnight hours of 05/24/2024. LVN B revealed she received a call from Resident #1's physician around 12:20 a.m. on 05/24/2024. The physician stated Resident #1 had a high potassium lab result and requested Resident #1 be sent to the hospital. LVN B said she called and set up transport, notified the resident representative and notified the RT on duty so they could transfer Resident #1 to a transport ventilator. LVN B said she looked at a dressing on his foot to make sure the dressing was clean but could not recall which foot. When asked if LVN B looked at Resident #1's heels before he left, she responded, no, I did not look at the heels and I don't remember if he had boots on his feet. LVN B was asked what wounds Resident #1 had on his body and LVN B stated, I think there is one on his foot and sacral area and I believe that is it. LVN B was asked when the last time she observed his heel wounds and she said, honestly I haven't seen them. LVN B stated she thought Resident #1 was picked up by EMS transport at approximately 1:30 a.m. During an interview with LVN C, 05/30/2024 at 11:32 a.m., LVN C was asked why she was standing at the nurses' station with a fly swatter. LVN C responded by saying, I don't know how it started but we have seen a lot of flies lately. I just killed one on 100 hall and was waiting to get back in my office. LVN C stated she thought the Administrator was ordering an air curtain for the door and said when the smokers went outside, the hallway door was left open, and the flies came in. During an interview with Resident #1's facility physician, 05/30/2024 at 11:57 a.m., the physician revealed he was Resident #1's primary physician at the facility and saw him several times a week. The physician stated he observed Resident #1's wounds on 05/21/2024 and said the left heel had eschar and he did not see any soft tissue. The facility physician stated he was notified by a physician at the hospital that Resident #1 had maggots in his left heel and said, I think what was changing was his circulation in his feet and they were getting ischemic and with that essential lack of circulation you will have a person be more vulnerable for infestation. When asked if it was possible for the wound to have opened and a fly lay eggs in the wound he said yes, someone must have left a window open or something, I don't really know. The facility physician said he had not had any concerns about wounds at this facility and that most of the facility wounds were showing improvement. An interview with the Hospital Wound Care RN, 05/30/2024 at 12:15 p.m., revealed the Wound Care RN received a consult request on 05/24/2024 to assess Resident #1. Wound Care RN revealed she assessed Resident #1 at approximately 1:00 p.m. and observed his left heel with black and dead tissue called eschar and underneath the eschar were maggots. Wound Care RN revealed the upper portion of the eschar was not intact and was able to be lifted up. Wound Care RN stated she was unsure how long they could have been there stating there were a lot of them, I removed about fifty myself with tweezers. The issue is they burrow down deeply so sometimes we cannot get access to them all until they start coming out. My understanding is the doctors are considering an amputation due to the infection in the left heel. An interview with the facility's DON, 05/31/2024 at 10:05 a.m., revealed LVN Treatment Nurse was responsible for wound care Monday - Friday. The DON stated wound care was completed by an assigned nurse or the charge nurse on the weekends. The DON revealed she spot checks the LVN Treatment Nurse to verify wound care of being completed. The DON also stated each resident was assigned a Champion (department manager) and the Champion was responsible for making daily rounds on their residents. The DON stated part of those rounds was to observe wound dressings to make sure they are dated and clean. The DON revealed they noticed an increase in flies at the beginning of May and some of the steps they took were to make sure the fly lights were working, have pest control come out to the facility twice a month, told staff to kill the flies, educated staff to remove food from rooms quickly after meal services and put out fans in rooms with resident with tracheotomies. When asked what harm could come to residents who are exposed to pests she stated, I am not sure what harm can come to them. Any bugs or just flies? If it is mosquitoes, they can bite them and give them viruses, cockroaches are dirty but I don't know if they give you infections. No one wants bugs on them, it is just gross. During an interview with the facility Administrator, 05/31/2024 at 11:07 a.m., the Administrator revealed the facility had identified an increase in flies in the facility and increased cleaning in resident rooms, identified high traffic areas and minimized doors that could be used. Called pest control and asked them to come out twice a month. The Administrator stated he ordered more pest control lights but there was a delay in delivery and arrived on 05/31/2024. When asked what harm could come to a resident who is exposed to pests, the Administrator said, I do not know, I am not an insect specialist. During an interview with the facility Maintenance Director, 05/13/2024 at 11:34 a.m., the Maintenance Director stated he had not received any specific training on pest control and said, I just go by what the pest control company tells me to do. The Maintenance Director stated staff were to report pest control concerns through the computerized maintenance program. When asked if he had seen an increase in work orders related to flies, he said no. When asked if staff had reported an increase in flies to him, he said no. The Maintenance Director was asked how the facility prevents pests and flies in the facility and he said the pest control company comes out once a month. The Maintenance Director stated the Administrator told him in April to call the pest control company to come out and do preventative maintenance on flies just to be sure we are ahead of the game. The Maintenance Director stated no one has talked to him about more fly activity in the facility and stated he had not attended any meetings or QA meetings regarding an increase in fly activity at the facility. The Maintenance Director stated the importance of a pest control programs was to provide a clean-living environment for the residents and stated pest control is a big part of keeping the residents healthy. During an interview with the Pest Control Service Manager, 05/31/2024 at 12:12 p.m., the Service Manager confirmed he oversaw the pest control service for this facility. The service manager stated they were treating the facility monthly for pests and the treatments included interior and exterior inspection for preventative treatment for flies and roaches and said they used liquid residuals and glue strips that cover all the pests as the different seasons come on. When asked if he had been asked to service the facility twice a month he stated 05/09/2024 was our regularly scheduled visit and then the facility called us for an increase in flies around 05/28/2024 of this week. The Service Manager stated they came out on 5/28/2024 and provided a treatment. The Service Manager stated the facility purchased 4 fly lights on 05/31/2024 and requested 4 more fly lights and would receive a total of 8 new fly lights. The Service Manager stated the facility has 2 fly lights and were installing them on 05/31/2024 and he stated the facility was purchasing an air curtain from another source. During an interview with the Hospital RN D, 05/31/2024 at 7:17 p.m., revealed Resident #1 arrived to the ER around approximately 02:11 a.m. on 05/24/2024. RN D stated she admitted Resident #1 into the ER at the hospital. RN D stated she assessed him upon entry to the ER and observed Resident #1 had on a boot to his left heel and stated the left heel had maggots inside of it and on the inside of the boot. She said there was dried blood on the inside of the boot and the boot looked like it had not been removed for a while. RN D revealed the EMS personnel stated they observed dried blood on the resident's bed and boot when he was picked up from the facility and the EMS personnel did not remove his boot prior to or during transport. RN D said she did not see any other maggots in his other wounds. This was determined to be an Immediate Jeopardy (IJ) on 05/30/2024 at 5:04 p.m. The Administrator was notified of the IJ and provided the IJ Template at 5:16 p.m. On 05/30/2024 the facility provided a plan of removal titled: Plan of Removal. The plan of removal was accepted on 05/30/2024 at 1:27 p.m. It was documented as follows: [Facility Name] 5/30/24 Plan of Removal Problem: Failure to maintain an effective pest control program. Interventions: ADHOC QA completed with IDT team on 5/30/24 Action completed: Facility was inspected for flies on 5/30/24, to include all resident rooms by maintenance director and Administrator. All windows in facility were checked to ensure they are closed properly on 5/30/24 All Window screens in facility were inspected by maintenance director and administrator to ensure they are installed properly on 5/30/24. Administrator and Maintenance director have placed standing fans at the front door and 100 hall door to help prevent flies from coming into facility on 5/30/24 Fly bags were placed externally around the facility to help prevent flies from entering facility on 5/30/24. 100% skin sweep was completed and All wounds assessed by DON and ADON on 5/30/24, no issues related to flys noted. [Pest Control Company Name] Pest control treated for flies on 5/30/24. Medical Director [name] was notified of the immediate Jeopardy situation on 5/30/24 On 5/31/24 Admin and DON identified residents who choose or prefer to have their windows open and will complete a weekly inspection of their windows screens to ensure they are in good condition and installed correctly. The following in-services were initiated by the RCN for all staff on 5/30/24 and completed on 5/30/24 Any staff member that sees flies must immediately attempt to remove the fly(ies) in the facility and notify The Administrator and Maintenance Director. If any staff member that observes open windows or torn or frayed windows screens in facility they will notify Admin and Maintenance Director immediately. The Following in-service was initiated on 5/31/24 by the RCN for all staff, with a completion date of 5/31/24 (Any staff not present for in-servicing on 5/31/24 will not be allowed to assume their duties until in-serviced) If any staff observes an issue with pest control/screens/windows or entry points they will Verbally notify the Administrator and Maintenance Director and place an entry into maintenance care software. The following in-services were initiated by the RCN on 5/30/24 for The Administrator and Facility Maintenance director and completed on 5/30/24. Admin and Maintenance Director must inspect all facility windows to ensure they are closed and all window screens to ensure they are installed properly. The Following in-service was initiated on 5/31/24 with Admin and Maintenance Director by RCN and completed on 5/31/24. Admin and Maintenance direct will be responsible for reviewing maintenance care logs 5 times a week to ensure any issues with pest control/screens/windows ort entry points are addressed appropriately. Admin and Maintenance director will be responsible. The following in-service was completed By RCN on 5/30/24 with HR coordinator and completed on 5/30/24. Any staff member hired after 5/30/24 will receive the above mentioned In-services upon hire. Admin and or Designee will be responsible to ensure all staff will receive the above mentioned in-services. Monitoring: Admin/Designee will conduct rounds in facility 5 times a week to ensure that all windows are closed, and window screens are installed properly. Results of rounds Will be placed on monitoring log for tracking. Admin/Designee will complete interviews with 5 staff members weekly x 6 weeks and periodically thereafter to ensure that staff are reporting the presence of flies appropriately. Staff will be asked the following questions. All staff reviews will be placed in the monitoring log for tracking. Have you seen flies in facility? If so, who did you notify and what immediate action was taken? DON and Tx nurse will conduct weekly skin checks and wound rounds x 6 weeks and periodically thereafter to ensure no issues with flies. All skin checks and wound round review will be placed on monitoring logs for tracking. The facility's POR verification was as follows: During an interview with the RCN, 05/31/2024 at 4:11 p.m., the RCN revealed she provided education to all staff on 5/30/2024 regarding removing flies from the facility, identifying open windows and torn window screens and notifying the Administrator and Maintenance Director immediately. The RCN confirmed she completed an in-service on 5/31/24 for all staff regarding pest control, window screens, windows and entry points and reporting these items to the Administrator and DON. The RCN confirmed she conducted an in-service with the Administrator and Maintenance Director on 5/30/24 regarding inspecting facility windows and window screens. RCN confirmed she conducted an in-service on 5/31/24 with the Administrator and Maintenance Director regarding their responsibility for reviewing maintenance care logs 5 times a week to ensure issues with pest control, screens windows or points of entry are addressed appropriately. The RCN confirmed she conducted an in-service with the HR Director on 5/30/24 regarding providing education on pest control to all new hires that are hired after 5/30/24. The RCN revealed a tracking log was created to track results on the audits that are being conducted by the Administrator, Maintenance Director and DON. An interview with the HR Director, 05/31/2024 at 4:40 p.m., revealed the HR Director received education from the RCN regarding new hire training on pest control for anyone hired after 05/30/2024. During an interview with the DON, 5/31/24 at 4:46 p.m., the DON stated she conducted 100% skin sweep with the Treatment Nurse on 5/30/24 and no issues were identified. The DON confirmed she notified the Medical Director about the IJ on 5/30/24. The DON confirmed she received education from the RCN on 5/30/2024 in regard to conducting weekly skin checks and rounds for 6 weeks and periodically thereafter to ensure no issues with flies. During an interview with the Administrator, 05/31/2024 at 5:00 p.m., the Administrator verified on 5/30/24, the facility was inspected for flies, windows were checked to ensure they were closed, window screens were inspected to ensure they were installed properly, floor fans were placed at the front door and 100 hall door, fly bags were placed externally to include 2 at the front door, one at the 100 door and 1 at the 300 hall door. The Administrator stated new window screens have been ordered for 106 windows. The Administrator also confirmed a 100% skin sweep was conducted by the DON and the Treatment Nurse on 5/30/24 and no issues were identified. The Administrator confirmed pest control treated the facility for flies on 05/30/2024 and created a proposal plan for further treatment. The Administrator confirmed the facility installed 4 new pest control lights in the facility on 5/31/24. The Administrator confirmed the Medical Director was notified of the IJ by the DON on 5/30/2024 and an Ad Hoc QAPI meeting was held on 5/30/2024. The Administrator further confirmed residents were interviewed about preferences and no residents prefer to have their windows open in the rooms at this time. The Administrator confirmed that he and the Maintenance Director received education from the RCN on inspecting facility windows and reviewing maintenance care logs 5 times a week to ensure any issues with pest control, screens, windows or entry points are addressed appropriately. The Administrator revealed he had a tracking log to record findings of his weekly audits being conducted. He stated the findings of the audits would be reviewed in the facility monthly QAPI meetings. During an interview with the Maintenance Director, 5/31/24 at 5:25 p.m., the Maintenance Director confirmed the facility was inspected for flies and windows screens on 5/30/24 and 5/31/24 by himself and the Administrator. The Maintenance Director confirmed that he and the Administrator received education from the RCN on inspecting facility windows and reviewing maintenance care logs 5 times a week to ensure any issues with pest control, screens, windows or entry points are addressed appropriately. During interviews conducted, 05/31/2024, with 16 employees scheduled for

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 8 residents (Resident #1) reviewed for treatment and services. The facility failed to ensure Resident #1 received skin care, showers/baths, ostomy care and wound care including weekly skin assessments, weekly wound measurements to the following wounds: -pressure ulcer to sacrum -pressure ulcer to left heel -pressure ulcer to right buttocks -pressure ulcer to right ankle -shear injury to right posterior thigh -shear injury to left posterior thigh -shear injury to right posterior flank -shear injury to right lower back Resident #1 suffered symptoms of anxiety and depression with a threat of self-harm and refused care which resulted in untreated wounds, maggots, gnats, and flies. The resident expired on [DATE]. On [DATE] at 6:30 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). This failure could affect residents with skin injures and wounds and colostomies and result in a wound infection, increase in wound size and severity, invasion of the body with maggots and other insects, sepsis, hospitalization , and death. The findings included: Record review of Resident #1's face sheet, dated [DATE] revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: necrotizing fasciitis (also known as flesh eating bacteria, a serious bacterial infection that results in death of the body's soft tissue which included symptoms of red, purple or discolored skin in the affected area and can cause severe pain), hypothyroidism (a condition in which the thyroid gland does not produce enough of certain hormones), type 2 diabetes mellitus (a condition which results from insufficient production of insulin, causing high blood sugar), anxiety disorder (mental illness that cause constant fear or worry), depression (mental health disorder which causes feelings of sadness or loss of interest), chronic pain syndrome (persistent or intermittent pain that last more than 3 months), pressure ulcer of unspecified site (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin, also known as a bed sore) and ankylosing spondylitis of lumbosacral region (inflammatory disease that over time, can cause some of the bones in the spine to fuse and causes pain). Record review of Resident #1's face sheet dated [DATE] revealed Resident #1 was listed as his own responsible party. Record review of Resident #1's Care Plan dated [DATE], last revised on [DATE] revealed the resident was at risk for skin breakdown around stoma (colostomy) with interventions which included: perform ostomy care as ordered. Record review of Resident #1's Care Plan dated [DATE], last revised on [DATE] revealed the resident had a potential for uncontrolled pain with interventions which included: administer analgesia as per order. Give ,d+[DATE] hour before treatments or care and the resident prefers to have pain controlled by medication and to be left alone, demands to not be turned or repositioned. Record review of Resident #1's Physician Order Summary for February 2022 revealed orders for colostomy care dated [DATE]: --apply colostomy water (frequency not specified) -change colostomy bag as needed -cleanse colostomy stoma (frequency not specified) -empty colostomy bag as needed Record review of Resident #1's Physician Order Summary for February 2022 revealed orders for wound care dated [DATE]: -pressure ulcer to left heel, cleanse wound with normal saline or wound cleanser, pat dry, apply collagen and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -pressure ulcer to right ankle, cleanse wound with normal saline or wound cleanser, pat dry, apply collagen and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -pressure ulcer to right buttocks, cleanse wound with normal saline or wound cleanser, pat dry, apply collagen and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -pressure ulcer to sacrum- cleanse wound with normal saline or wound cleanser, apply hydrafera blue and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -shearing to right lower back- cleanse wound with normal saline or wound cleanser, pat dry, apply triad and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -shearing to left posterior thigh- cleanse wound with normal saline or wound cleanser, pat dry, apply triad and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -shearing to right posterior thigh- cleanse wound with normal saline or wound cleanser, pat dry, apply triad and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -shearing to right posterior flank- cleanse wound with normal saline or wound cleanser, pat dry, apply triad and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -skin graft to left thigh- cleanse wound with normal saline or wound cleanser, pat dry, apply xeroform and cover with dry dressing every Monday, Wednesday, and Friday for wound care. -surgical wound to left hip- cleanse wound with normal saline or wound cleanser, pat dry, apply betadine and cover with dry dressing every Monday, Wednesday, and Friday for wound care. Record review of Resident #1's initial skin assessment dated [DATE] signed by the former Wound Care Nurse revealed Resident #1 had the following skin issues: -pressure ulcer to sacrum 1.5 cm x 2.0 cm -pressure ulcer to left heel 3.5 cm x 3.0 cm -pressure ulcer to right buttocks 2.0 cm x 0.8 cm x 0.1 cm -pressure ulcer to right ankle 3 cm x 2 cm -shearing to right posterior thigh 11.2 cm x 5.0 cm x 0.2 cm -shearing to left posterior thigh 2.0 cm x 2.5 cm -shearing to right posterior flank 2.3 cm x 1.5 cm x 0.1 cm -shearing to right lower back 1 cm x 1 cm x 0.1 cm Record review of Resident #1's weekly pressure ulcer assessment to the sacrum dated [DATE] signed by the DON revealed a stage 2 pressure ulcer measuring 1 cm x 1.5 cm x 0 cm without exudates (drainage), undermining, or tunneling and wound care orders 3 times a week. Wound documented as present upon admission. Record review of Resident #1's weekly pressure ulcer assessment to left heel dated [DATE] signed by the DON revealed an unstageable pressure wound to the left heel measuring 3.5 cm x 3.0 cm by an undetermined depth with eschar (dead tissue and 100% necrotic tissue (dead tissue) with wound care orders 3 times a week. Wound documented as present upon admission. Record review of Resident #1's weekly pressure ulcer assessment to right buttock dated [DATE] signed by the DON revealed a stage 2 pressure wound measuring 2.0 cm x 0.8 cm x 0.1 cm with new pink or shiny tissue and no exudates (drainage), undermining, or tunneling present and wound care ordered 3 times a week. Wound documented as present upon admission. Record review of Resident #1's weekly pressure ulcer assessment to right ankle dated [DATE] signed by the DON revealed a stage 2 pressure wound 2.6 cm x 1.5 cm x 0 cm with epithelial (new pink or shiny tissue) with no exudates (drainage) undermining or tunneling present with wound care ordered 3 times a week. Wound documented as present upon admission. Record review of Resident #1's Care Plan dated [DATE] and last revised on [DATE] revealed the resident had pressure injuries to the following areas: stage 2 pressure ulcer to sacrum, stage 2 pressure ulcer to right buttock, unstageable wound to left heal related to resident refusal for wound care, repositioning and baths these wounds in progress are at high risk for worsening, accurate staging is difficult to determine. Refusals of care with interventions which included: incontinent care after each episode and apply moisture barrier, notify nurse immediately of any new areas of skin breakdown, report loose or missing dressings to the nurse, left heel ulcer, right buttock-cleanse with normal saline or wound cleanser pat dry, apply collagen (used for wounds with moderate to heavy exudates (drainage) to promote healing) and cover with dry dressing Monday, Wednesday, and Friday. Sacrum ulcer-cleanse with normal saline or wound cleanser, pat dry, apply hydrafera blue cover (antibacterial foam dressing) and dry dressing Monday, Wednesday, and Friday. Record review of Resident #1's Care Plan dated [DATE] revealed Resident #1 had an ADL (activity of daily living) self-care performance deficit and required the assistance of two or more staff for bathing, bed mobility, toilet use, transferring and dressing. The ADL care plan did not address resident refusals of care. Record review of Resident #1's Care Plan dated [DATE] revealed Resident #1 had diabetes mellitus with interventions which included: check all of body for breaks in skin and treat promptly as ordered by a doctor. Record review of Resident #1's Care Plan dated [DATE] revealed Resident #1 had a surgical site to left hip and was at risk for infection with interventions which included: observe for signs and symptoms of infection (increased redness, increased pain, drainage, etc.) report to physician if noted. Record review of Resident #1's Care Plan dated [DATE] and last revised on [DATE] revealed Resident #1 had a psychosocial well-being problem related to little interest or pleasure in doing things with interventions which included: encourage participation from resident who depends on others to make own decisions. Record review of Resident #1's Care Plan dated [DATE], last revised on [DATE] revealed Resident #1 had a behavior problem related to anxiety, depression, refused to take showers, weights, reposition in bed, and wound care for trauma informed care due to history of neglect in the community: the resident's refusals of care can lead to but not limited to infections, worsening of wounds, hospitalization , and possible death. Resident is aware of the consequences and continues to opt out of care the majority of the time. The ombudsman is aware of the situation with interventions which included: administer medications as ordered, assist the resident to develop more appropriate methods of coping and interacting. Refer to psych and psychological services for evaluation and treatments, explain all procedures to the resident before starting and allow to adjust to changes, if reasonable, discuss the president's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Resident #1 will agree to shower once a week minimum and trauma informed care: praise any indication of the resident's progress/improvement in behavior. Record review of a facility document titled Negotiated Risk Agreement for Resident #1, dated [DATE] signed by the DON revealed the negotiated agreement was with Resident #1 who had multiple shearing and pressure wounds. Resident refuse showers, repositioning, and wound care. The possible negative consequences were documented as delay/prevent wound healing, risk for skin breakdown/pressure wounds. Infection that may lead to sepsis or death. Alternatives/interventions offered by the facility; pain management offered prior to repositioning, bathing, and wound care. The final agreement: The resident acknowledges risk, states will allow staff to perform bed baths once a week, wound care and repositioning as tolerated. The resident's signature was left blank, the resident's representative signature was left blank, and the physician signature was left blank. Record review of Resident #1's weekly skin assessment dated [DATE] signed by the DON revealed Resident #1 had the following skin issues: (last skin assessment where Resident #1 did not refuse) -skin graft to left thigh 19.5 cm x 14.5 cm -surgical wound to left hip 2.0 cm x 1.5 cm -shearing to right posterior thigh 11.2 cm x 5.0 cm x 0.2 cm -shearing to left posterior thigh 2.0 cm x 2.5 cm -shearing to right posterior flank 2.3 cm, x 1.5 cm x 0.1 cm -shearing to right lower back 1 cm x 1 cm x 0.1 cm -pink epithelization (new skin) to left ischium -see ulcer report (for pressure ulcer documentation) Record review of Resident #1's Weekly Ulcer assessment dated [DATE] and signed by the former Wound Care Nurse revealed a stage 2 pressure ulcer measuring 1 x 1.5 cm x 0 cm with pink or shiny epithelium. Record review of Resident #1's Weekly Ulcer Assessment to right buttock dated [DATE] signed by the former Wound Care Nurse revealed a stage 2 pressure ulcer measuring 2.0 cm x 0.8 cm x 0.1 cm with pink or shiny epithelium. Record review of Resident #1's Weekly Ulcer Assessment to right ankle dated [DATE] and signed by the former Wound Care Nurse revealed a stage 2 pressure ulcer measuring 0.5 cm x 0.5 cm x 0 cm with a note indicating wound was closed. Record review of Resident #1's electronic medical record revealed weekly skin assessment attempts dated [DATE]-[DATE] were documented as resident refused. Record review of Resident #1's electronic medical record revealed Resident #1 Weekly Pressure Ulcer Assessments from [DATE]-[DATE] were documented as refused. Weekly Wound Assessments were not documented after [DATE]. Record review of Resident #1's Physical Medicine Rehabilitation Follow Up dated [DATE] note signed by the Pain Management Physician revealed: Resident #1 stated that pain was currently being controlled. Record review of a facility document titled Negotiated Risk Agreement for Resident #1, dated [DATE] signed by the DON revealed the negotiated agreement was with Resident #1 who had multiple shearing and pressure wounds. The resident desire or preference was documented as Resident #1 did not want dressings applied to wounds. The possible/probably negative consequences were documented as delay/prevent wound healing, risk for skin breakdown/pressure wounds, infection that may lead to sepsis or death. Alternatives/interventions facility offered: pain management offered prior to applying dressing. What was the final agreement? Resident acknowledges risk, continues to request not be applied. The resident, signature was left blank, the resident representative signature was left blank, and the physician signature was left blank. Record review of Resident #1's physician orders revealed an order dated [DATE] for psych to evaluate and treat. Record review of Resident #1's Physical Medicine Rehabilitation Follow up dated [DATE] note signed by the Pain Management Physician revealed: spoke with wound care nurse and she stated that Resident #1's wounds were stable. Unable to make progress with healing due to the fact that patient only will allow staff to perform wound care and baths once per week. Resident #1 declines services when he is turned repositioned. This is despite the fact that patient is on a significant pain management regimen including 3 different opioids. Record review of Resident #1's WARs for [DATE] revealed: -MASD to left inner thigh, pressure ulcer to left heel, pressure ulcer to right buttocks, pressure ulcer to sacrum, shearing to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, skin graft to left thigh, surgical wound to left hip had missing documentation on [DATE], was documented as provided on 8 dates and was documented as refused on 4 dates. Record review of Resident #1's Psychiatry Initial Consult dated [DATE] signed by the Physician Assistant for psych services revealed Resident #1 was referred for depression, noncompliance, anxiety, and sleep disorder. The DON reports the patient to be noncompliant with care. Patient was seen, resting in his bed, alert and conversant. Denies feeling depressed or anxious. Says he is bored because he is a young man in a nursing home .appears without distress or agitation. Appears calm, cooperative, obese, and poorly groomed. Nursing staff to monitor and document any new or worsening mood/behaviors and notify psych services. Anxiety: no anxiety complaints, no medication, continue to monitor. Major depressive disorder, single episode, mild. No depressive complaints. Patient with noncompliance with care. No medications Continue to monitor. Sleep disorders: minimal insomnia complaints, continue melatonin nightly as ordered. Continue to monitor. Record review of Resident #1's Quarterly Social Service assessment dated [DATE] signed by the former Social Worker revealed the former Social Worker documented: Resident #1 required full assist, had depression and anxiety with no behaviors. She documented that a psych referral was made but there was no documentation about refusals of care. Record review of Resident #1's Care Plan Conference dated [DATE] revealed Resident #1 attended the conference signed by MDS Coordinator E revealed: Will continue POC (plan of care). There was no documentation refusals of care were discussed on the document. Record review of Resident #1's hospital notes dated [DATE] revealed the resident was admitted to a local hospital for wound care management. The hospital record revealed: sent from an outside facility for wound care evaluation and management. Patient mentions that he has chronic wounds on his back that have been doing okay .as per the records patient was refusing the wound care over there (at nursing facility). Patient was evaluated by psychiatry over here and they cleared the patient and patient has full capacity for making decisions and is aware of his situation. Patient is found to have an elevated WBC count (can indicate infection) and was admitted to the hospital for wound care. He admitted that he has refused wound care in the past as it could be painful. He vehemently denied that he refused medication or to be bathed. Patient has capacity to make decisions at this time. Resident #1 refused wound assessment in the hospital. Record review of hospital records for Resident #1 from a local hospital dated [DATE] revealed Resident #1 was a [AGE] year-old young male with past medical history of ankylosing spondylitis with chronic back wound who was sent from (nursing facility) for wound care evaluation and management. Patient mentions that he has chronic wounds on his back but is doing okay otherwise. Per the records patient was refusing the wound care over there. Patient was evaluated by the psychiatry over here and the cleared the patient and patient has full capacity for making decisions and is aware of his situation. Record review of hospital records for Resident #1 from a local hospital dated [DATE] revealed: Discussed the patient case (Resident #1) with nursing facility Medical Director. Patient is noncompliant with the wound care over there and that facility is not fully equipped with taking care of the complex wound care which patient requires. Continue antibiotics and wound care. Record review of hospital records for Resident #1 from a local hospital dated [DATE] revealed: Patient Discharge Information: reason for visit: worsening wounds decubitus (pressure ulcer). Discharge to: skilled nursing facility (nursing home), discharge instructions: additional patient education. Record review of Resident #1's WARS for [DATE] revealed (Resident #1 hospitalized [DATE]-[DATE]): -MASD to left inner thigh, pressure ulcer to left heel, pressure ulcer to right ankle, was documented as provided on 5 dates and documented as refused on 4 dates/opportunities -pressure ulcer to right buttocks, pressure ulcer to sacrum, pressure ulcer to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, skin graft to left thigh and surgical wound to left hip was documented as provided on 4 dates and refused on 5 dates/opportunities. Record review of Resident #1's WARs for [DATE] revealed: -MASD to left inner thigh, pressure ulcer to left heel, pressure ulcer to right ankle, pressure ulcer to right buttocks, pressure ulcer to sacrum, shearing to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, skin graft to left thigh, surgical wound to left hip had missing documentation of wound care on two dates, had documentation wound care was provided on 4 dates and had wound care documented as refused on 7 dates/opportunities. Record review of Resident #1's Psychiatry Progress Note dated [DATE] signed by Psychiatry Nurse Practitioner revealed Resident #1 was seen for his depression, noncompliance anxiety and sleep disorder. Resident #1 denied depression or anxiety. Reports eating and sleeping well. Denied wanting or needing anything at this time. Patient appears without distress or agitation. Nursing staff to monitor and document any new or worsening moods/behaviors and notify psych services. Record review of Resident #1's Behavioral Health Progress Note dated [DATE] signed by the Psychiatric LCSW revealed: a 20-minute session with Resident #1. The resident was talkative and shared about his family, friends and past related to his depression, anxiety, and grief. There was no documentation of refusals of care and no new orders or update to the plan of care. Record review of a Hospice Referral Intake Sheet dated [DATE] revealed the NF requested a referral intake for Resident #1. On [DATE] a note was documented which stated the hospice physician stated Resident #1 was not appropriate (for hospice) at this time. Record review of Resident #1's Behavioral Health Progress Note date [DATE] signed by the PA (Physician's Assistant) for psychology services. The document indicated Resident #1 had resistance to care. Resident #1 denied feeling depressed. Says he is just bored and does not have anything to do here. Resident #1 says he does have difficulty sleeping at night and always has had a problem with this. He said therapy has not been coming in because his wounds are not healed enough. He stated staff was in today to discuss hospice vs. moving to another facility vs. staying here. He is not certain what he is going to do and says he will take the weekend to make the decision. Nursing staff to monitor and document any new or worsening moods/behaviors and notify psych services. Record review of Resident #1's Behavioral Health Progress Note dated [DATE] signed by the Psychiatric LCSW revealed: reason for referral was anxiety and depression with psychiatric symptoms which included: anxiety, chronic pain, helplessness, hopelessness, life dissatisfaction, sadness/depression, anhedonia (lack of pleasure) socially isolating and sleep increase. During session resident presented as depressed with flat affect (no emotions to situations that normally elicit emotions). Resident #1's ambivalence was high ad he was stuck in mixed feelings about change. Confidence was low and he doubted his ability to change. There were no notes on refusals of care and no orders or updates to his plan of care. Record review of Resident #1's Care Plan dated [DATE] and last revised on [DATE] revealed Resident #1 had an impaired cognitive function or impaired thought process of refusing care with interventions which included: administer medications as ordered, keep resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion, monitor/document/report to MD any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of Resident #1's PASRR intake notes dated [DATE] revealed the PASRR Habilitation Coordinator met with Resident #1, SW, MDS Coordinator E, Director of Rehab. The notes revealed: The DON, and MDS Coordinator stated Resident #1 refused wound care, medical care and showers. Resident #1 has refused to take labs (lab work). Resident #1 needs extensive care such as shower, change of clothes and transfers. Alternate placement: Resident #1 was asked if he wished to remain in the nursing facility. He stated 'Yes, until I get better than I want to move back home with my (family member). Record review of Resident #1's Social Service Quarterly assessment dated [DATE] signed by the Social Worker revealed the Social Worker documented: Resident #1 required full assistants with activities of daily living, was bed bound and refused all ancillary services included dental, podiatry, optometry, and psych services. The Social Worker also documented Resident #1 had anxiety and depression which made it difficult for him to adjust to the nursing home, engage with peers and was also refusing wound care and showers. She documented the social worker assisted with meeting Resident #1's personal needs while she was in the facility. Record review of Resident #1's WARs for [DATE] revealed: -MASD to left inner thigh, pressure ulcer to left heel, pressure ulcer to right ankle, pressure ulcer to sacrum, shearing to right lower back, and shearing to left posterior thigh had no documentation of wound care on [DATE], had wound care documented as provided on 4 dates and had 9 documentations of refused wound care. -pressure ulcer to right buttocks, shearing to right posterior flank, shearing to right posterior thigh, skin graft to left thigh and surgical wound to left hip had missing documentation of wound care on [DATE], had wound care documented as provided on 3 dates and had wound care documented as refused on 10 dates/opportunities. Record review of Resident #1's Care Plan dated [DATE], last revised on [DATE] revealed the resident had DD (developmental disability) and was PASRR positive for diagnoses of hypothyroidism before age 22 with interventions which included Habilitation Services. Record review of Resident #1's Care Plan Conference dated [DATE] signed by the Social Worker on [DATE] revealed: Resident #1 attended the care plan conference with a note resident self-RP, confirmed (Resident #1) full code .Resident refused PASRR services. Nursing: continues to refuse wound care and showers, identified a[s} a trauma informed care resident, receiving palliative care (treatment of discomfort symptoms and stress of serious illness and typically terminally ill while the patient still receives treatment for their disease process). Activities: spends majority of time in his room watching TV, on his laptop or on his phone. Refuses ancillary services, some signs/symptoms of depression, refuses to engage with psych. Record review of Resident #1's WARs for [DATE] revealed: -MASD to left inner thigh, pressure ulcer to left heel, pressure ulcer to right ankle, pressure ulcer to right buttocks, pressure ulcer to sacrum, shearing to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, skin graft to left thigh and surgical wound to left hip all ordered 3 times a week on Monday, Wednesday and Friday were all documented as wound care provided on [DATE] and [DATE] and were all documented as refused on 11 other opportunities. Record review of Resident #1's WARs for [DATE] revealed: -MASD to left inner thigh, pressure ulcer to right ankle, pressure ulcer to right buttocks, pressure ulcer to sacrum, shearing to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, shearing to left inner thigh were all ordered 3 times a week on Monday, Wednesday and Friday and had no documentation for administration on [DATE] and [DATE] and documented as refused on all other opportunities (11 opportunities). -pressure ulcer to left heel, skin graft to left thigh, surgical wound to left hip were documented as administered on [DATE], there was no documentation of care on [DATE] and [DATE] and wound care was documented as refused on all other opportunities (10 opportunities). Record review of Resident #1's Behavioral Health Progress Note dated [DATE] and signed by the Psych LCSW revealed: psychiatric symptoms included: anxiety, chronic pain helplessness, hopelessness, life dissatisfaction, sadness/depression, anhedonia (lack of pleasure), socially isolating and sleep increase. Mood neutral normal. Resident presented as groomed within normal limits .He shared his thoughts about his family, his childhood and struggles with not being able to see any future beyond age 25. Treatment plan: individual therapy, psychological assessment, psychiatry consult and staff/family consultation. Prognosis: Excellent. This assessment did not have any notes related to refusals of care. Record review of Resident #1's Psychiatry Progress Note dated [DATE] revealed: Patient was seen for a follow-up visit regarding his depression, noncompliance, anxiety, and sleep disorder. Staff reports Resident #1's anxiety is very high which causes him to be controlling. He has been refusing showers. Resident #1 was alert and conversant. He stated he wishes the staff would understand who he is and what he's been through and what he's going through right now. He says his anxiety is still high, says the meds help. Says he did not get a shower last week and still has not gotten one this week. Says he has not refused, says they come in and rush him and he needs time to take his anxiety meds and mentally prepare. Resident #1 was described as calm and cooperative with good eye-contact with mild impairment of judgement. Increased Zoloft to 150 mg, renew Xanax for 30 days, patient is using it almost daily. Nursing staff to monitor and document any new or worsening moods/behaviors and notify psych services. Record review of Resident #1's WARs (Wound Administration Record) for [DATE] (Resident #1 in facility between [DATE]-[DATE]) revealed: -MASD to left inner thigh ordered 3 times a week on Monday, Wednesday and Friday was provided on one occasion [DATE] out of 6 opportunities for wound care. 5 opportunities were documented as refused. -pressure ulcer to left heel, pressure ulcer to right ankle, pressure ulcer to right buttocks, pressure ulcer to sacrum, shearing to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, skin graft to left thigh and surgical wound to left hip were all ordered 3 times a week on Monday, Wednesday and Friday was documented as refused on all occasion or 6 opportunities. Record review of Resident #1's SBAR (Change of Condition) Form dated [DATE] signed by RN A revealed: Resident #1 had a behavior change that was a danger to self or others with suicide potential which started on [DATE] with physician orders to send to the hospital. Record review of a text message dated [DATE] between an unknown staff member and the Psychiatric Physician's Assistant regarding Resident #1 revealed: unknown staff member stated: Resident #1 stated he was going to hurt self with fork, going to send out for psych eval . The Physician's Assist responded: .sounds like a good plan. Let me know when he's back and what they do. Record review of Resident #1's hospital records from a local hospital dated [DATE] revealed: Patient (Resident #1) brought in by EMS for suicidal ideation and intent to kill himself with a fork. Patient has been noncompliant with his medical treatment. Last seen by telepsych (tele phone visit as opposed to an in-person visit) on [DATE]. Patient reports ongoing pain that exacerbates his anxiety and poor sleep. Patient is calm, cooperative with fair insight and judgement, oriented x 4 (alert and [NAME][TRUNCATED]

Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 8 Residents (Resident #1) reviewed for quality of care, in that; The facility failed to ensure Resident #1 was appropriately placed in the nursing facility when he had a history of personal care and wound care refusals and uncontrolled pain and failed to promptly discharge Resident #1 when his continued refusals of personal hygiene, assessments and wound care prevented appropriate treatment of his medical conditions and resulted in sepsis, infestation of insects including maggots, gnats and flies and death. On [DATE] at 6:30 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). This failure could place residents with wounds and refusals of care and could place them at risk for improper or ineffective wound care and treatment. The findings included: Record review of Resident #1's face sheet, dated [DATE] revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: necrotizing fasciitis (also known as flesh eating bacteria, a serious bacterial infection that results in death of the body's soft tissue which included symptoms of red, purple or discolored skin in the affected area and can cause severe pain), hypothyroidism (a condition in which the thyroid gland does not produce enough of certain hormones), type 2 diabetes mellitus (a condition which results from insufficient production of insulin, causing high blood sugar), anxiety disorder (mental illness that cause constant fear or worry), depression (mental health disorder which causes feelings of sadness or loss of interest), chronic pain syndrome (persistent or intermittent pain that last more than 3 months), pressure ulcer of unspecified site (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin, also known as a bed sore) and ankylosing spondylitis of lumbosacral region (inflammatory disease that over time, can cause some of the bones in the spine to fuse and causes pain). Record review of Resident #1's face sheet dated [DATE] revealed Resident #1 was listed as his own responsible party. Record review of Resident #1's Admission Packet dated [DATE] revealed 17. Hospital Transfers: If resident desires to be readmitted after discharge. Resident shall be treated as a new applicant for purposes of admission. Resident may be transferred or discharged if: necessary for Resident's welfare and Resident's needs cannot be met in the (nursing facility). Resident is endangering the safety of other person in the (nursing facility). Resident is endangering the health of other individuals in the (nursing facility). Record review of Resident #1's hospital records from a local rehabilitation facility dated [DATE]-[DATE] (prior to admission to the nursing facility) revealed Resident #1 had multiple decubitus ulcers, wounds to sacrum/coccyx area, buttocks, posterior trunk, back, buttocks, left hip, left leg and bilateral heels. During a previous hospital stay he had multiple debridement's (surgical removal of dead tissue) and diverting colostomy (surgical procedure to bring one end of large intestine through abdominal wall to divert away from rectum and wounds to the area to promote wound healing). Resident #1 had impaired mobility, debility, bilateral lower extremity paresis related to ankylosing spondylitis (muscle weakness to lower limbs), impaired ADL's (personal care) and critical illness myopathy (serious health condition causing weakening of nerves and muscles using following a stay in intensive care). Resident #1 refused to shower .complained of pain in which pain meds had been changed/adjusted. He was alert and oriented (cognitively intact) and no longer had IV push (rapid delivery) pain meds prior to wound care. -Resident #1 had a pain level of ,d+[DATE] prior to moving him for wound care and ,d+[DATE] (indication of severe pain) that stayed there the entire assessment and bed bath. He was given IV Dilaudid approximately 15 minutes prior to wound care (IV Dilaudid is a very strong opioid pain medication that when delivered through the IV has an almost immediate affect and is not available for use in a nursing home). -All wounds chronic, moist and with an odor. Peri wound skin in general is unclean, there are multiple areas of bleeding within the graft sites on the bilateral thighs. Patient has chronic infection . -Wound care orders written, hopefully patient will be able to cooperate and comply with full recommendations, though it is not likely. Record review of Resident #1's initial skin assessment dated [DATE] signed by the former Wound Care Nurse revealed Resident #1 had the following skin issues: -pressure ulcer to sacrum 1.5 cm x 2.0 cm -pressure ulcer to left heel 3.5 cm x 3.0 cm -pressure ulcer to right buttocks 2.0 cm x 0.8 cm x 0.1 cm -pressure ulcer to right ankle 3 cm x 2 cm -shearing to right posterior thigh 11.2 cm x 5.0 cm x 0.2 cm -shearing to left posterior thigh 2.0 cm x 2.5 cm -shearing to right posterior flank 2.3 cm x 1.5 cm x 0.1 cm -shearing to right lower back 1 cm x 1 cm x 0.1 cm Record review of Resident #1's Care Plan dated [DATE], last revised on [DATE] revealed the resident had a potential for uncontrolled pain with interventions which included: administer analgesia as per order. Give ,d+[DATE] hour before treatments or care and the resident prefers to have pain controlled by medication and to be left alone, demands to not be turned or repositioned. Record review of Resident #1's Care Plan dated [DATE] and last revised on [DATE] revealed the resident had pressure injuries to the following areas: stage 2 pressure ulcer to sacrum, stage 2 pressure ulcer to right buttock, unstageable wound to left heal related to resident refusal for wound care, repositioning and baths these wounds in progress are at high risk for worsening, accurate staging is difficult to determine. Refusals of care with interventions which included: incontinent care after each episode and apply moisture barrier, notify nurse immediately of any new areas of skin breakdown, report loose or missing dressings to the nurse, left heel ulcer, right buttock-cleanse with normal saline or wound cleanser pat dry, apply collagen (used for wounds with moderate to heavy exudates (drainage) to promote healing) and cover with dry dressing Monday, Wednesday, and Friday. Sacrum ulcer-cleanse with normal saline or wound cleanser, pat dry, apply hydrafera blue cover (antibacterial foam dressing) and dry dressing Monday, Wednesday, and Friday. Record review of Resident #1's Care Plan dated [DATE] revealed Resident #1 had an ADL (activity of daily living) self-care performance deficit and required the assistance of two or more staff for bathing, bed mobility, toilet use, transferring and dressing. Record review of Resident #1's Care Plan dated [DATE] revealed Resident #1 had a surgical site to left hip and was at risk for infection with interventions which included: observe for signs and symptoms of infection (increased redness, increased pain, drainage, etc.) report to physician if noted. Record review of Resident #1's Care Plan dated [DATE], last revised on [DATE] revealed Resident #1 had a behavior problem related to anxiety, depression, refused to take showers, weights, reposition in bed, and wound care for trauma informed care due to history of neglect in the community: the resident's refusals of care can lead to but not limited to infections, worsening of wounds, hospitalization , and possible death. Resident is aware of the consequences and continues to opt out of care the majority of the time. The ombudsman is aware of the situation with interventions which included: administer medications as ordered, assist the resident to develop more appropriate methods of coping and interacting. Refer to psych and psychological services for evaluation and treatments, explain all procedures to the resident before starting and allow to adjust to changes, if reasonable, discuss the president's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Resident #1 will agree to shower once a week minimum and trauma informed care: praise any indication of the resident's progress/improvement in behavior. Record review of a facility document titled Negotiated Risk Agreement for Resident #1, dated [DATE] signed by the DON revealed the negotiated agreement was with Resident #1 who had multiple shearing and pressure wounds. Resident refuse showers, repositioning, and wound care. The possible negative consequences were documented as delay/prevent wound healing, risk for skin breakdown/pressure wounds. Infection that may lead to sepsis or death. Alternatives/interventions offered by the facility; pain management offered prior to repositioning, bathing, and wound care. The final agreement: The resident acknowledges risk, states will allow staff to perform bed baths once a week, wound care and repositioning as tolerated. The president's signature was left blank, the resident's representative signature was left blank, and the physician signature was left blank. Record review of Resident #1's electronic medical record revealed the facility documented weekly skin assessment attempts as resident refusals every week from [DATE]-[DATE]. Record review of a facility document titled Negotiated Risk Agreement for Resident #1, dated [DATE] signed by the DON revealed the negotiated agreement was with Resident #1 who had multiple shearing and pressure wounds. The resident desire or preference was documented as Resident #1 did not want dressings applied to wounds. The possible/probably negative consequences were documented as delay/prevent wound healing, risk for skin breakdown/pressure wounds, infection that may lead to sepsis or death. Alternatives/interventions facility offered: pain management offered prior to applying dressing. What was the final agreement? Resident acknowledges risk, continues to request not be applied. The resident, signature was left blank, the resident representative signature was left blank, and the physician signature was left blank. Record review of Resident #1's physician orders revealed an order dated [DATE] for psych to evaluate and treat. Record review of Resident #1's Physical Medicine Rehabilitation Follow up dated [DATE] note signed by the Pain Management Physician revealed: spoke with wound care nurse and she stated that Resident #1's wounds were stable. Unable to make progress with healing due to the fact that patient only will allow staff to perform wound care and baths once per week. Resident #1 declines services when he is turned repositioned. This is despite the fact that patient is on a significant pain management regimen including 3 different opioids. Record review of Resident #1's hospital notes dated [DATE] revealed the resident was admitted to a local hospital for wound care management. The hospital record revealed: sent from an outside facility for wound care evaluation and management. Patient mentions that he has chronic wounds on his back that have been doing okay .as per the records patient was refusing the wound care over there. Patient was evaluated by psychiatry over here and they cleared the patient and patient has full capacity for making decisions and is aware of his situation. Patient is found to have an elevated WBC count (can indicate infection) and was admitted to the hospital for wound care. He admitted that he has refused wound care in the past as it could be painful. He vehemently denied that he refused medication or to be bathed. Patient has capacity to make decisions at this time. Resident #1 refused wound assessment in the hospital. Record review of hospital records for Resident #1 from a local hospital dated [DATE] revealed: Discussed the patient case (Resident #1) with nursing facility Medical Director. Patient is noncompliant with the wound care over there and that facility is not fully equipped with taking care of the complex wound care which patient requires. Continue antibiotics and wound care. Record review of Resident #1's Behavioral Health Progress Note date [DATE] signed by the PA (Physician's Assistant) for psychology services. The document indicated Resident #1 had resistance to care. Resident #1 denied feeling depressed. Says he is just bored and does not have anything to do here. Resident #1 says he does have difficulty sleeping at night and always has had a problem with this. He said therapy has not been coming in because his wounds are not healed enough. He stated staff was in today to discuss hospice vs. moving to another facility vs. staying here. He is not certain what he is going to do and says he will take the weekend to make the decision. Nursing staff to monitor and document any new or worsening moods/behaviors and notify psych services. Record review of Resident #1's Care Plan dated [DATE] and last revised on [DATE] revealed Resident #1 had an impaired cognitive function or impaired thought process of refusing care with interventions which included: administer medications as ordered, keep resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion, monitor/document/report to MD any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of Resident #1's PASRR intake notes dated [DATE] revealed the PASRR Habilitation Coordinator met with Resident #1, SW, MDS Coordinator E, Director of Rehab. The notes revealed: The DON, and MDS Coordinator stated Resident #1 refused wound care, medical care and showers. Resident #1 has refused to take labs (lab work). Resident #1 needs extensive care such as shower, change of clothes and transfers. Alternate placement: Resident #1 was asked if he wished to remain in the nursing facility. He stated 'Yes, until I get better than I want to move back home with my (family member). Record review of Resident #1's Social Service Quarterly assessment dated [DATE] signed by the Social Worker revealed the Social Worker documented: Resident #1 required full assistants with activities of daily living, was bed bound and refused all ancillary services included dental, podiatry, optometry, and psych services. Record review of a Hospice Referral Intake Sheet dated [DATE] revealed the NF requested a referral intake for Resident #1. On [DATE] a note was documented which stated the hospice physician stated Resident #1 was not appropriate (for hospice) at this time. Record review of Resident #1's Care Plan Conference dated [DATE] signed by the Social Worker on [DATE] revealed: Resident #1 refused PASRR services. Nursing: continues to refuse wound care and showers. Refuses ancillary services, some signs/symptoms of depression, refuses to engage with psych. Record review of Resident #1's WARs for [DATE] revealed: -MASD to left inner thigh, pressure ulcer to left heel, pressure ulcer to right ankle, pressure ulcer to right buttocks, pressure ulcer to sacrum, shearing to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, skin graft to left thigh and surgical wound to left hip all ordered 3 times a week on Monday, Wednesday and Friday were all documented as wound care provided on [DATE] and [DATE] and were all documented as refused on 11 other opportunities. Record review of Resident #1's WARs for [DATE] revealed: -MASD to left inner thigh, pressure ulcer to right ankle, pressure ulcer to right buttocks, pressure ulcer to sacrum, shearing to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, shearing to left inner thigh were all ordered 3 times a week on Monday, Wednesday and Friday and had no documentation for administration on [DATE] and [DATE] and documented as refused on all other opportunities (11 opportunities). -pressure ulcer to left heel, skin graft to left thigh, surgical wound to left hip were documented as administered on [DATE], there was no documentation of care on [DATE] and [DATE] and wound care was documented as refused on all other opportunities (10 opportunities). Record review of Resident #1's WARs (Wound Administration Record) for [DATE] (Resident #1 in facility between [DATE]-[DATE]) revealed: -MASD to left inner thigh ordered 3 times a week on Monday, Wednesday and Friday was provided on one occasion [DATE] out of 6 opportunities for wound care. 5 opportunities were documented as refused. -pressure ulcer to left heel, pressure ulcer to right ankle, pressure ulcer to right buttocks, pressure ulcer to sacrum, shearing to right lower back, shearing to left posterior thigh, shearing to right posterior flank, shearing to right posterior thigh, skin graft to left thigh and surgical wound to left hip were all ordered 3 times a week on Monday, Wednesday and Friday was documented as refused on all occasion or 6 opportunities. Record review of Resident #1's SBAR (Change of Condition) Form dated [DATE] signed by RN A revealed: Resident #1 had a behavior change that was a danger to self or others with suicide potential which started on [DATE] with physician orders to send to the hospital. Record review of Resident #1's hospital records from a local hospital dated [DATE] revealed: Patient (Resident #1) brought in by EMS for suicidal ideation and intent to kill himself with a fork. Patient has been noncompliant with his medical treatment. Last seen by telepsych (tele phone visit as opposed to an in-person visit) on [DATE].Patient reports ongoing pain that exacerbates his anxiety and poor sleep. Patient is calm cooperative with fair insight and judgement, oriented x 4 (alert and oriented) and intellectual functioning within normal limits. Risk assessment: the patient is not at imminent risk for suicide based on the denial of suicidal ideation. Resident #1 with chronic leg and sacral wounds. Patient has finally had dressing/bedsheets changed after 8 days. This happened after hours of discussion, multiple trips to his room and putting a temporary hold on his pain medications. Pictures from the wound/dressing changes reviewed. His back looks horrible. WBC (white blood cell count) increasing (sign of infection). Chronic wounds, drainage, malodorous (smelling very unpleasant) discharge. Sepsis with worsening wounds and UTI (urinary tract infection). Palliative care consult for pain management. Uncontrolled pain, anxiety disorder. Record review of Resident #1''s hospital records from a local hospital dated [DATE]-[DATE] revealed: 21-yr old bedbound nursing home resident .chronic ulcers with diverting colostomy, presented from nursing home after reportedly making a suicidal comment, although patient adamantly denied here. Upon arrival patient was found to be extremely malodorous, apparently had been regularly refusing wound care the nursing home per notes. admitted for sepsis (infection that is spread through the body). Patient refuses physical exams here, refuses wound care, wound not do a CT scan despite adequate sedation, ended up being done under general anesthesia. He refuses nurses to reposition him, he refused to allow his bedding to be changed for 8 days patient evaluated by psych on ,d+[DATE], ,d+[DATE] and ,d+[DATE]. Wound cultures are growing pseudomonas, Providencia, and proteus (bacteria). Of note, patients white count has been elevated for several months. Pt refused to work with PT/OT (physical and occupational therapy). An acute rehab facility (LTAC) will not accept a patient who does not have a potential to improve or is unwilling to participate with therapy. Sepsis due to acute on chronic sacral and bilateral lower extremity wounds and osteomyelitis, chronic pain, anxiety. Palliative care consulted: patient stated his pain is usually well managed outpatient (nursing home) this implies patient's chronic pain needs are not increasing. Patient has been extremely noncompliant. Patient does not cooperate with the nursing staff, does not work with physical and occupational therapy, and does not let anybody touch him. His wounds were last seen 7 days ago, and he has been sitting on them soiled. Extensive discussion with the patient he is vitally stable does not appear to be in pain but states that his pain is unbearable, and he requires IV Dilaudid every 3 hours just to keep him comfortable. Patient states he is not against wound care changes, but he needs a notice of at least 24 hours to mentally prepare him. Patient has questionable compliance as he does keep arguing but does not make any tangible sense. Record review of Resident #1's Readmission assessment dated [DATE] signed by LVN F revealed: Resident #1 was readmitted from hospital after suicidal ideation, with pain described by Resident #1 as constant, rated as 8 out of 10 upon admission. Non-compliance with medication, treatment and resistant to care was marked on the record. Record review of Resident #1's NP note upon re-admission to facility dated [DATE] revealed: plan: long discussion with patient, counseled on anxiety management, pain management .4 more weeks of antibiotic. Discussion with Administration: Resident #1 may likely get 30-day notice due to non-compliance. Record review of a facility document titled Negotiated Risk Agreement for Resident #1, dated [DATE] which was marked as in progress: and had not been signed by any facility staff revealed Resident #1 had multiple shearing and pressure wounds and he did not want dressing applied to wounds and does not allow staff to perform skin assessments. The possible/probably negative consequences were documented as delay/prevent wound healing, risk for skin breakdown/pressure wounds, infection that may lead to sepsis or death. Alternatives/interventions the facility offered: pain management offered prior to applying assessment and wound care. The final agreement: the resident acknowledges risk, continues to refuse skin assessment and wound care. The documented indicated Resident #1 refused to sign the document. The resident representative and physician signatures were left blank. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMs score of 15 (scale of ,d+[DATE]) which indicated the resident was cognitively intact. Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident required extensive assistance from two or more persons for physical assistance with bed mobility (turning side to side or positioning in bed), dressing, toilet use and extensive assistance of one staff person for personal hygiene (excluding showers/baths) and was coded as activity did not occur for assistance with bathing. Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident did not have signs of delirium, the resident did not respond to questions about his mood but had symptoms of B. feeling or appearing down, depressed, or hopeless nearly every day D. feeling tired or having little energy nearly every day and had rejections of care that occurred daily. Record review of Resident #1's progress notes for [DATE] revealed: -[DATE] at 3:00 p.m.: resident lying in bed, denies pain, room [NAME] of foul odor due to resident continues to refuse to shower or have treatment done. Physician and DON aware. Documented by former Wound Care Nurse. -[DATE] at 8:22 a.m.: resident informed of shower day and offered medications prior to aides coming to assist with Hoyer (mechanical lift). Resident proceeded to refuse medication and shower stating, not today. Administrator and DON made aware. Documented by LVN G. -[DATE] at 5:53 p.m.: resident continues to refuse. Resident continues to make excuses to refuse showers and wound treatment. MD made aware. Documented for former Wound Care Nurse. Record review of Resident #1's 30-Day Discharge Letter dated [DATE] revealed: This letter is a written notification that you will be discharged from the nursing facility effective 31 days from receipt of this letter. The effective date of discharge is [DATE] (date error). This discharge is based on ongoing issues of refusing care that is not only putting your health and wee-being in jeopardy but also affecting the sanitary condition of the facility for other residents. The facility has attempted to work with you through these behaviors, but you continue to refuse all care that is offered to you. The document was signed by the Administrator. There was no signature from Resident #1. Record review of Resident #1's [DATE] WAR (Wound Administrator Record) revealed: -Wound care to left heel one time a day every 7 days for pressure injury: wound care was refused on [DATE], [DATE] and [DATE]. Wound care was documented as administered one time for this month during [DATE]. -wound care to left posterior thigh one time a day every 7 days for shearing: wound care was documented as refused on [DATE], [DATE], [DATE], [DATE], and [DATE]. Wound care was not provided on any days for this wound in [DATE]. -wound care to right ankle, one time a day every 7 days for pressure injury: documented as refused on [DATE], [DATE], [DATE], [DATE], and [DATE]. Wound care was not provided on any days for this wound in [DATE]. -wound care to right buttocks one time a day every 7 days for pressure injury: documented as refused on [DATE], [DATE], [DATE], [DATE], and [DATE]. Wound care was not provided on any days for this wound in [DATE]. -wound care to right lower back one time a day every 7 days for shearing; documented as refused on [DATE], [DATE], [DATE], [DATE], and [DATE]. Wound care was not provided on any days for this wound in [DATE]. -wound care to right posterior flank one time a day every 7 days for shearing: documented as refused on [DATE], [DATE], [DATE], [DATE], and [DATE]. Wound care was not provided on any days for this wound in [DATE]. -wound care to right posterior thigh one time a day every 7 days for shearing: documented as refused on [DATE], [DATE], [DATE], [DATE], and [DATE]. Wound care was not provided on any days for this wound in [DATE]. -wound care to sacrum one time a day every 7 days for wound care: documented as refused on [DATE], [DATE], [DATE], [DATE], and [DATE]. Wound care was not provided on any days for this wound in [DATE]. Record review of Resident #1's of an ADL care sheet from [DATE] to [DATE] revealed no full-body bath/shower, sponge bath or transfer in/out of tub/shower were performed for Resident #1. Record review of Resident #1's Nurse Progress Notes dated [DATE] at 4:08 p.m., the DON documented: malodor noted coming from Resident #1's room. Upon visual inspection resident's bed sheets appear stained and soiled .offered to change bed sheets, however, resident refused. Informed Resident #1 refusing to change his sheets may lead to infection due to open wounds. Resident #1 stated, I'm fine. Offered a shower or bed bath and to provide wound care, resident refused. Resident #1 has not allowed skin assessments, wound care or showers since returning to facility from previous hospital stay. Provided resident with education regarding signs and symptoms of infection and sepsis. Re-educated resident that refusal of care may lead to infection, hospitalization , or death. Resident #1 replied the doctor from the hospital said he was okay, just leave me alone please. MD notified or residents refusal of care No new orders given at this time, per MD, we will continue to respect resident right to refuse treatment. Record review of Resident #1's WAR for [DATE] revealed: -wound care to left heal one time a day every 7 days was documented as refused on [DATE] and [DATE]. Wound care was not provided for this wound in [DATE]. -wound care to left posterior thigh one time a day every 7 days for shearing: documented as refused on [DATE] and [DATE]. Wound care was not provided for this wound in [DATE]. -wound care to right ankle, one time a day every 7 days for pressure injury: documented as refused on [DATE] and [DATE]. Wound care was not provided for this wound in [DATE]. -wound care to right buttocks one time a day every 7 days for pressure injury: documented as refused on [DATE] and [DATE]. Wound care was not provided for this wound in [DATE]. -wound care to right lower back one time a day every 7 days for shearing: documented as refused on [DATE] and [DATE]. Wound care was not provided for this wound in [DATE]. -wound care to right posterior flank one time a day every 7 days for shearing: documented as refused on [DATE] and [DATE]. Wound care was not provided for this wound in [DATE]. -wound care to right posterior thigh one time a day every 7 days for shearing: documented as refused on [DATE] and [DATE]. Wound care was not provided for this wound in [DATE]. -wound care to sacrum one time a day every 7 days for wound care: documented as refused on [DATE] and [DATE]. Wound care was not provided for this wound in [DATE]. Record review of Resident #1 Nurse Progress Notes dated [DATE] at 5:45 p.m. by LVN F revealed: CNA's (unknown) informed this nurse of Resident #1 not looking well. Resident appeared lethargic, eyes rolled to back of head and not responding to verbal stimuli. Rapid response called out. Oxygen applied and AED applied, pulse was noted so no shock advised. This nurse called 911 .upon transferring Resident #1 to stretcher, white bugs were noted on the bed. Record review of Resident #1's EMS Patient Care Report #2 dated [DATE] revealed EMS were notified at 5:57 p.m. on [DATE] and responded to the nursing facility for a report of unresponsive patient (Resident #1). Primary impression was listed as altered mental status with secondary impression of sepsis/septicemia and abnormal vital signs. Initial vital signs were Blood pressure ,d+[DATE] (very low), respirations 34 (high, normal ,d+[DATE]), level of consciousness: unresponsive in nursing home. Narrative: 22 y.o. male found unresponsive covered in urine, feces, flies, and maggots at nursing home. Staff called when patient went unresponsive, and staff thought patient was in cardiac arrest. Confused stories if CPR took place and how long CPR took place but CPR was not being performed upon fire arrival. Patient had pulse and was breathing but unresponsive. Staff stated Resident #1 had been at the facility a few weeks and had been declining any care for over a week. Resident #1 was in bed with man sac (large piece of material that is used to move or transport a patient) in a stew of urine and feces with ruptured colostomy bag, maggots, and flies in abundance .patient transported in Trendelenburg (lying on back with feet raised lower than head to promote blood flow to vital organs) and was never responsive to EMS during encounter. Resident #1 just moaning and occasionally screaming during transport .staff at ER taking pictures of patient as patient was cleaned and cared for. Record review of Resident #1's EMS Patient Care Report #2 dated [DATE] revealed EMS were notified at 5:57 p.m. on [DATE] and responded to the nursing facility for a report of unresponsive patient (Resident #1). Primary impression was listed as altered [NAME][TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries to 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for pressure ulcers, in that: 1. Resident #1 did not receive wound care as ordered by a physician during September and October 2020 to treat a pressure ulcer to her coccyx/sacrum for 15 of 25 opportunities which resulted in a decline in the wound condition and increase in size of the sacral ulcer. Resident #1 did not receive wound care as ordered by a physician during October 2020 to her lower back, right 2nd toe, or right great toe. 2. Resident #2 did not receive wound care as ordered by a physician during October 2020 to treat pressure ulcers to the right heel, left buttocks, left foot, right buttocks or left ear for 5 of 5 opportunities. 3. Resident #3 did not receive wound care as ordered by a physician during October 2020 to treat pressure ulcers to the left 1st toe, right heel, sacrum or surgical wound to left great toe for 17 of 26 opportunities. 4. Resident #4 did not receive wound care and treatment in October 2020 to treat two newly identified pressure injuries to the right 5th toe. 5. Resident #5 did not receive wound care and treatment in October 2020 to a newly identified deep tissue injury to the left thigh. These deficient practices affected residents with pressure ulcer wounds and resulted in deterioration and has the potential to result in development of infection,[MEDICAL CONDITION], and pain and a decline in health. These failures resulted in identification of Immediate Jeopardy (IJ) on 10/29/2020 at 4:55 p.m. The immediacy was lifted on 11/01/2020, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern until interventions were put in place for all residents who required wound care treatments. The findings were: 1. Record review of a face sheet for Resident #1, dated 10/27/2020, revealed an admission date of [DATE], and a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of a Provider Investigation Report, dated 10/25/2020, revealed on 10/25/2020 at 6:30 p.m. an allegation of neglect to Resident #1 was made related to a pressure ulcer to the sacrum. Further review of the report revealed the facility indicated Resident #1 was on hospice services and the DON and nursing consultant had been working with the doctor on treatment of [REDACTED].#1's family member called EMS to transfer the resident to the hospital for further treatment of [REDACTED]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3 which indicated a severe cognitive impairment. Resident #1 required extensive assistance for ADL's of two staff persons. Further review revealed at the time of the assessment Resident #1 was at risk for developing pressure ulcers/injuries but had no unhealed wounds or skin conditions and the resident was on hospice care. Record review of Resident #1's Care Plan, initiated on 06/12/2020 and last revised on 10/26/2020, revealed, Resident #1 has an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to sacrum (area near the tailbone), right great toe DTI (deep tissue injury), right lower back DTI unstageable, right 2nd toe stage 4 pressure ulcer and right heal DTI unstageable, with interventions which included, administer treatments as ordered and monitor for effectiveness, replace loose or missing dressings PRN, follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #1's Weekly Skin Assessment (performed by a Licensed Nurse), dated 08/25/2020, revealed the resident did not have any documented skin issues or pressure ulcers. Record review of Resident #1's Weekly Skin Assessment, dated 09/18/2020, revealed, unstageable to sacrum 10 cm x 12 cm. Treatment already ordered. Wound consult ordered . Record review of Resident #1's Weekly Pressure Ulcer Assessment (performed by a Licensed Nurse), dated 09/18/2020, revealed, unstageable pressure ulcer to sacrum which measured 10 cm x 12 cm with yellow or white slough and 25% necrotic tissue and no exudate. The surrounding skin color was described as pink in color. The wound had a mild odor. Record review of Resident #1's Weekly Ulcer Assessment, dated 09/26/2020, revealed an unstageable pressure injury to the coccyx which measured 4 cm x 4 cm with yellow or white slough and 75% necrotic tissue and no exudate. The surrounding skin was described as brown in color. Record review of Resident #1's Wound Evaluation and Management Summary, the Wound Care Physician's initial evaluation, dated 09/28/2020, revealed an unstageable due to necrosis sacral wound measuring 2.6 cm x 2.8 cm with moderate serous exudate and 100% necrotic tissue. A surgical debridement was performed. Plan of Care read: My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 72 days. This estimate is made with an 80% degree of certainty. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/03/2020, revealed an unstageable pressure injury to coccyx which measured 4 cm x 4 cm and has eschar, black, brown or tan adhered to the wound with yellow or white slough, 75% necrotic tissue and no exudate. The surrounding skin was described as brown in color and the wound had a mild odor. The resident was treated with antibiotic therapy for 10 days. Record review of Resident #1's Weekly Pressure Ulcer Assessment, dated 10/07/2020, revealed a Stage IV pressure ulcer to sacrum which measured 5 cm x 6 cm with an undetermined depth with eschar black, brown or tan adhered to the wound 100% necrotic tissue, moderate exudate which was yellow in color with a strong odor. Record review of Resident #1's Wound Evaluation and Management Summary, written by the Wound Care Physician and dated 10/7/2020, revealed a stage 4 pressure wound to sacrum which measured 5 x 6 cm with a surface area of 30 cm with moderate serious exudate and 100% necrotic tissue. Surgical debridement was performed with a note that read, stage 4 pressure wound to sacrum-deteriorated due to generalized decline of patient. Record review of Resident #1's Weekly Pressure Ulcer Assessment, dated 10/13/2020, revealed a stage IV pressure ulcer to sacrum which measured 11 cm x 10 cm with an undetermined depth with eschar black, brown or tan adhered to the wound 100% necrotic tissue with tunneling which was 6 inches of tunneling at 5 o'clock (position) with bone visible. Skin surrounding wound was described as, brown with maceration the wound contained a strong odor. The wound is marked as not having declined. Record review of a Wound Care Telemedicine Follow up Evaluation, dated 10/16/2020 by the Wound Care Physician, revealed, A telemedicine visit provided to ensure COVID-19 infection control and prevention as no in-person visit was possible due to COVID-19. Patient examined via telemedicine; wound discussed with Wound Care Nurse (LVN C), including offloading techniques and debridement options as well as wound dressing. Site 1: Stage IV wound to sacrum measuring 5 cm x 6 cm with a total surface area of 30 cm, with moderate serous exudate and 100% black necrotic tissue. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a stage IV pressure ulcer to sacrum which measured 11.2 cm x 10 cm with an undetermined depth. The wound was described as having eschar, black, brown or tan adhered to the wound, 100% necrotic tissue with a moderate amount of tan exudate that was opaque or purulent in color without tunneling and with bone exposure. The surrounding skin had peripheral tissue [MEDICAL CONDITION] and was black in color. The wound was described as having a, strong odor, without signs and symptoms of infection. The wound is further described as not having declined. Record review of Resident #1's Wound Evaluation and Management Summary, dated 10/19/2020, revealed, site 1: stage 4 pressure wound to sacrum, measuring 11.2 cm x 10 cm with a surface area of 112 cubic cm. Moderate serous exudate, 80% necrotic tissue. The wound is described as, deteriorated. The wound was surgically debrided. Site 3: unstageable deep tissue injury of the right first toe measuring 1.5 cm x 0.8 cm. Site 4: right medial second toe, unstageable due to necrosis which measured 1.1 cm x 0.8 cm with light serous exudate, 90% necrotic tissue. Treatment plan for site 4 to include xeroform (petroleum based fine-mesh gauze dressing) sterile gauze applied once daily for 30 days with a secondary dressing of a gauze island (multi-layered gauze dressing), apply daily for 30 days. Site 5: unstageable deep tissue injury to right heel which measured 5.1 cm x 5 cm with a surface area of 25.50 cm. Site 6: deep tissue injury to right lower back which measured 1.7 cm x 2 cm. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right lower back deep tissue pressure injury measuring 1.7 cm x 2 cm. The wound was closed. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right heel deep tissue pressure injury measuring 5.1 cm x 5 cm. The wound was described as closed. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right medial second toe unstageable pressure wound measuring 1.1 cm x 0.8 cm. The wound was described as having eschar, black brown or tan adhered to the wound with light exudate which was bloody. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right first toe deep tissue pressure injury which measured 1.5 cm x 0.8 cm. The wound was described as closed. Record review of Resident #1's Physician order [REDACTED]. a. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] (medication used to treat and prevent wound infection) to wound bed and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 09/12/2020 and discontinued on 10/07/2020. b. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020 and discontinued on 10/07/2020. Record review of Resident #1's WAR (Wound Administration Record) for September 2020 revealed: a. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care, with a start date of 09/12/2020, and discontinued on 10/07/2020 was not documented as completed on: 09/12/2020, 09/13/2020, 09/14/2020, 09/15/2020, 09/16/2020, 09/20/2020, 09/24/2020, 09/27/2020. Further review revealed Resident #1's wound care treatment was completed 11 of 19 opportunities or 58% of the time. b. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020, and discontinued on 10/07/2020 revealed there was no documentation any PRN application of wound care treatments performed in September 2020. Record review of Resident #1's Physician order [REDACTED].>a. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care, with a start date of 09/12/2020 and discontinued on 10/07/2020. b. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020 and discontinued on 10/07/2020. c. Skin prep to left lower back one time a day for wound healing, with a start date of 10/20/2020. d. Skin prep to right 2nd toe unstageable one time a day for wound healing, with a start date of 10/20/2020. e. Skin prep to right great toe deep tissue injury one time a day for wound healing, with a start date of 10/20/2020. f. Skin prep to right heel deep tissue injury unstageable one time a day for wound healing, with a start date of 10/21/2020. g. Cleanse coccyx area with normal saline, pat dry, apply Thera-honey (medical grade honey used to promote removal of necrotic tissue to wounds), calcium alginate (plant based algae dressing used to absorb excess fluid and promote removal of dead tissue), cover with Opti-lock (absorbent wound dressing) and secure with Keflex tape, with a start date of 10/20/2020. h. Cleanse sacrum with normal saline, pat dry, apply Santyl (prescription medication that removes dead tissue from wounds so they can start to heal), then apply calcium alginate and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 10/08/2020, and discontinued on 10/19/2020. Further review revealed there was no documentation of a new order starting on 10/20/2020 for wound care of Resident #1's sacrum. Record review of Resident #1's WAR for October 2020 revealed: a. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care. The order was discontinued on 10/07/2020 and was not documented as completed in October 2020 on: 10/01/2020, 10/03/2020, 10/04/2020, 10/05/2020, or 10/07/2020. Further review revealed the wound care treatment was completed 2 of 7 opportunities or 29% of the time. b. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care. The order was discontinued on 10/07/2020. There was no documentation for any PRN wound care treatments provided to the resident. c. Skin prep to left lower back one time a day for wound healing, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed Resident #1's wound care treatment was completed 3 of 6 opportunities or 50% of the time. d. Skin prep to right 2nd toe unstageable one time a day for wound healing with a start date of 10/20/2020 was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. e. Skin prep to right great toe deep tissue injury one time a day for wound healing, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. f. Skin prep to right heel deep tissue injury unstageable one time a day for wound healing, with a start date of 10/21/2020, was not documented as completed on: 10/22/20, 10/24/20, or 10/25/20. Further review revealed the wound care treatment was completed 2 of 5 opportunities or 33% of the time. g. Cleanse coccyx area with normal saline, pat dry, apply Thera-honey, calcium alginate, cover with Opti-lock and secure with Keflex tape, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. h. Cleanse sacrum with normal saline, pat dry, apply Santyl, then apply calcium alginate and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 10/08/2020 and discontinued on 10/19/2020, was not documented as completed on: 10/08/2020, 10/10/2020, 10/11/2020, 10/13/2020, 10/14/2020, 10/16/2020, 10/17/2020, or 10/19/2020. Further review revealed the wound care treatment was completed 4 of 12 opportunities or 33% of the time. Record review of hospital Admission Notes, dated 10/26/2020, for Resident #1 revealed, Resident brought to the emergency department by EMS due to a large decubitus ulcer on the patient's sacrum. The wound is approximately 12 cm x 12 cm in length. Skin: 12 cm x 12 cm tunneling (wound that has a channel that tunnels from the wound into the muscle or tissue) sacral decubitus ulcer with purulent (contains pus) discharge, appears infected. Primary Diagnosis: [REDACTED]. Record review of Resident #1's hospital Wound Care Note, dated 10/26/2020, revealed, left medial ankle: deep tissue injury measuring 3 cm x 1.8 cm the skin is intact with non-blanching red/maroon/purple tissue. Right heel: deep tissue injury measuring 2 cm x 2 cm the skin is intact with non-blanching maroon. Right 1st toe-[MEDICAL CONDITION] measuring 1 cm x 1.7 cm the wound is covered with black necrotic (dead) tissue. Right 2nd toe: [MEDICAL CONDITION] measuring 1.3 cm x 2.3 cm the wound is covered with black necrotic tissue. Sacrum: stage 4 pressure injury measuring 13 cm x 8 cm x 2.5 cm the wound is covered with large yellow and black/grey slough . moderate thick serous (yellowish-colored fluid) drainage, foul odor noted. Observation on 10/27/2020 at 9:10 a.m., at a local hospital, revealed Resident #1 was awake, but unable to answer interview questions due to cognitive status. Further observation of Resident #1's skin with the assistance of a local hospital RN revealed skin injuries as follows: - A quarter sized area to outside of right ankle that had a non-blanchable dark red/purple colored deep tissue injury that was non-blanchable. Skin remains intact. - A black discoloration to right first toe on medial side. - A right 2nd toe completely black from tip to foot with broken necrotic skin that was open and weeping. The tissue between the first and second toe was black, open, necrotic and weeping. There was also necrotic black tissue on the first digit between the toes. - A deep tissue injury to right heel with red dislocation on a large portion of the heel and a quarter to half dollar size area of induration where the skin had turned a dark purple/black and a small area of broken skin - A quarter sized area of non-blanchable dark red/purple colored deep tissue injury to the right lower back area with the skin intact. - A very large sacral wound from just above the anus to the area level with the resident's upper hip bone. There was a complete loss of skin and underlying tissue with exposure of the coccyx bone. The upper portion and both sides of the wound had dark black necrotic tissue with a strong foul odor. There was a large amount of tan/brown drainage noted on the dressing. During an interview on 10/27/2020 at 9:00 a.m. with RN from a local hospital revealed Resident #1's admitting [DIAGNOSES REDACTED]. During an interview on 10/27/2020 at 9:43 a.m. with Resident #1's RP revealed family had not seen Resident #1 in person since the beginning of the COVID-19 pandemic when the nursing facilities closed to visitors. Resident #1's RP stated on 10/25/2020 when she entered Resident #1's room she smelled a foul odor in the room and assumed the resident had a BM and need to be changed. Resident #1's RP stated two CNAs came to change the resident while the RP and family stood behind the privacy curtain. The RP stated she heard one of the CNAs say, Oh my God! How am I supposed to clean her? The RP stated she came out from behind the curtain and saw the wound to Resident #1's buttocks and back, which did not have a dressing on the wound. Resident #1's RP stated the wound was very large and they could see the resident's bone in the wound and the wound had a bad odor. Resident #1's RP stated she called EMS services on 10/25/2020 so Resident #1's wounds could get treatment at the hospital. During an interview on 10/28/2020 at 1:32 p.m., LVN B stated she had had been assigned as Charge Nurse for Resident #1 on multiple occasions. LVN B stated Resident #1 started out with, just a small place on her bottom, which became the large wound that it was at the time of the investigation, 10/28/2020. LVN B stated, It happened so fast. I don't know how it happened. LVN B further confirmed on 10/25/2020 she was assigned to care for Resident #1 and, had planned on performing wound care, but it just didn't work out that way. LVN B stated she was not aware Resident #1's family was going to be visiting the resident. When LVN B learned the family had requested peri-care for the resident LVN B asked the family to leave, but they refused. LVN B stated the family got upset at the sight of the wound. The interview further revealed LVN B was not sure when the wound to the sacrum last had a dressing because the dressing, gets nasty from BM and drainage from the wound soaks through the dressing. LVN B stated she did not want to change the dressing every day, unless the dressing was just completely soaked and had to come off. LVN B further stated, It just depends on how bad it is. I am sure it has a foul odor. I mean, the wound was sloughing (dead tissue shedding from the wound). LVN B then held up two of her hands side to side to indicate how big the sacral wound had become and confirmed that bone was showing in the wound. During an interview on 10/28/2020 at 4:50 p.m., CNA D confirmed on 10/25/2020 Resident #1's sacral wound did not have a dressing on it and the dressing had not fallen off in the resident's brief. CNA D stated she, freaked out because it (sacral wound) was so big and had bone showing. CNA D confirmed the resident's family was in the room and they were crying. CNA D stated she went to get help from the nurses because the wound had stool on it and she didn't know what to do. CNA D confirmed wound dressings were not getting changed because the facility did not have a wound care nurse. CNA D stated she had reported her concerns to an unknown medication aide and a charge nurse who no longer works at the facility. Record review of Resident #1's hospice book (undated) provided by the hospice agency revealed there was no record of Registered Nursing visits or care provided. Record review of Resident #1's medical record revealed no documentation of services provided by the hospice agency or visits to the facility. During an interview on 10/29/2020 at approximately 11:30 a.m. with the Hospice Administrator confirmed the hospice was assigned to Resident #1. The Hospice Administrator stated due to COVID-19 and visitation limitations the facility had stopped all hospice staff coming into the facility. On 08/21/2020, one Hospice RN was allowed into the facility every other week. On 09/02/2020, Resident #1 had a stage II pressure ulcer to her sacrum. On 09/18/2020, there was a significant increase of the size of the wound and the Hospice Physician ordered antibiotics for Resident #1 due to a foul odor from the wound as recommended by the Wound Care Physician. On 09/20/2020, the nursing facility allowed the Hospice agency to increase the visits to 2 times a week due to a decline in Resident #1's wound. The Hospice Administrator stated hospice did not provide daily wound care to hospice residents. The hospice agency assessed the resident and reports to the hospice physician for any needed orders in coordination with care provided by the facility. During an interview on 10/29/2020 at 4:25 p.m., LVN H confirmed she was assigned as the day shift charge nurse for Resident #1 on 10/19/2020. LVN H further confirmed she did not know if Resident #1's sacral wound had a dressing on it on 10/19/2020 because she did not look at, assess, or perform wound care treatment to Resident #1's pressure ulcers. LVN H stated, it was my first day and I was busy. LVN H further stated typically the Wound Care Nurse performed dressing changes. During an interview on 10/29/2020 at 4:27 p.m., CNA G stated, Resident #1 had a, very ugly, nasty wound, to her bottom which had started off very small and got really big. Further interview with CNA G confirmed she never saw the wound without a dressing but did note the same dressing on the wound for 2-3 days at a time. CNA G stated she informed an agency charge nurse (unidentified) who said, okay. CNA G confirmed she did not tell anyone else in management because the CNAs were supposed to follow a chain of command. During an interview with the Wound Care Physician on 10/28/2020 at approximately 4:05 p.m., the Wound Care Physician confirmed she was treating Resident #1's pressure wound. The Wound Care Physician described Resident #1's wounds as, frankly necrotic, really big stage 4 ulcer approximately 6 cm x 10 cm. The Wound Care Physician stated she had debrided (the medical removal of dead, damaged, or infected tissue to improve the healing potential of healthy tissue) a fair amount of necrotic tissue from Resident #1's wound. The Wound Care Physician confirmed Resident #1 had orders for wound care once a day, and stated the wound may require a second dressing change and the wound care would need to be completed again. The Wound Care Physician stated the facility did not have a Wound Care Nurse for one month and during that time the physician would make rounds on the residents with wounds by herself. The Wound Care Physician stated during her rounds there may have been an occasion where there had not been a dressing change as ordered, here or there, but generally speaking she did not notice any concerns. 2. Record review of Resident #2's face sheet, dated 10/27/2020, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score had not been assessed and not interviewable, and required total assistance from staff with 1-2 staff persons. Further review revealed at the time of the assessment Resident #2 was at risk for developing pressure ulcers/injuries and had an unhealed pressure ulcer/injury over a bony prominence. Record review of Resident #2's Care Plan, first initialized on 08/25/2020 and last revised on 09/10/2020, revealed the resident had pressure ulcers: stage 3 to right ear, stage 2 to right heel, unstageable to left lateral foot, stage 2 to left buttocks and stage 3 to buttocks with a plan of care which included: administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressing PRN. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #2's Physician order [REDACTED].>a. Apply skin prep to right heel one time a day for wound healing, with a start date of 10/17/2020. b. Cleanse left buttock with normal saline, pat dry, apply barrier cream every day, one time a day for wound healing, with a start date of 10/08/2020 that was discontinued on 10/16/2020. c. Cleanse left buttocks area with normal saline, apply Medi-honey and calcium alginate with dry dressing one time a day for wound healing, with a start date of 10/17/2020. d. Cleanse wound to left foot with normal saline, pat dry, apply calcium alginate, cover with dry dressing every day, one time a day for wound healing, with a start date of 10/10/2020 and was discontinued on 10/16/2020. e. Cleanse left lateral foot with normal saline, apply Medi-honey and calcium alginate and cover with dry dressing one time a day for wound healing, with a start date of 10/17/2020. f. Cleanse right buttocks area with normal saline apply Medi-honey and calcium alginate with dry dressing daily, one time a day for wound healing, with a start date of 10/17/2020 g. Cleanse right (incorrectly documented as right instead of left) ear area, pat dry, apply piece of collagen, one time a day for wound healing, with a start date of 10/17/2020. Further review of the Physician order [REDACTED].#2's left ear. Record review of Resident #2's WAR for October 2020 revealed: a. Apply skin prep to right heel one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020, 10/20/2020, 10/22/2020, 10/24/2020, or 10/26/2020. Further review revealed the wound care treatment was administered 5 out of 10 opportunities or 50% of the time. b. Cleanse left buttock with normal saline, pat dry, apply barrier cream every day, one time a day for wound healing, with a start date of 10/08/2020 that was discontinued on 10/16/2020, was not documented as completed on 10/08/2020, 10/09/2020, 10/10/2020, 10/11/2020, 10/12/2020, 10/13/2020, 10/14/2020, 10/15/2020 or 10/16/2020. Further review revealed there was no documentation that Resident #1 received this wound care treatment and therefore wound care was performed 0% of the time. c. Cleanse left buttocks area with normal saline, apply Medi-honey and calcium alginate with dry dressing one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020, 10/20/2020, 10/22/2020, 10/24/2020, 10/25/2020, or 10/26/20. Further review revealed the wound care treatment was performed 5 out of 10 opportunities or 50% of the time. d. Cleanse wound to left foot with normal saline, pat dry, apply calcium alginate, cover with dry dressing every day, one time a day for wound healing, with a start date of 10/10/2020 and was discontinued on 10/16/2020, was not documented as performed on 10/10/2020, 10/11/2020, 10/12/2020, 10/13/2020, 10/14/2020, 10/15/2020 or 10/16/2020. Further review revealed there was no evidence this order for wound care was ever completed and therefore wound care was performed 0% of the time. e. Cleanse left lateral foot with normal saline, apply Medi-honey and calcium alginate and cover with dry dressing one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/20, 10/20/2020 10/22/2020, 10/24/2020 or 10/26/2020. Further review revealed the treatment was performed 5 out of 10 opportunities for a total of 50% of the time. f. Cleanse right buttocks area with normal saline apply Medi-honey and calcium alginate with dry dressing daily, one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020, 10/20/2020, 10/22/2020, 10/24/2020 or 10/26/2020. Further review revealed the treatment was performed 5 out of 10 opportunities for a total of 50% of the time. g. Cleanse right ear area, pat dry, apply piece of collagen, one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020. 10/20/2020, 10/22/2020, 10/24/2020 or 10/26/2020. Further review revealed the treatment was performed 5 out of 10 opportunities for a total of 50% of the time. Observation on 10/27/2020 at 10:45 a.m. with CNA A revealed Resident #2's skin had a large open skin injury to the resident's left mid lateral plantar foot area that had full-thickness skin and tissue loss with areas that were dark brown and black consistent with necrosis and an irregular boarder with flaps of loose skin. There was no dressing on the wound. Further observation revealed a 4 x 4 dressing to Resident #2's right sacral/buttocks area which was heavily soiled all the wa (TRU

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for 5 of 7 residents (Residents #1, #2, #3, #4, and #5) whose care was reviewed for neglect, when it failed to provide required structures and processes in order to meet the needs of residents, in that: 1. The facility failed to implement written policies to include: coordination of resident care and communication between the Charge Nurses, Wound Care Treatment Nurse, hospice provider and facility management to ensure Resident #1 received pressure ulcer care and treatment as prescribed by a doctor to Resident #1's sacrum, lower back, right 2nd toe or right great toe for 15 of 25 opportunities. 2. The facility failed to have a structure in place to ensure agency nurses and newly hired staff were monitored, trained and had adequate supervision to ensure wound care was provided as ordered by a physician for Residents #2 and #3. a. Resident #2 did not receive wound care to the right heel, left buttocks, left foot, right buttocks or left ear for 5 of 5 opportunities. b. Resident #3 did not receive wound care to left first toe, right heel, sacrum or surgical wound to left great toe for 17 of 26 opportunities. 3. The facility failed to have a structure in place to ensure residents with newly acquired pressure injuries were quickly identified, the change of condition was communicated with the physician and the wounds received care and treatment: a. LVN B did not notify Resident #4's physician or provide care and treatment to two newly identified wounds to the residents left 5th toe. b. LVN B did not notify Resident #5's physician or provide care and treatment to a newly identified deep tissue injury to the residents left thigh. These deficient practices affected residents who had pressure ulcers and/or required wound care and could place them at risk of infection, decline of the condition of the wound and could result in worsening health status, hospitalization , and a serious decline in health. The findings were: 1. Record review of a face sheet for Resident #1, dated 10/27/2020, revealed an admission date of [DATE], and a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan, initiated on 06/12/2020 and last revised on 10/26/2020, revealed, Resident #1 has an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to sacrum (area near the tailbone), right great toe DTI (deep tissue injury), right lower back DTI unstageable, right 2nd toe stage 4 pressure ulcer and right heal DTI unstageable, with interventions which included, administer treatments as ordered and monitor for effectiveness, replace loose or missing dressings PRN, follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #1's Weekly Skin Assessment (performed by a Licensed Nurse), dated 08/25/2020, revealed the resident did not have any documented skin issues or pressure ulcers. Record review of Resident #1's Weekly Skin Assessment, dated 09/18/2020, revealed, unstageable to sacrum 10 cm x 12 cm. Treatment already ordered. Wound consult ordered . Record review of Resident #1's Weekly Pressure Ulcer Assessment (performed by a Licensed Nurse), dated 09/18/2020, revealed, unstageable pressure ulcer to sacrum which measured 10 cm x 12 cm with yellow or white slough and 25% necrotic tissue and no exudate. The surrounding skin color was described as pink in color. The wound had a mild odor. Record review of Resident #1's Weekly Ulcer Assessment, dated 09/26/2020, revealed an unstageable pressure injury to the coccyx which measured 4 cm x 4 cm with yellow or white slough and 75% necrotic tissue and no exudate. The surrounding skin was described as brown in color. Record review of Resident #1's Wound Evaluation and Management Summary, the Wound Care Physician's initial evaluation, dated 09/28/2020, revealed an unstageable due to necrosis sacral wound measuring 2.6 cm x 2.8 cm with moderate serous exudate and 100% necrotic tissue. A surgical debridement was performed. Plan of Care read: My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 72 days. This estimate is made with an 80% degree of certainty. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/03/2020, revealed an unstageable pressure injury to coccyx which measured 4 cm x 4 cm and has eschar, black, brown or tan adhered to the wound with yellow or white slough, 75% necrotic tissue and no exudate. The surrounding skin was described as brown in color and the wound had a mild odor. The resident was treated with antibiotic therapy for 10 days. Record review of Resident #1's Weekly Pressure Ulcer Assessment, dated 10/07/2020, revealed a Stage IV pressure ulcer to sacrum which measured 5 cm x 6 cm with an undetermined depth with eschar black, brown or tan adhered to the wound 100% necrotic tissue, moderate exudate which was yellow in color with a strong odor. Record review of Resident #1's Wound Evaluation and Management Summary, written by the Wound Care Physician and dated 10/7/2020, revealed a stage 4 pressure wound to sacrum which measured 5 x 6 cm with a surface area of 30 cm with moderate serious exudate and 100% necrotic tissue. Surgical debridement was performed with a note that read, stage 4 pressure wound to sacrum-deteriorated due to generalized decline of patient. Record review of Resident #1's Weekly Pressure Ulcer Assessment, dated 10/13/2020, revealed a stage IV pressure ulcer to sacrum which measured 11 cm x 10 cm with an undetermined depth with eschar black, brown or tan adhered to the wound 100% necrotic tissue with tunneling which was 6 inches of tunneling at 5 o'clock (position) with bone visible. Skin surrounding wound was described as, brown with maceration the wound contained a strong odor. The wound is marked as not having declined. Record review of a Wound Care Telemedicine Follow up Evaluation, dated 10/16/2020 by the Wound Care Physician, revealed, A telemedicine visit provided to ensure COVID-19 infection control and prevention as no in-person visit was possible due to COVID-19. Patient examined via telemedicine; wound discussed with Wound Care Nurse (LVN C), including offloading techniques and debridement options as well as wound dressing. Site 1: Stage IV wound to sacrum measuring 5 cm x 6 cm with a total surface area of 30 cm, with moderate serous exudate and 100% black necrotic tissue. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a stage IV pressure ulcer to sacrum which measured 11.2 cm x 10 cm with an undetermined depth. The wound was described as having eschar, black, brown or tan adhered to the wound, 100% necrotic tissue with a moderate amount of tan exudate that was opaque or purulent in color without tunneling and with bone exposure. The surrounding skin had peripheral tissue [MEDICAL CONDITION] and was black in color. The wound was described as having a, strong odor, without signs and symptoms of infection. The wound is further described as not having declined. Record review of Resident #1's Wound Evaluation and Management Summary, dated 10/19/2020, revealed, site 1: stage 4 pressure wound to sacrum, measuring 11.2 cm x 10 cm with a surface area of 112 cubic cm. Moderate serous exudate, 80% necrotic tissue. The wound is described as, deteriorated. The wound was surgically debrided. Site 3: unstageable deep tissue injury of the right first toe measuring 1.5 cm x 0.8 cm. Site 4: right medial second toe, unstageable due to necrosis which measured 1.1 cm x 0.8 cm with light serous exudate, 90% necrotic tissue. Treatment plan for site 4 to include xeroform (petroleum based fine-mesh gauze dressing) sterile gauze applied once daily for 30 days with a secondary dressing of a gauze island (multi-layered gauze dressing), apply daily for 30 days. Site 5: unstageable deep tissue injury to right heel which measured 5.1 cm x 5 cm with a surface area of 25.50 cm. Site 6: deep tissue injury to right lower back which measured 1.7 cm x 2 cm. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right lower back deep tissue pressure injury measuring 1.7 cm x 2 cm. The wound was closed. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right heel deep tissue pressure injury measuring 5.1 cm x 5 cm. The wound was described as closed. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right medial second toe unstageable pressure wound measuring 1.1 cm x 0.8 cm. The wound was described as having eschar, black brown or tan adhered to the wound with light exudate which was bloody. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right first toe deep tissue pressure injury which measured 1.5 cm x 0.8 cm. The wound was described as closed. Record review of Resident #1's Physician order [REDACTED]. a. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] (medication used to treat and prevent wound infection) to wound bed and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 09/12/2020 and discontinued on 10/07/2020. b. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020 and discontinued on 10/07/2020. Record review of Resident #1's WAR (Wound Administration Record) for September 2020 revealed: a. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care, with a start date of 09/12/2020, and discontinued on 10/07/2020 was not documented as completed on: 09/12/2020, 09/13/2020, 09/14/2020, 09/15/2020, 09/16/2020, 09/20/2020, 09/24/2020, 09/27/2020. Further review revealed Resident #1's wound care treatment was completed 11 of 19 opportunities or 58% of the time. b. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020, and discontinued on 10/07/2020 revealed there was no documentation any PRN application of wound care treatments performed in September 2020. Record review of Resident #1's Physician order [REDACTED].>a. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care, with a start date of 09/12/2020 and discontinued on 10/07/2020. b. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020 and discontinued on 10/07/2020. c. Skin prep to left lower back one time a day for wound healing, with a start date of 10/20/2020. d. Skin prep to right 2nd toe unstageable one time a day for wound healing, with a start date of 10/20/2020. e. Skin prep to right great toe deep tissue injury one time a day for wound healing, with a start date of 10/20/2020. f. Skin prep to right heel deep tissue injury unstageable one time a day for wound healing, with a start date of 10/21/2020. g. Cleanse coccyx area with normal saline, pat dry, apply Thera-honey (medical grade honey used to promote removal of necrotic tissue to wounds), calcium alginate (plant based algae dressing used to absorb excess fluid and promote removal of dead tissue), cover with Opti-lock (absorbent wound dressing) and secure with Keflex tape, with a start date of 10/20/2020. h. Cleanse sacrum with normal saline, pat dry, apply Santyl (prescription medication that removes dead tissue from wounds so they can start to heal), then apply calcium alginate and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 10/08/2020, and discontinued on 10/19/2020. Further review revealed there was no documentation of a new order starting on 10/20/2020 for wound care of Resident #1's sacrum. Record review of Resident #1's WAR for October 2020 revealed: a. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care. The order was discontinued on 10/07/2020 and was not documented as completed in October 2020 on: 10/01/2020, 10/03/2020, 10/04/2020, 10/05/2020, or 10/07/2020. Further review revealed the wound care treatment was completed 2 of 7 opportunities or 29% of the time. b. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care. The order was discontinued on 10/07/2020. There was no documentation for any PRN wound care treatments provided to the resident. c. Skin prep to left lower back one time a day for wound healing, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed Resident #1's wound care treatment was completed 3 of 6 opportunities or 50% of the time. d. Skin prep to right 2nd toe unstageable one time a day for wound healing with a start date of 10/20/2020 was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. e. Skin prep to right great toe deep tissue injury one time a day for wound healing, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. f. Skin prep to right heel deep tissue injury unstageable one time a day for wound healing, with a start date of 10/21/2020, was not documented as completed on: 10/22/20, 10/24/20, or 10/25/20. Further review revealed the wound care treatment was completed 2 of 5 opportunities or 33% of the time. g. Cleanse coccyx area with normal saline, pat dry, apply Thera-honey, calcium alginate, cover with Opti-lock and secure with Keflex tape, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. h. Cleanse sacrum with normal saline, pat dry, apply Santyl, then apply calcium alginate and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 10/08/2020 and discontinued on 10/19/2020, was not documented as completed on: 10/08/2020, 10/10/2020, 10/11/2020, 10/13/2020, 10/14/2020, 10/16/2020, 10/17/2020, or 10/19/2020. Further review revealed the wound care treatment was completed 4 of 12 opportunities or 33% of the time. Record review of hospital Admission Notes, dated 10/26/2020, for Resident #1 revealed, Resident brought to the emergency department by EMS due to a large decubitus ulcer on the patient's sacrum. The wound is approximately 12 cm x 12 cm in length. Skin: 12 cm x 12 cm tunneling (wound that has a channel that tunnels from the wound into the muscle or tissue) sacral decubitus ulcer with purulent (contains pus) discharge, appears infected. Primary Diagnosis: [REDACTED]. Record review of Resident #1's hospital Wound Care Note, dated 10/26/2020, revealed, left medial ankle: deep tissue injury measuring 3 cm x 1.8 cm the skin is intact with non-blanching red/maroon/purple tissue. Right heel: deep tissue injury measuring 2 cm x 2 cm the skin is intact with non-blanching maroon. Right 1st toe-[MEDICAL CONDITION] measuring 1 cm x 1.7 cm the wound is covered with black necrotic (dead) tissue. Right 2nd toe: [MEDICAL CONDITION] measuring 1.3 cm x 2.3 cm the wound is covered with black necrotic tissue. Sacrum: stage 4 pressure injury measuring 13 cm x 8 cm x 2.5 cm the wound is covered with large yellow and black/grey slough . moderate thick serous (yellowish-colored fluid) drainage, foul odor noted. Record review of Resident #1's hospice book (undated) provided by the hospice agency revealed there was no record of Registered Nursing visits or care provided. Record review of Resident #1's medical record revealed no documentation of services provided by the hospice agency or visits to the facility. Record review of a Provider Investigation Report, dated 10/25/2020, revealed on 10/25/2020 at 6:30 p.m. an allegation of neglect to Resident #1 was made related to a pressure ulcer to the sacrum. Further review of the report revealed the facility indicated Resident #1 was on hospice services and the DON and nursing consultant had been working with the doctor on treatment of [REDACTED].#1's family member called EMS to transfer the resident to the hospital for further treatment of [REDACTED]. Following an investigation, the Administrator marked the allegation of neglect as unfounded. Observation on 10/27/2020 at 9:10 a.m., at a local hospital, revealed Resident #1 was awake, but unable to answer interview questions due to cognitive status. Further observation of Resident #1's skin with the assistance of a local hospital RN revealed skin injuries as follows: - A quarter sized area to outside of right ankle that had a non-blanchable dark red/purple colored deep tissue injury that was non-blanchable. Skin remains intact. - A black discoloration to right first toe on medial side. - A right 2nd toe completely black from tip to foot with broken necrotic skin that was open and weeping. The tissue between the first and second toe was black, open, necrotic and weeping. There was also necrotic black tissue on the first digit between the toes. - A deep tissue injury to right heel with red dislocation on a large portion of the heel and a quarter to half dollar size area of induration where the skin had turned a dark purple/black and a small area of broken skin - A quarter sized area of non-blanchable dark red/purple colored deep tissue injury to the right lower back area with the skin intact. - A very large sacral wound from just above the anus to the area level with the resident's upper hip bone. There was a complete loss of skin and underlying tissue with exposure of the coccyx bone. The upper portion and both sides of the wound had dark black necrotic tissue with a strong foul odor. There was a large amount of tan/brown drainage noted on the dressing. During an interview on 10/27/2020 at 9:00 a.m. with RN from a local hospital revealed Resident #1's admitting [DIAGNOSES REDACTED]. During an interview on 10/27/2020 at 9:43 a.m. with Resident #1's RP revealed family had not seen Resident #1 in person since the beginning of the COVID-19 pandemic when the nursing facilities closed to visitors. Resident #1's RP stated on 10/25/2020 when she entered Resident #1's room she smelled a foul odor in the room and assumed the resident had a BM and need to be changed. Resident #1's RP stated two CNAs came to change the resident while the RP and family stood behind the privacy curtain. The RP stated she heard one of the CNAs say, Oh my God! How am I supposed to clean her? The RP stated she came out from behind the curtain and saw the wound to Resident #1's buttocks and back, which did not have a dressing on the wound. Resident #1's RP stated the wound was very large and they could see the resident's bone in the wound and the wound had a bad odor. Resident #1's RP stated she called EMS services on 10/25/2020 so Resident #1's wounds could get treatment at the hospital. During an interview on 10/28/2020 at 1:32 p.m., LVN B stated she had had been assigned as Charge Nurse for Resident #1 on multiple occasions. LVN B stated Resident #1 started out with, just a small place on her bottom, which became the large wound that it was at the time of the investigation, 10/28/2020. LVN B stated, It happened so fast. I don't know how it happened. LVN B further confirmed on 10/25/2020 she was assigned to care for Resident #1 and, had planned on performing wound care, but it just didn't work out that way. LVN B stated she was not aware Resident #1's family was going to be visiting the resident. When LVN B learned the family had requested peri-care for the resident LVN B asked the family to leave, but they refused. LVN B stated the family got upset at the sight of the wound. The interview further revealed LVN B was not sure when the wound to the sacrum last had a dressing because the dressing, gets nasty from BM and drainage from the wound soaks through the dressing. LVN B stated she did not want to change the dressing every day, unless the dressing was just completely soaked and had to come off. LVN B further stated, It just depends on how bad it is. I am sure it has a foul odor. I mean, the wound was sloughing (dead tissue shedding from the wound). LVN B then held up two of her hands side to side to indicate how big the sacral wound had become and confirmed that bone was showing in the wound. During an interview with the Wound Care Physician on 10/28/2020 at approximately 4:05 p.m., the Wound Care Physician confirmed she was treating Resident #1. The Wound Care Physician described Resident #1's wounds as, frankly necrotic, really big stage 4 ulcer approximately 6 cm x 10 cm. The Wound Care Physician stated she had debrided a fair amount of necrotic tissue from the wound. The Wound Care Physician confirmed Resident #1 had orders for wound care once a day and stated the wound may require a second dressing change and the wound care would need to be completed again. During an interview on 10/28/2020 at 4:50 p.m., CNA D confirmed on 10/25/2020 Resident #1's sacral wound did not have a dressing on it and the dressing had not fallen off in the resident's brief. CNA D stated she, freaked out because it (sacral wound) was so big and had bone showing. CNA D confirmed the resident's family was in the room and they were crying. CNA D stated she went to get help from the nurses because the wound had stool on it and she didn't know what to do. CNA D confirmed wound dressings were not getting changed because the facility did not have a wound care nurse. CNA D stated she had reported her concerns to an unknown medication aide and a charge nurse who no longer works at the facility. During an interview with ADON E on 10/28/2020 at 5:10 p.m., ADON E confirmed on 10/25/2020 he was asked by staff to assist with wound care on Resident #1. ADON E stated the wound did not have a dressing on it when he observed the wound and indicated the CNAs may have pulled it off as part of providing care to the resident. ADON E stated, We have a wound care nurse who is in charge of making sure wound care is performed. ADON E further stated the charge nurse on day shift is also responsible for wound care or if the dressing becomes soiled any nurse on any shift is responsible for changing the dressing. ADON E stated, Resident #1 was on hospice and either hospice or the charge nurse should be responsible for Resident #1's wound care. When asked how hospice communicated whether or not they had performed wound care to the staff, ADON E stated he did not know where hospice documented their care. During an interview with ADON F on 10/28/2020 at 5:35 p.m., ADON F stated the charge nurses were ultimately responsible for ensuring the residents to which they were assigned received wound care. During an interview on 10/29/2020 at approximately 11:30 a.m. with the Hospice Administrator confirmed the hospice was assigned to Resident #1. The Hospice Administrator stated due to COVID-19 and visitation limitations the facility had stopped all hospice staff coming into the facility. On 08/21/2020, one Hospice RN was allowed into the facility every other week. On 09/02/2020, Resident #1 had a stage II pressure ulcer to her sacrum. On 09/18/2020, there was a significant increase of the size of the wound and the Hospice Physician ordered antibiotics for Resident #1 due to a foul odor from the wound as recommended by the Wound Care Physician. On 09/20/2020, the nursing facility allowed the Hospice agency to increase the visits to 2 times a week due to a decline in Resident #1's wound. The Hospice Administrator stated hospice did not provide daily wound care to hospice residents. The hospice agency assessed the resident and reports to the hospice physician for any needed orders in coordination with care provided by the facility. During an interview on 10/29/2020 at 4:25 p.m., LVN H confirmed she was assigned as the day shift charge nurse for Resident #1 on 10/19/2020. LVN H further confirmed she did not know if Resident #1's sacral wound had a dressing on it on 10/19/2020 because she did not look at, assess, or perform wound care treatment to Resident #1's pressure ulcers. LVN H stated, it was my first day and I was busy. LVN H further stated typically the Wound Care Nurse performed dressing changes. During an interview with the Medical Director (MD) on 10/29/2020 at 3:40 PM, the MD stated, in regards to Resident #1's sacral wound, The wound started very small, but Resident #1 has been declining for 4-5 months. She (Resident #1) developed this bedsore while being treated for [REDACTED]. The resident (Resident #1) is not eating well and has low protein. The MD further stated, I have not seen the wound and I did not examine the wound. I don't like to undo the dressings. The MD stated, I don't know who is doing wound care (for Resident #1). Is it the hospice care or the facility? Hospice was supposed to be doing care. I do not know who is responsible for wound care. Record review of the facility's policy titled, Hospice Services, dated 07/13/2020, revealed: 2. The facility must have a legally binding written agreement for the provision of arranged services with a recognized hospice provider. 8. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. 2a. Record review of Resident #2's face sheet, dated 10/27/2020, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score had not been assessed and not interviewable, and required total assistance from staff with 1-2 staff persons. Further review revealed at the time of the assessment Resident #2 was at risk for developing pressure ulcers/injuries and had an unhealed pressure ulcer/injury over a bony prominence. Record review of Resident #2's Care Plan, first initialized on 08/25/2020 and last revised on 09/10/2020, revealed the resident had pressure ulcers: stage 3 to right ear, stage 2 to right heel, unstageable to left lateral foot, stage 2 to left buttocks and stage 3 to buttocks with a plan of care which included: administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressing PRN. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #2's Physician order [REDACTED].>a. Apply skin prep to right heel one time a day for wound healing, with a start date of 10/17/2020. b. Cleanse left buttock with normal saline, pat dry, apply barrier cream every day, one time a day for wound healing, with a start date of 10/08/2020 that was discontinued on 10/16/2020. c. Cleanse left buttocks area with normal saline, apply Medi-honey and calcium alginate with dry dressing one time a day for wound healing, with a start date of 10/17/2020. d. Cleanse wound to left foot with normal saline, pat dry, apply calcium alginate, cover with dry dressing every day, one time a day for wound healing, with a start date of 10/10/2020 and was discontinued on 10/16/2020. e. Cleanse left lateral foot with normal saline, apply Medi-honey and calcium alginate and cover with dry dressing one time a day for wound healing, with a start date of 10/17/2020. f. Cleanse right buttocks area with normal saline apply Medi-honey and calcium alginate with dry dressing daily, one time a day for wound healing, with a start date of 10/17/2020 g. Cleanse right (incorrectly documented as right instead of left) ear area, pat dry, apply piece of collagen, one time a day for wound healing, with a start date of 10/17/2020. Further review of the Physician order [REDACTED].#2's left ear. Record review of Resident #2's WAR for October 2020 revealed: a. Apply skin prep to right heel one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020, 10/20/2020, 10/22/2020, 10/24/2020, or 10/26/2020. Further review revealed the wound care treatment was administered 5 out of 10 opportunities or 50% of the time. b. Cleanse left buttock with normal saline, pat dry, apply barrier cream every day, one time a day for wound healing, with a start date of 10/08/2020 that was discontinued on 10/16/2020, was not documented as completed on 10/08/2020, 10/09/2020, 10/10/2020, 10/11/2020, 10/12/2020, 10/13/2020, 10/14/2020, 10/15/2020 or 10/16/2020. Further review revealed there was no documentation that Resident #1 received this wound care treatment and therefore wound care was performed 0% of the time. c. Cleanse left buttocks area with normal saline, apply Medi-honey and calcium alginate with dry dressing one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020, 10/20/2020, 10/22/2020, 10/24/2020, 10/25/2020, or 10/26/20. Further review revealed the wound care treatment was performed 5 out of 10 opportunities or 50% of the time. d. Cleanse wound to left foot with normal saline, pat dry, apply calcium alginate, cover with dry dressing every day, one time a day for wound healing, with a start date of 10/10/2020 and was discontinued on 10/16/2020, was not documented as performed on 10/10/2020, 10/11/2020, 10/12/2020, 10/13/2020, 10/14/2020, 10/15/2020 or 10/16/2020. Further review revealed there was no evidence this order for wound care was ever completed and therefore wound care was performed 0% of the time. e. Cleanse left lateral foot with normal saline, apply Medi-honey and calcium alginate and cover with dry dressing one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/20, 10/20/2020 10/22/2020, 10/24/2020 or 10/26/2020. Further review revealed the treatment was performed 5 out of 10 opportunities for a total of 50% of the time. f. Cleanse right buttocks area with normal saline apply Medi-honey and calcium alginate with dry dressing daily, one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020, 10/20/2020, 10/22/2020, 10/24/2020 or 10/26/2020. Further review revealed the treatment was performed 5 out of 10 opportunities for a total of 50% of the time. g. Cleanse right ear area, pat dry, apply piece of collagen, one time a day for wound healing, with a sta (TRUNCATE

Based on observation, interview, and record review, the facility failed to implement written policies and procedures and failed to provide adequate training of staff to ensure residents were free from neglect for 5 of 7 residents (Residents #1, #2, #3, #4 and #5) whose care was reviewed for neglect, in that: 1. The facility failed to implement written policies to include: coordination of resident care and communication between the Charge Nurses, Wound Care Treatment Nurse, hospice provider and facility management to ensure Resident #1 received pressure ulcer care and treatment as prescribed by a doctor to Resident #1's sacrum, lower back, right 2nd toe or right great toe for 15 of 25 opportunities. 2. The facility failed to have a structure in place to ensure agency nurses and newly hired staff were monitored, trained and had adequate supervision to ensure wound care was provided as ordered by a physician for Residents #2 and #3. a. Resident #2 did not receive wound care to the right heel, left buttocks, left foot, right buttocks or left ear for 5 of 5 opportunities. b. Resident #3 did not receive wound care to left first toe, right heel, sacrum or surgical wound to left great toe for 17 of 26 opportunities. 3. The facility failed to have a structure in place to ensure residents with newly acquired pressure injuries were quickly identified, the change of condition was communicated with the physician and the wounds received care and treatment: a. LVN B did not notify Resident #4's physician or provide care and treatment to two newly identified wounds to the residents left 5th toe. b. LVN B did not notify Resident #5's physician or provide care and treatment to a newly identified deep tissue injury to the residents left thigh. These deficient practices could affect residents who had pressure ulcers and/or required wound care and could place them at risk of infection, decline of the condition of the wound and could result in worsening health status, hospitalization , and a serious decline in health. The findings were: Record review of the facility's policy titled, Abuse/Neglect, dated 03/29/2018, revealed, The resident has the right to be free from abuse, neglect, and misappropriation of resident property, and exploitation as defined in this subpart. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish, or emotional distress. B. Training: The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. C. Prevention: The facility will provide the residents, families and staff an environment free from abuse and neglect. 1. Record review of a face sheet for Resident #1, dated 10/27/2020, revealed an admission date of [DATE], and a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3 which indicated a severe cognitive impairment. Resident #1 required extensive assistance for ADL's of two staff persons. Further review revealed at the time of the assessment Resident #1 was at risk for developing pressure ulcers/injuries but had no unhealed wounds or skin conditions and the resident was on hospice care. Record review of Resident #1's Care Plan, initiated on 06/12/2020 and last revised on 10/26/2020, revealed, Resident #1 has an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to sacrum (area near the tailbone), right great toe DTI (deep tissue injury), right lower back DTI unstageable, right 2nd toe stage 4 pressure ulcer and right heal DTI unstageable, with interventions which included, administer treatments as ordered and monitor for effectiveness, replace loose or missing dressings PRN, follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #1's Weekly Skin Assessment (performed by a Licensed Nurse), dated 08/25/2020, revealed the resident did not have any documented skin issues or pressure ulcers. Record review of Resident #1's Weekly Skin Assessment, dated 09/18/2020, revealed, unstageable to sacrum 10 cm x 12 cm. Treatment already ordered. Wound consult ordered . Record review of Resident #1's Weekly Pressure Ulcer Assessment (performed by a Licensed Nurse), dated 09/18/2020, revealed, unstageable pressure ulcer to sacrum which measured 10 cm x 12 cm with yellow or white slough and 25% necrotic tissue and no exudate. The surrounding skin color was described as pink in color. The wound had a mild odor. Record review of Resident #1's Weekly Ulcer Assessment, dated 09/26/2020, revealed an unstageable pressure injury to the coccyx which measured 4 cm x 4 cm with yellow or white slough and 75% necrotic tissue and no exudate. The surrounding skin was described as brown in color. Record review of Resident #1's Wound Evaluation and Management Summary, the Wound Care Physician's initial evaluation, dated 09/28/2020, revealed an unstageable due to necrosis sacral wound measuring 2.6 cm x 2.8 cm with moderate serous exudate and 100% necrotic tissue. A surgical debridement was performed. Plan of Care read: My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 72 days. This estimate is made with an 80% degree of certainty. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/03/2020, revealed an unstageable pressure injury to coccyx which measured 4 cm x 4 cm and has eschar, black, brown or tan adhered to the wound with yellow or white slough, 75% necrotic tissue and no exudate. The surrounding skin was described as brown in color and the wound had a mild odor. The resident was treated with antibiotic therapy for 10 days. Record review of Resident #1's Weekly Pressure Ulcer Assessment, dated 10/07/2020, revealed a Stage IV pressure ulcer to sacrum which measured 5 cm x 6 cm with an undetermined depth with eschar black, brown or tan adhered to the wound 100% necrotic tissue, moderate exudate which was yellow in color with a strong odor. Record review of Resident #1's Wound Evaluation and Management Summary, written by the Wound Care Physician and dated 10/7/2020, revealed a stage 4 pressure wound to sacrum which measured 5 x 6 cm with a surface area of 30 cm with moderate serious exudate and 100% necrotic tissue. Surgical debridement was performed with a note that read, stage 4 pressure wound to sacrum-deteriorated due to generalized decline of patient. Record review of Resident #1's Weekly Pressure Ulcer Assessment, dated 10/13/2020, revealed a stage IV pressure ulcer to sacrum which measured 11 cm x 10 cm with an undetermined depth with eschar black, brown or tan adhered to the wound 100% necrotic tissue with tunneling which was 6 inches of tunneling at 5 o'clock (position) with bone visible. Skin surrounding wound was described as, brown with maceration the wound contained a strong odor. The wound is marked as not having declined. Record review of a Wound Care Telemedicine Follow up Evaluation, dated 10/16/2020 by the Wound Care Physician, revealed, A telemedicine visit provided to ensure COVID-19 infection control and prevention as no in-person visit was possible due to COVID-19. Patient examined via telemedicine; wound discussed with Wound Care Nurse (LVN C), including offloading techniques and debridement options as well as wound dressing. Site 1: Stage IV wound to sacrum measuring 5 cm x 6 cm with a total surface area of 30 cm, with moderate serous exudate and 100% black necrotic tissue. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a stage IV pressure ulcer to sacrum which measured 11.2 cm x 10 cm with an undetermined depth. The wound was described as having eschar, black, brown or tan adhered to the wound, 100% necrotic tissue with a moderate amount of tan exudate that was opaque or purulent in color without tunneling and with bone exposure. The surrounding skin had peripheral tissue [MEDICAL CONDITION] and was black in color. The wound was described as having a, strong odor, without signs and symptoms of infection. The wound is further described as not having declined. Record review of Resident #1's Wound Evaluation and Management Summary, dated 10/19/2020, revealed, site 1: stage 4 pressure wound to sacrum, measuring 11.2 cm x 10 cm with a surface area of 112 cubic cm. Moderate serous exudate, 80% necrotic tissue. The wound is described as, deteriorated. The wound was surgically debrided. Site 3: unstageable deep tissue injury of the right first toe measuring 1.5 cm x 0.8 cm. Site 4: right medial second toe, unstageable due to necrosis which measured 1.1 cm x 0.8 cm with light serous exudate, 90% necrotic tissue. Treatment plan for site 4 to include xeroform (petroleum based fine-mesh gauze dressing) sterile gauze applied once daily for 30 days with a secondary dressing of a gauze island (multi-layered gauze dressing), apply daily for 30 days. Site 5: unstageable deep tissue injury to right heel which measured 5.1 cm x 5 cm with a surface area of 25.50 cm. Site 6: deep tissue injury to right lower back which measured 1.7 cm x 2 cm. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right lower back deep tissue pressure injury measuring 1.7 cm x 2 cm. The wound was closed. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right heel deep tissue pressure injury measuring 5.1 cm x 5 cm. The wound was described as closed. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right medial second toe unstageable pressure wound measuring 1.1 cm x 0.8 cm. The wound was described as having eschar, black brown or tan adhered to the wound with light exudate which was bloody. Record review of Resident #1's Weekly Ulcer Assessment, dated 10/19/2020, revealed a right first toe deep tissue pressure injury which measured 1.5 cm x 0.8 cm. The wound was described as closed. Record review of Resident #1's Physician order [REDACTED]. a. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] (medication used to treat and prevent wound infection) to wound bed and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 09/12/2020 and discontinued on 10/07/2020. b. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020 and discontinued on 10/07/2020. Record review of Resident #1's WAR (Wound Administration Record) for September 2020 revealed: a. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care, with a start date of 09/12/2020, and discontinued on 10/07/2020 was not documented as completed on: 09/12/2020, 09/13/2020, 09/14/2020, 09/15/2020, 09/16/2020, 09/20/2020, 09/24/2020, 09/27/2020. Further review revealed Resident #1's wound care treatment was completed 11 of 19 opportunities or 58% of the time. b. Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020, and discontinued on 10/07/2020 revealed there was no documentation any PRN application of wound care treatments performed in September 2020. Record review of Resident #1's Physician order [REDACTED].>a. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care, with a start date of 09/12/2020 and discontinued on 10/07/2020. b. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care, with a start date of 09/11/2020 and discontinued on 10/07/2020. c. Skin prep to left lower back one time a day for wound healing, with a start date of 10/20/2020. d. Skin prep to right 2nd toe unstageable one time a day for wound healing, with a start date of 10/20/2020. e. Skin prep to right great toe deep tissue injury one time a day for wound healing, with a start date of 10/20/2020. f. Skin prep to right heel deep tissue injury unstageable one time a day for wound healing, with a start date of 10/21/2020. g. Cleanse coccyx area with normal saline, pat dry, apply Thera-honey (medical grade honey used to promote removal of necrotic tissue to wounds), calcium alginate (plant based algae dressing used to absorb excess fluid and promote removal of dead tissue), cover with Opti-lock (absorbent wound dressing) and secure with Keflex tape, with a start date of 10/20/2020. h. Cleanse sacrum with normal saline, pat dry, apply Santyl (prescription medication that removes dead tissue from wounds so they can start to heal), then apply calcium alginate and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 10/08/2020, and discontinued on 10/19/2020. Further review revealed there was no documentation of a new order starting on 10/20/2020 for wound care of Resident #1's sacrum. Record review of Resident #1's WAR for October 2020 revealed: a. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN every day shift for wound care. The order was discontinued on 10/07/2020 and was not documented as completed in October 2020 on: 10/01/2020, 10/03/2020, 10/04/2020, 10/05/2020, or 10/07/2020. Further review revealed the wound care treatment was completed 2 of 7 opportunities or 29% of the time. b. Sacrum cleanse with normal saline, pat dry, apply [MEDICATION NAME] to wound bed and cover with dry dressing every day and PRN for wound care. The order was discontinued on 10/07/2020. There was no documentation for any PRN wound care treatments provided to the resident. c. Skin prep to left lower back one time a day for wound healing, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed Resident #1's wound care treatment was completed 3 of 6 opportunities or 50% of the time. d. Skin prep to right 2nd toe unstageable one time a day for wound healing with a start date of 10/20/2020 was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. e. Skin prep to right great toe deep tissue injury one time a day for wound healing, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. f. Skin prep to right heel deep tissue injury unstageable one time a day for wound healing, with a start date of 10/21/2020, was not documented as completed on: 10/22/20, 10/24/20, or 10/25/20. Further review revealed the wound care treatment was completed 2 of 5 opportunities or 33% of the time. g. Cleanse coccyx area with normal saline, pat dry, apply Thera-honey, calcium alginate, cover with Opti-lock and secure with Keflex tape, with a start date of 10/20/2020, was not documented as completed on: 10/22/2020, 10/24/2020, or 10/25/2020. Further review revealed the wound care treatment was completed 3 of 6 opportunities or 50% of the time. h. Cleanse sacrum with normal saline, pat dry, apply Santyl, then apply calcium alginate and cover with dry dressing every day and PRN, every day shift for wound care, with a start date of 10/08/2020 and discontinued on 10/19/2020, was not documented as completed on: 10/08/2020, 10/10/2020, 10/11/2020, 10/13/2020, 10/14/2020, 10/16/2020, 10/17/2020, or 10/19/2020. Further review revealed the wound care treatment was completed 4 of 12 opportunities or 33% of the time. Record review of hospital Admission Notes, dated 10/26/2020, for Resident #1 revealed, Resident brought to the emergency department by EMS due to a large decubitus ulcer on the patient's sacrum. The wound is approximately 12 cm x 12 cm in length. Skin: 12 cm x 12 cm tunneling (wound that has a channel that tunnels from the wound into the muscle or tissue) sacral decubitus ulcer with purulent (contains pus) discharge, appears infected. Primary Diagnosis: [REDACTED]. Record review of Resident #1's hospital Wound Care Note, dated 10/26/2020, revealed, left medial ankle: deep tissue injury measuring 3 cm x 1.8 cm the skin is intact with non-blanching red/maroon/purple tissue. Right heel: deep tissue injury measuring 2 cm x 2 cm the skin is intact with non-blanching maroon. Right 1st toe-[MEDICAL CONDITION] measuring 1 cm x 1.7 cm the wound is covered with black necrotic (dead) tissue. Right 2nd toe: [MEDICAL CONDITION] measuring 1.3 cm x 2.3 cm the wound is covered with black necrotic tissue. Sacrum: stage 4 pressure injury measuring 13 cm x 8 cm x 2.5 cm the wound is covered with large yellow and black/grey slough . moderate thick serous (yellowish-colored fluid) drainage, foul odor noted. Record review of Resident #1's hospice book, undated, provided by the hospice agency revealed there was no record of Registered Nursing visits or care provided. Record review of Resident #1's medical record revealed no documentation of services provided by the hospice agency or visits to the facility. Record review of a Provider Investigation Report, dated 10/25/2020, revealed on 10/25/2020 at 6:30 p.m. an allegation of neglect to Resident #1 was made related to a pressure ulcer to the sacrum. Further review of the report revealed the facility indicated Resident #1 was on hospice services and the DON and nursing consultant had been working with the doctor on treatment of [REDACTED].#1's family member called EMS to transfer the resident to the hospital for further treatment of [REDACTED]. Following an investigation, the Administrator marked the allegation of neglect as unfounded. Observation on 10/27/2020 at 9:10 a.m., at a local hospital, revealed Resident #1 was awake, but unable to answer interview questions due to cognitive status. Further observation of Resident #1's skin with the assistance of a local hospital RN revealed skin injuries as follows: - A quarter sized area to outside of right ankle that had a non-blanchable dark red/purple colored deep tissue injury that was non-blanchable. Skin remains intact. - A black discoloration to right first toe on medial side. - A right 2nd toe completely black from tip to foot with broken necrotic skin that was open and weeping. The tissue between the first and second toe was black, open, necrotic and weeping. There was also necrotic black tissue on the first digit between the toes. - A deep tissue injury to right heel with red dislocation on a large portion of the heel and a quarter to half dollar size area of induration where the skin had turned a dark purple/black and a small area of broken skin - A quarter sized area of non-blanchable dark red/purple colored deep tissue injury to the right lower back area with the skin intact. - A very large sacral wound from just above the anus to the area level with the resident's upper hip bone. There was a complete loss of skin and underlying tissue with exposure of the coccyx bone. The upper portion and both sides of the wound had dark black necrotic tissue with a strong foul odor. There was a large amount of tan/brown drainage noted on the dressing. During an interview on 10/27/2020 at 9:00 a.m. with RN from a local hospital revealed Resident #1's admitting [DIAGNOSES REDACTED]. During an interview on 10/27/2020 at 9:43 a.m. with Resident #1's RP revealed family had not seen Resident #1 in person since the beginning of the COVID-19 pandemic when the nursing facilities closed to visitors. Resident #1's RP stated on 10/25/2020 when she entered Resident #1's room she smelled a foul odor in the room and assumed the resident had a BM and need to be changed. Resident #1's RP stated two CNAs came to change the resident while the RP and family stood behind the privacy curtain. The RP stated she heard one of the CNAs say, Oh my God! How am I supposed to clean her? The RP stated she came out from behind the curtain and saw the wound to Resident #1's buttocks and back, which did not have a dressing on the wound. Resident #1's RP stated the wound was very large and they could see the resident's bone in the wound and the wound had a bad odor. Resident #1's RP stated she called EMS services on 10/25/2020 so Resident #1's wounds could get treatment at the hospital. During an interview on 10/28/2020 at 1:32 p.m., LVN B stated she had had been assigned as Charge Nurse for Resident #1 on multiple occasions. LVN B stated Resident #1 started out with, just a small place on her bottom, which became the large wound that it was at the time of the investigation, 10/28/2020. LVN B stated, It happened so fast. I don't know how it happened. LVN B further confirmed on 10/25/2020 she was assigned to care for Resident #1 and, had planned on performing wound care, but it just didn't work out that way. LVN B stated she was not aware Resident #1's family was going to be visiting the resident. When LVN B learned the family had requested peri-care for the resident LVN B asked the family to leave, but they refused. LVN B stated the family got upset at the sight of the wound. The interview further revealed LVN B was not sure when the wound to the sacrum last had a dressing because the dressing, gets nasty from BM and drainage from the wound soaks through the dressing. LVN B stated she did not want to change the dressing every day, unless the dressing was just completely soaked and had to come off. LVN B further stated, It just depends on how bad it is. I am sure it has a foul odor. I mean, the wound was sloughing (dead tissue shedding from the wound). LVN B then held up two of her hands side to side to indicate how big the sacral wound had become and confirmed that bone was showing in the wound. During an interview with the Wound Care Physician on 10/28/2020 at approximately 4:05 p.m., the Wound Care Physician confirmed she was treating Resident #1. The Wound Care Physician described Resident #1's wounds as, frankly necrotic, really big stage 4 ulcer approximately 6 cm x 10 cm. The Wound Care Physician stated she had debrided a fair amount of necrotic tissue from the wound. The Wound Care Physician confirmed Resident #1 had orders for wound care once a day and stated the wound may require a second dressing change and the wound care would need to be completed again. During an interview on 10/28/2020 at 4:50 p.m., CNA D confirmed on 10/25/2020 Resident #1's sacral wound did not have a dressing on it and the dressing had not fallen off in the resident's brief. CNA D stated she, freaked out because it (sacral wound) was so big and had bone showing. CNA D confirmed the resident's family was in the room and they were crying. CNA D stated she went to get help from the nurses because the wound had stool on it and she didn't know what to do. CNA D confirmed wound dressings were not getting changed because the facility did not have a wound care nurse. CNA D stated she had reported her concerns to an unknown medication aide and a charge nurse who no longer works at the facility. During an interview with ADON E on 10/28/2020 at 5:10 p.m., ADON E confirmed on 10/25/2020 he was asked by staff to assist with wound care on Resident #1. ADON E stated the wound did not have a dressing on it when he observed the wound and indicated the CNAs may have pulled it off as part of providing care to the resident. ADON E stated, We have a wound care nurse who is in charge of making sure wound care is performed. ADON E further stated the charge nurse on day shift is also responsible for wound care or if the dressing becomes soiled any nurse on any shift is responsible for changing the dressing. ADON E stated, Resident #1 was on hospice and either hospice or the charge nurse should be responsible for Resident #1's wound care. When asked how hospice communicated whether or not they had performed wound care to the staff, ADON E stated he did not know where hospice documented their care. During an interview with ADON F on 10/28/2020 at 5:35 p.m., ADON F stated the charge nurses were ultimately responsible for ensuring the residents to which they were assigned received wound care. During an interview on 10/29/2020 at approximately 11:30 a.m. with the Hospice Administrator confirmed the hospice was assigned to Resident #1. The Hospice Administrator stated due to COVID-19 and visitation limitations the facility had stopped all hospice staff coming into the facility. On 08/21/2020, one Hospice RN was allowed into the facility every other week. On 09/02/2020, Resident #1 had a stage II pressure ulcer to her sacrum. On 09/18/2020, there was a significant increase of the size of the wound and the Hospice Physician ordered antibiotics for Resident #1 due to a foul odor from the wound as recommended by the Wound Care Physician. On 09/20/2020, the nursing facility allowed the Hospice agency to increase the visits to 2 times a week due to a decline in Resident #1's wound. The Hospice Administrator stated hospice did not provide daily wound care to hospice residents. The hospice agency assessed the resident and reports to the hospice physician for any needed orders in coordination with care provided by the facility. During an interview on 10/29/2020 at 4:25 p.m., LVN H confirmed she was assigned as the day shift charge nurse for Resident #1 on 10/19/2020. LVN H further confirmed she did not know if Resident #1's sacral wound had a dressing on it on 10/19/2020 because she did not look at, assess, or perform wound care treatment to Resident #1's pressure ulcers. LVN H stated, it was my first day and I was busy. LVN H further stated typically the Wound Care Nurse performed dressing changes. During an interview with the Medical Director (MD) on 10/29/2020 at 3:40 PM, the MD stated, in regards to Resident #1's sacral wound, The wound started very small, but Resident #1 has been declining for 4-5 months. She (Resident #1) developed this bedsore while being treated for [REDACTED]. The resident (Resident #1) is not eating well and has low protein. The MD further stated, I have not seen the wound and I did not examine the wound. I don't like to undo the dressings. The MD stated, I don't know who is doing wound care (for Resident #1). Is it the hospice care or the facility? Hospice was supposed to be doing care. I do not know who is responsible for wound care. Record review of the facility's policy titled, Hospice Services, dated 07/13/2020, revealed: 2. The facility must have a legally binding written agreement for the provision of arranged services with a recognized hospice provider. 8. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. Record review of Resident #2's face sheet, dated 10/27/2020, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score had not been assessed and not interviewable, and required total assistance from staff with 1-2 staff persons. Further review revealed at the time of the assessment Resident #2 was at risk for developing pressure ulcers/injuries and had an unhealed pressure ulcer/injury over a bony prominence. Record review of Resident #2's Care Plan, first initialized on 08/25/2020 and last revised on 09/10/2020, revealed the resident had pressure ulcers: stage 3 to right ear, stage 2 to right heel, unstageable to left lateral foot, stage 2 to left buttocks and stage 3 to buttocks with a plan of care which included: administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressing PRN. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #2's Physician order [REDACTED].>a. Apply skin prep to right heel one time a day for wound healing, with a start date of 10/17/2020. b. Cleanse left buttock with normal saline, pat dry, apply barrier cream every day, one time a day for wound healing, with a start date of 10/08/2020 that was discontinued on 10/16/2020. c. Cleanse left buttocks area with normal saline, apply Medi-honey and calcium alginate with dry dressing one time a day for wound healing, with a start date of 10/17/2020. d. Cleanse wound to left foot with normal saline, pat dry, apply calcium alginate, cover with dry dressing every day, one time a day for wound healing, with a start date of 10/10/2020 and was discontinued on 10/16/2020. e. Cleanse left lateral foot with normal saline, apply Medi-honey and calcium alginate and cover with dry dressing one time a day for wound healing, with a start date of 10/17/2020. f. Cleanse right buttocks area with normal saline apply Medi-honey and calcium alginate with dry dressing daily, one time a day for wound healing, with a start date of 10/17/2020 g. Cleanse right (incorrectly documented as right instead of left) ear area, pat dry, apply piece of collagen, one time a day for wound healing, with a start date of 10/17/2020. Further review of the Physician order [REDACTED].#2's left ear. Record review of Resident #2's WAR for October 2020 revealed: a. Apply skin prep to right heel one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020, 10/20/2020, 10/22/2020, 10/24/2020, or 10/26/2020. Further review revealed the wound care treatment was administered 5 out of 10 opportunities or 50% of the time. b. Cleanse left buttock with normal saline, pat dry, apply barrier cream every day, one time a day for wound healing, with a start date of 10/08/2020 that was discontinued on 10/16/2020, was not documented as completed on 10/08/2020, 10/09/2020, 10/10/2020, 10/11/2020, 10/12/2020, 10/13/2020, 10/14/2020, 10/15/2020 or 10/16/2020. Further review revealed there was no documentation that Resident #1 received this wound care treatment and therefore wound care was performed 0% of the time. c. Cleanse left buttocks area with normal saline, apply Medi-honey and calcium alginate with dry dressing one time a day for wound healing, with a start date of 10/17/2020, was not documented as completed on 10/19/2020, 10/20/2020, 10/22/2020, 10/24/2020, 10/25/2020, or 10/26/20. Further review revealed the wound care treatment was performed 5 out of 10 opportunities or 50% of the time. d. Cleanse wound to left foot with normal saline, pat dry, apply calcium alginate, cover with dry dressing every day, one time a day for wound healing, with a start date of 10/10/2020 and was discontinued on 10/16/202 (TRUNCATED)

Based on observation, interview, and record review, the faciity failed to implement policies and procedures that prohibit neglect of residents for 4 of 6 residents (#1, 2, 9 and 12) on 1 of 4 halls (300) whose care was reviewed for safe smoking in that: 1. Resident #9 had not been assessed for safe smoking, per facility policy and procedure, for 20 days after admission and was smoking, unsupervised, in a non-designated smoking area. 2. Resident #2 had cigarettes and a lighter in her possession and was smoking in a non-designated smoking area. 3. Residents #1 and #12 had not been assessed for safe smoking, per facility policy and procedure, for 20 days after admission. 4. Residents #1, 2, and 9 kept cigarettes in their rooms. Resident #1 also had cigarette butts in his room. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 04/16/14. While the IJ was removed on 04/16/14, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to facility not yet completing in-service training for all staff on enforcement of the smoking policy and counseling all residents who smoked and their families regarding rules for smoking at the facility. These failures could result in fire hazard with injury and could affect 24 residents living in the 300 hall of the facility. Findings: 1. Review of Resident #9's Face Sheet, undated, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour with LVN A on 04/16/14 at 7:00 a.m., revealed Resident #9 standing immediately outside the glass door at the end of the 100 hall, smoking, unsupervised, in an non-designated smoking area. LVN A escorted the surveyor outside the 100 hall glass door, around the corner of the building to a covered area that she identified as the smoking area. There were no other residents in the designated smoking area and no staff member at the smoking area to distribute cigarettes and lighters or to supervise residents smoking. In an interview on 04/16/145 at 7:06 a.m., LVN A said RA E was going to go outside and supervise residents smoking. Review of Resident #9's clinical record revealed there was no smoking assessment and there was no Care Plan to address smoking. In an interview on 04/16/14 at 7:43 a.m., LVN B, who was working on the 100 hall, said to determine if a resident was a safe smoker, he would review the resident's clinical record for a smoking assessment. When LVN B reviewed Resident #9's clinical record, he acknowledged there was no smoking assessment filed in the record. LVN B said he would ask the DON if he did not find a smoking assessment for a resident. LVN B said he had not seen Resident #9 go outside to smoke and that the resident might have gone out the door at the same time as another resident who he said had been assessed as safe to smoke without supervision. LVN B said, to his understanding, if a resident was assessed as a safe smoker, the resident was allowed to keep cigarettes and lighters. In an interview on 04/16/14 at 8:12 a.m., LVN C, who was working on the 300 hall, said residents were assessed for safe smoking on admission. LVN C said the smoking assessments were supposed to be in the residents' charts (clinical records). LVN C said if she did not find a safe smoking assessment in a resident's chart, she would perform an assessment herself. LVN C said many residents got out of bed early and went outside by themselves. LVN C said she saw Resident #9 go outside at approximately 7:00 a.m. and she thought there was a staff member outside at that time to supervise smoking. LVN C said she had not seen a smoking assessment for Resident #9. LVN C did not say she had done an assessment for Resident #9 as she thought there was a staff member outside to supervise residents smoking. LVN C said she did not go outside to verify the presence of a supervising staff member for smoking. Observation on 04/16/14 at 9:16 a.m., revealed Housekeeper D was outside in the smoking area supervising residents. In an interview at that time, Housekeeper D said cigarettes and a lighter were stored in a plastic box that she was holding and were kept at the nurses' desk. Housekeeper D said the scheduled smoking times were 9:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m., but that she had seen residents go outside to smoke at other times. Housekeeper D said she had seen residents with cigarettes and lighters in the facility. Observation on 04/16/14 at 4:01 p.m., revealed the DON conducted resident room searches, after an IJ was identified, for cigarettes and lighters and found 6 cigarettes in Resident #9's room. Interviews were attempted with Resident #9. The resident was not in his room. 2. Review of Resident #2's Face Sheet, undated, revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission MDS, dated [DATE], revealed she had a BIMS score of 15 (corresponding to intact cognition). Observation during initial tour with LVN A on 04/16/14 at 7:00 a.m., revealed the designated smoking area was outside the 100 hall glass door, around the corner of the building, and in a covered area. There were no residents smoking in the designated smoking area and no staff member to distribute cigarettes and lighters or to supervise residents smoking. As LVN A and the surveyor approached the glass door to the 100 hall to enter the faciity, Resident #2 stepped outside the door and immediately took out a cigarette and lighter, lit the cigarette, and began to smoke. Observation on 04/16/14 at 7:09 a.m., revealed Resident #2 told LVN A she obtained the lighter she was using from Resident #1. Resident #2 gave the lighter to LVN A. Review of Resident #2's clinical record revealed no smoking assessment and no Care Plan to address smoking. In an interview on 04/16/14 at 7:20 a.m., the DON said Resident #2's smoking assessment might be on the computer. At 7:28 a.m., the DON said she did not locate the smoking assessment in the resident's computer records. In an interview on 04/16/14 at 7:29 a.m., LVN A said the resident's smoking assessment might be in the Social Worker's (SW) office. LVN A said the SW's office was locked but that he was on his way to the facility. In an interview on 04/16/14 at 7:55 a.m., the Administrator said she had unlocked the SW's office and found two smoking assessments. One of the assessments was for Resident #2. Review with the Administrator revealed Resident #2 had been assessed as being a safe smoker. In an interview on 04/16/14 at 8:50 a.m., Resident #2 said she kept cigarettes at all times in her jacket pocket and that she was given a lighter by Resident #1 that morning. Resident #2 took a packet of cigarettes from her jacket pocket but said that she no longer had the lighter. Resident #2 said she told staff on admission that she did not feel safe keeping a lighter. Resident #2 said she kept cigarettes all the time, that she would go out to smoke every 3 to 4 hours, and that she had been told no one had to go out with her. Observation on 04/16/14 at 4:20 p.m. revealed the DON conducted resident room searches for cigarettes and lighters and found a cigarette and a half in Resident #2's room. (The DON said the SW and GVN H had conducted room searches for cigarettes and lighters immediately after an IJ was identified). 3. Review of Resident #1's Face Sheet, undated, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS dated [DATE], revealed he was assessed as having a BIMS score of 11 (corresponding to moderate cognitive impairment). Observation inside the 100 hall on 04/16/14 at 7:04 a.m., revealed Resident #1 approached the glass door leading to the smoking area and attempted to open the door. Resident #1 did not enter the door code prior to opening the door. A door alarm sounded. Staff silenced the alarm. Observation on 04/16/14 at 7:06 a.m., revealed LVN A asked Resident #1 where he was going. Resident #1 said he was going to smoke and indicated he had cigarettes in his pants pocket. Resident #1 said he had given his lighter to Resident #2. Review of Resident #1's clinical record revealed there was no smoking assessment and no Care Plan that addressed smoking. In an interview on 04/16/14 at 7:20 a.m., the DON said Resident #1's smoking assessment might be on the computer. At 7:28 a.m., the DON said she did not locate the smoking assessment in the resident's computer records. In an interview on 04/16/14 at 7:29 a.m., LVN A said the resident's smoking assessment might be in the Social Worker's (SW) office. LVN A said the SW's office was locked but that he was on his way to the facility. In an interview on 04/16/14 at 7:55 a.m., the Administrator said she had unlocked the SW's office and found two smoking assessments for residents other than Resident #1. In an interview on 04/16/14 at 8:12 a.m., LVN C said she had not seen a smoking assessment for Resident #1. LVN C did not say she had done an assessment for Resident #1 as she thought there was a staff member present in the smoking area to supervise residents smoking . LVN C said she did not go outside to verify the presence of a supervising staff member for smoking. In an interview on 04/16/14 at 8:55 a.m., Resident #1 said he kept cigarettes in his room night stand and a lighter on his overbed table. Resident #1 said the lighter was not on the overbed table at the moment and that he obtained the lighter the night before. Resident #1's roommate came around the privacy curtain and said he had given Resident #1 the lighter. Resident #1 said he usually went out to smoke 3 times a day and that he was now supposed to have someone go out with him when he smoked. Resident #1 said a family member brought him cigarettes and lighters. Resident #1 opened the top drawer of his night stand and revealed 2 packets of cigarettes. Resident #1 opened the bottom drawer of his night stand and revealed approximately 5 cigarette butts on a thin metal tray-like object. In an interview on 04/16/14 at 9:02 a.m., Resident #1's roommate said he no longer smoked and that he gave Resident #1 a lighter the night before. Resident #1's roommate said he did not remember what the time was when he gave Resident #1 the lighter. Observation on 04/16/14 at 4:00 p.m., revealed the DON conducted resident room searches for cigarettes and lighters and found cigarette butts from Resident #1's room (the SW and GVN H conducted room searches for cigarettes and lighters immediately after an IJ was identified ). 4. Record review of Resident #12's clinical record revealed an undated Face Sheet that documented her date of admission was 03/27/14. Resident #12's [DIAGNOSES REDACTED]. There was no admission smoking assessment or Care Plan for smoking. Observation and interview on 04/16/14 at 9:20 a.m., revealed Resident #12 was sitting in the smoking area, smoking. Resident #12 said her cigarettes were in the plastic box that Housekeeper D was holding. Review of a list provided by the SW dated 04/16/14, revealed he found and collected cigarettes and lighters from 3 resident rooms that included Resident #12's room. In a telephone interview on 04/16/14 at 2:38 p.m., the Medical Director said resident safe smoking assessments should be conducted on a case by case basis. The Medical Director said the determination of a resident's ability to smoke safely should include a decision by residents' attending physicians, including psychiatric services. In an interview on 04/17/14 at 6:12 a.m., CNA M said she had seen residents going out to smoke without staff accompanying them. CNA M said when she confronted the residents about having cigarettes and lighters, the residents became angry. CNA M said she had seen residents return from the smoking area into the building with cigarettes and lighters in their possession. CNA M said she started seeing residents go outside and return to the building in possession of cigarettes and lighters early this year. CNA M said she did not know who decided residents were safe to smoke without supervision. In an interview on 04/17/14 at 6:21 a.m., LVN B said residents were allowed to keep cigarettes and lighters in their rooms after it was determined they were safe smokers. LVN B said the residents were allowed to keep the cigarettes and lighters to honor their rights. LVN B said he did not see all residents who went out to smoke. LVN B said he did not remember which staff began to allow residents to keep cigarettes and lighters in their rooms. In an interview on 04/17/14 at 6:28 a.m., the Administrator said she was ultimately responsible for enforcing the facility smoking policy. The Administrator said she never decided to allow residents to keep cigarettes and lighters in their rooms. The Administrator said cigarettes and lighters were supposed to be collected when residents were admitted to the facility. After admission, the Administrator said the charge nurses were responsible for day to day enforcement of the policy. The Administrator said she was not supervising the nursing staff to assure that they enforced the smoking policy and ensured residents were supervised when smoking. The Administrator said 9 residents were admitted on [DATE] from a group home that closed. The Administrator said 7 of the 9 residents smoked and that their cigarettes and lighters were collected upon admission. The Administrator said that, since admission, the 7 residents either had gone out on pass and returned with cigarettes or their visitors brought them cigarettes and lighters. The Administrator said the charge nurses on the 300 hall should have been monitoring the residents for cigarettes and lighters in rooms. In an interview on 04/17/14 at 10:28 a.m., the DON said all staff were responsible for enforcing the smoking policy. The DON said the SW was responsible for enforcing the smoking policy with each resident as well as the charge nurses and CNAs. The DON said she did not know who was responsible for assuring residents did not keep cigarettes and lighters in their rooms or who was to supervise staff to assure they monitored residents keeping cigarettes and lighters in rooms. The DON said the facility would have to "figure that out on the plan of correction." In an interview on 04/22/14 at 9:55 a.m., the Administrator said the facility could not define any date in which residents began to keep cigarettes and lighters in their rooms but started sometime after 03/28/14 with the admission of the residents from the group home. The Administrator said CNAs working in residents' rooms should have looked for cigarettes and lighters. The Administrator said the CNAs would not have looked inside residents' dresser or night stand drawers. The Administrator said according to the smoking policy, residents were not supposed to keep cigarettes or lighters in their rooms. In an interview on 04/22/14 at 10:20 a.m., the SW said he was working part-time at the facility, approximately one hour a day, until 04/16/14 when he began full-time employment. The SW said he was present on 03/28/14 and completed a few smoking assessments, but not for Residents #1, 9, or 12. The SW said he completed the assessments by observing residents smoking and would then assess safe habits while smoking. The SW said he collected cigarettes and lighters when he performed the assessments but that residents must have acquired more after admission. The SW said that prior to his full-time employment, GVN H was performing smoking assessments. The SW said he completed smoking assessments on all residents who smoked on 04/16/14 (after surveyor intervention as SW was not present in facility when surveyor noted lack of assessments). In an interview on 04/22/14 at 10:40 a.m., GVN H said he did not know who was supposed to perform assessments for safe smoking when the SW was not in the facility or who should have been doing the assessments when the facility was without a full-time SW. GVN H said he had not been performing the safe smoking assessments. GVN H said there had been no residents who smoked admitted from December, 2013 to 03/27/14. GVN H said residents began keeping cigarettes and lighters in their rooms sometime after 03/27/14 with the admission of the residents from the group home. GVN H said the residents on the 300 hall hid cigarettes and lighters. In an interview on 04/22/14 at 11:45 a.m., the Administrator said she performed smoking assessments on all residents who smoked in December, 2013. Review of the facility Smoking Policy, undated, revealed: -The Policy was: "It is the policy of this facility to establish and maintain resident smoking policies." -The Procedure included: -"A smoking assessment will be conducted by the Social Worker for all residents who request to smoke. This assessment is to determine the safety status of the resident in his/her ability to smoke safely." -The time frame for the smoking assessment to be completed included: ---"Upon admission if resident requests to smoke." ---"Residents are NOT allowed to keep any smoking materials on themselves or in their rooms, this includes matches and/or lighters." Review of the Job Description for Administrator, undated, revealed the position summary was: -"Under the direct supervision of the Regional Vice President, the Administrator leads and directs the overall operation of the faiclity in accordance with resident needs, government regulations and company policies so as to maintain excellent care for the residents while achieving the facility's business objectives" Essential position functions included: -"Conducts regular rounds to monitor operations of all departments, cleanliness and appearance of facility, morale of staff and to ensure resident needs are being addressed" Review of the Job Description for Director of Nursing, undated, revealed the essential position functions included: -"Conduct regular rounds and monitor resident activity, assess residents' physical and psychosocial status, and monitor care activities and documentation to ensure the delivery of nursing care according to physicians orders, care plans, and established standards and facility policies" The Administrator was notified on 04/16/14 at 10:03 a.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 04/16/14 and accepted by the Program Manager on 04/16/14 at 2:26 p.m. The facility took the following actions to remove the IJ: -All smokers were immediately assessed for safe smoking and the facility conducted a Care Plan review -The SW conducted an audit of all smokers' rooms for cigarettes and lighters and collected any found. All smoking materials were stored and kept locked in the medication room. -The facility was to begin daily audits of smokers' rooms for smoking materials until full compliance was achieved. Residents who did not agree to comply with the smoking policy were to be given a 30 day notice of discharge. -Residents who smoked were to receive counseling regarding the smoking policy that included instructions to either place unused smoking materials in a storage box for safekeeping or to leave used materials in the proper receptacles in the smoking area. Residents were to sign a copy of the smoking policy to ensure acknowledgement and understanding. -Residents' family members and responsible parties were to be contacted and counseled to bring any smoking materials to the nurses' desk for resident safekeeping. -The code for the door leading to the smoking area was to be changed so that residents wishing to smoke would have to request exit from a staff member. -All staff were to receive in-services regarding the smoking policy. -"No Smoking" signs were placed on walls outside the 100 hall door. -The Medical Director and State Ombudsman were notified of smoking policy procedures. The Ombudsman was invited to meet with all residents who smoked to reinforce the smoking policy for all residents' safety. Interviews with nurses and CNAs on 04/16/14 from 3:00 p.m. to 3:43 p.m. and 04/17/14 from 6:00 to 6:12 a.m. revealed nurses and CNAs had received training on the facility smoking policy and enforcement of the policy. They all listed the designated smoking times as 9AM, 1PM, 4PM, and 7PM. They all said residents were not to keep smoking materials in room, and following passes or having visitors, all smoking items were to be stored in the medication room. Interviews with residents who smoked on 04/17/14 from 8:57 a.m. to 10:55 a.m., revealed they received counseling on the smoking policy. Review of Resident Safe Smoking Assessments revealed all residents who smoked had been assessed/re-assessed on 04/16/14 and signed copies of the Smoking Policy. On 04/16/14 at 2:32 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of potential harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the Plan of Removal were completed. In an interview on 04/22/14 at 9:55 a.m., the Administrator said all staff in-services on the smoking policy and procedure, resident/family counseling, and smoking assessments were completed on 04/16/14 at approximately 4:00 p.m. In an interview on 04/22/14 at 9:55 a.m., the Administrator said all staff in-services on the smoking policy and procedure, resident/family counseling, and smoking assessments were completed on 04/16/14 at approximately 4:00 p.m. According to a census list dated 04/15/14 and information provided by the facility on 04/17/14, there were 24 residents living on the 300 hall, including 6 former group home residents who smoked.

Based on observation, interview, and record review, the faciity failed to implement written policies and procedures that prohibit neglect of residents for 4 of 6 residents (#1, 2, 9 and 12) on 1 of 4 halls (300) whose care was reviewed for safe smoking in that: 1. Resident #9 had not been assessed for safe smoking, per facility policy and procedure, for 20 days after admission and was smoking, unsupervised, in a non-designated smoking area. 2. Resident #2 had cigarettes and a lighter in her possession and was smoking in a non-designated smoking area. 3. Residents #1 and #12 had not been assessed for safe smoking, per facility policy and procedure, for 20 days after admission. 4. Residents #1, 2, and 9 kept cigarettes in their rooms. Resident #1 also had cigarette butts in his room. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 04/16/14. While the IJ was removed on 04/16/14, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was an immediate jeopardy due to facility not yet completing in-service training for all staff on enforcement of the smoking policy and counseling all residents who smoked and their families regarding rules for smoking at the facility. These failures could result in fire hazard with injury and could affect 24 residents, including 6 former group home residents who smoked, living in the 300 hall of the facility. Findings: Review of the facility in-service on Abuse dated 04/16/14 revealed the definition of neglect was: -"Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs." Review of the facility Smoking Policy, undated, revealed: -The Policy was: "It is the policy of this facility to establish and maintain resident smoking policies." -The Procedure included: -"A smoking assessment will be conducted by the Social Worker for all residents who request to smoke. This assessment is to determine the safety status of the resident in his/her ability to smoke safely." -The time frame for the smoking assessment to be completed included: ---"Upon admission if resident requests to smoke." ---"Residents are NOT allowed to keep any smoking materials on themselves or in their rooms, this includes matches and/or lighters." Review of the Job Description for Administrator, undated, revealed the position summary was: -"Under the direct supervision of the Regional Vice President, the Administrator leads and directs the overall operation of the faiclity in accordance with resident needs, government regulations and company policies so as to maintain excellent care for the residents while achieving the facility's business objectives" Essential position functions included: -"Conducts regular rounds to monitor operations of all departments, cleanliness and appearance of facility, morale of staff and to ensure resident needs are being addressed" Review of the Job Description for Director of Nursing, undated, revealed the essential position functions included: -"Conduct regular rounds and monitor resident activity, assess residents' physical and psychosocial status, and monitor care activities and documentation to ensure the delivery of nursing care according to physicians orders, care plans, and established standards and facility policies" 1. Review of Resident #9's Face Sheet, undated, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour with LVN A on 04/16/14 at 7:00 a.m., revealed Resident #9 standing immediately outside the glass door at the end of the 100 hall, smoking, unsupervised, in an non-designated smoking area. LVN A escorted the surveyor outside the 100 hall glass door, around the corner of the building to a covered area that she identified as the smoking area. There were no other residents in the designated smoking area and no staff member at the smoking area to distribute cigarettes and lighters or to supervise residents smoking. In an interview on 04/16/145 at 7:06 a.m., LVN A said RA E was going to go outside and supervise residents smoking. Review of Resident #9's clinical record revealed there was no smoking assessment and there was no Care Plan to address smoking. In an interview on 04/16/14 at 7:43 a.m., LVN B, who was working on the 100 hall, said to determine if a resident was a safe smoker, he would review the resident's clinical record for a smoking assessment. When LVN B reviewed Resident #9's clinical record, he acknowledged there was no smoking assessment filed in the record. LVN B said he would ask the DON if he did not find a smoking assessment for a resident. LVN B said he had not seen Resident #9 go outside to smoke and that the resident might have gone out the door at the same time as another resident who he said had been assessed as safe to smoke without supervision. LVN B said, to his understanding, if a resident was assessed as a safe smoker, the resident was allowed to keep cigarettes and lighters. In an interview on 04/16/14 at 8:12 a.m., LVN C, who was working on the 300 hall, said residents were assessed for safe smoking on admission. LVN C said the smoking assessments were supposed to be in the residents' charts (clinical records). LVN C said if she did not find a safe smoking assessment in a resident's chart, she would perform an assessment herself. LVN C said many residents got out of bed early and went outside by themselves. LVN C said she saw Resident #9 go outside at approximately 7:00 a.m. and she thought there was a staff member outside at that time to supervise smoking. LVN C said she had not seen a smoking assessment for Resident #9. LVN C did not say she had done an assessment for Resident #9 as she thought there was a staff member outside to supervise residents smoking. LVN C said she did not go outside to verify the presence of a supervising staff member for smoking. Observation on 04/16/14 at 9:16 a.m., revealed Housekeeper D was outside in the smoking area supervising residents. In an interview at that time, Housekeeper D said cigarettes and a lighter were stored in a plastic box that she was holding and were kept at the nurses' desk. Housekeeper D said the scheduled smoking times were 9:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m., but that she had seen residents go outside to smoke at other times. Housekeeper D said she had seen residents with cigarettes and lighters in the facility. Observation on 04/16/14 at 4:01 p.m., revealed the DON conducted resident room searches, after an IJ was identified, for cigarettes and lighters and found 6 cigarettes in Resident #9's room. Interviews were attempted with Resident #9. The resident was not in his room. 2. Review of Resident #2's Face Sheet, undated, revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission MDS, dated [DATE], revealed she had a BIMS score of 15 (corresponding to intact cognition). Observation during initial tour with LVN A on 04/16/14 at 7:00 a.m., revealed the designated smoking area was outside the 100 hall glass door, around the corner of the building, and in a covered area. There were no residents smoking in the designated smoking area and no staff member to distribute cigarettes and lighters or to supervise residents smoking. As LVN A and the surveyor approached the glass door to the 100 hall to enter the faciity, Resident #2 stepped outside the door and immediately took out a cigarette and lighter, lit the cigarette, and began to smoke. Observation on 04/16/14 at 7:09 a.m., revealed Resident #2 told LVN A she obtained the lighter she was using from Resident #1. Resident #2 gave the lighter to LVN A. Review of Resident #2's clinical record revealed no smoking assessment and no Care Plan to address smoking. In an interview on 04/16/14 at 7:20 a.m., the DON said Resident #2's smoking assessment might be on the computer. At 7:28 a.m., the DON said she did not locate the smoking assessment in the resident's computer records. In an interview on 04/16/14 at 7:29 a.m., LVN A said the resident's smoking assessment might be in the Social Worker's (SW) office. LVN A said the SW's office was locked but that he was on his way to the facility. In an interview on 04/16/14 at 7:55 a.m., the Administrator said she had unlocked the SW's office and found two smoking assessments. One of the assessments was for Resident #2. Review with the Administrator revealed Resident #2 had been assessed as being a safe smoker. In an interview on 04/16/14 at 8:50 a.m., Resident #2 said she kept cigarettes at all times in her jacket pocket and that she was given a lighter by Resident #1 that morning. Resident #2 took a packet of cigarettes from her jacket pocket but said that she no longer had the lighter. Resident #2 said she told staff on admission that she did not feel safe keeping a lighter. Resident #2 said she kept cigarettes all the time, that she would go out to smoke every 3 to 4 hours, and that she had been told no one had to go out with her. Observation on 04/16/14 at 4:20 p.m. revealed the DON conducted resident room searches for cigarettes and lighters and found a cigarette and a half in Resident #2's room. (The DON said the SW and GVN H had conducted room searches for cigarettes and lighters immediately after an IJ was identified). 3. Review of Resident #1's Face Sheet, undated, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS dated [DATE], revealed he was assessed as having a BIMS score of 11 (corresponding to moderate cognitive impairment). Observation inside the 100 hall on 04/16/14 at 7:04 a.m., revealed Resident #1 approached the glass door leading to the smoking area and attempted to open the door. Resident #1 did not enter the door code prior to opening the door. A door alarm sounded. Staff silenced the alarm. Observation on 04/16/14 at 7:06 a.m., revealed LVN A asked Resident #1 where he was going. Resident #1 said he was going to smoke and indicated he had cigarettes in his pants pocket. Resident #1 said he had given his lighter to Resident #2. Review of Resident #1's clinical record revealed there was no smoking assessment and no Care Plan that addressed smoking. In an interview on 04/16/14 at 7:20 a.m., the DON said Resident #1's smoking assessment might be on the computer. At 7:28 a.m., the DON said she did not locate the smoking assessment in the resident's computer records. In an interview on 04/16/14 at 7:29 a.m., LVN A said the resident's smoking assessment might be in the Social Worker's (SW) office. LVN A said the SW's office was locked but that he was on his way to the facility. In an interview on 04/16/14 at 7:55 a.m., the Administrator said she had unlocked the SW's office and found two smoking assessments for residents other than Resident #1. In an interview on 04/16/14 at 8:12 a.m., LVN C said she had not seen a smoking assessment for Resident #1. LVN C did not say she had done an assessment for Resident #1 as she thought there was a staff member present in the smoking area to supervise residents smoking . LVN C said she did not go outside to verify the presence of a supervising staff member for smoking. In an interview on 04/16/14 at 8:55 a.m., Resident #1 said he kept cigarettes in his room night stand and a lighter on his overbed table. Resident #1 said the lighter was not on the overbed table at the moment and that he obtained the lighter the night before. Resident #1's roommate came around the privacy curtain and said he had given Resident #1 the lighter. Resident #1 said he usually went out to smoke 3 times a day and that he was now supposed to have someone go out with him when he smoked. Resident #1 said a family member brought him cigarettes and lighters. Resident #1 opened the top drawer of his night stand and revealed 2 packets of cigarettes. Resident #1 opened the bottom drawer of his night stand and revealed approximately 5 cigarette butts on a thin metal tray-like object. In an interview on 04/16/14 at 9:02 a.m., Resident #1's roommate said he no longer smoked and that he gave Resident #1 a lighter the night before. Resident #1's roommate said he did not remember what the time was when he gave Resident #1 the lighter. Observation on 04/16/14 at 4:00 p.m., revealed the DON conducted resident room searches for cigarettes and lighters and found cigarette butts from Resident #1's room (the SW and GVN H conducted room searches for cigarettes and lighters immediately after an IJ was identified ). 4. Record review of Resident #12's clinical record revealed an undated Face Sheet that documented her date of admission was 03/27/14. Resident #12's [DIAGNOSES REDACTED]. There was no admission smoking assessment or Care Plan for smoking. Observation and interview on 04/16/14 at 9:20 a.m., revealed Resident #12 was sitting in the smoking area, smoking. Resident #12 said her cigarettes were in the plastic box that Housekeeper D was holding. Review of a list provided by the SW dated 04/16/14, revealed he found and collected cigarettes and lighters from 3 resident rooms that included Resident #12's room. In a telephone interview on 04/16/14 at 2:38 p.m., the Medical Director said resident safe smoking assessments should be conducted on a case by case basis. The Medical Director said the determination of a resident's ability to smoke safely should include a decision by residents' attending physicians, including psychiatric services. In an interview on 04/17/14 at 6:12 a.m., CNA M said she had seen residents going out to smoke without staff accompanying them. CNA M said when she confronted the residents about having cigarettes and lighters, the residents became angry. CNA M said she had seen residents return from the smoking area into the building with cigarettes and lighters in their possession. CNA M said she started seeing residents go outside and return to the building in possession of cigarettes and lighters early this year. CNA M said she did not know who decided residents were safe to smoke without supervision. In an interview on 04/17/14 at 6:21 a.m., LVN B said residents were allowed to keep cigarettes and lighters in their rooms after it was determined they were safe smokers. LVN B said the residents were allowed to keep the cigarettes and lighters to honor their rights. LVN B said he did not see all residents who went out to smoke. LVN B said he did not remember which staff began to allow residents to keep cigarettes and lighters in their rooms. In an interview on 04/17/14 at 6:28 a.m., the Administrator said she was ultimately responsible for enforcing the facility smoking policy. The Administrator said she never decided to allow residents to keep cigarettes and lighters in their rooms. The Administrator said cigarettes and lighters were supposed to be collected when residents were admitted to the facility. After admission, the Administrator said the charge nurses were responsible for day to day enforcement of the policy. The Administrator said she was not supervising the nursing staff to assure that they enforced the smoking policy and ensured residents were supervised when smoking. The Administrator said 9 residents were admitted on [DATE] from a group home that closed. The Administrator said 7 of the 9 residents smoked and that their cigarettes and lighters were collected upon admission. The Administrator said that, since admission, the 7 residents either had gone out on pass and returned with cigarettes or their visitors brought them cigarettes and lighters. The Administrator said the charge nurses on the 300 hall should have been monitoring the residents for cigarettes and lighters in rooms. In an interview on 04/17/14 at 10:28 a.m., the DON said all staff were responsible for enforcing the smoking policy. The DON said the SW was responsible for enforcing the smoking policy with each resident as well as the charge nurses and CNAs. The DON said she did not know who was responsible for assuring residents did not keep cigarettes and lighters in their rooms or who was to supervise staff to assure they monitored residents keeping cigarettes and lighters in rooms. The DON said the facility would have to "figure that out on the plan of correction." In an interview on 04/22/14 at 9:55 a.m., the Administrator said the facility could not define any date in which residents began to keep cigarettes and lighters in their rooms but started sometime after 03/28/14 with the admission of the residents from the group home. The Administrator said CNAs working in residents' rooms should have looked for cigarettes and lighters. The Administrator said the CNAs would not have looked inside residents' dresser or night stand drawers. The Administrator said according to the smoking policy, residents were not supposed to keep cigarettes or lighters in their rooms. In an interview on 04/22/14 at 10:20 a.m., the SW said he was working part-time at the facility, approximately one hour a day, until 04/16/14 when he began full-time employment. The SW said he was present on 03/28/14 and completed a few smoking assessments, but not for Residents #1, 9, or 12. The SW said he completed the assessments by observing residents smoking and would then assess safe habits while smoking. The SW said he collected cigarettes and lighters when he performed the assessments but that residents must have acquired more after admission. The SW said that prior to his full-time employment, GVN H was performing smoking assessments. The SW said he completed smoking assessments on all residents who smoked on 04/16/14 (after surveyor intervention as SW was not present in facility when surveyor noted lack of assessments). In an interview on 04/22/14 at 10:40 a.m., GVN H said he did not know who was supposed to perform assessments for safe smoking when the SW was not in the facility or who should have been doing the assessments when the facility was without a full-time SW. GVN H said he had not been performing the safe smoking assessments. GVN H said there had been no residents who smoked admitted from December, 2013 to 03/27/14. GVN H said residents began keeping cigarettes and lighters in their rooms sometime after 03/27/14 with the admission of the residents from the group home. GVN H said the residents on the 300 hall hid cigarettes and lighters. In an interview on 04/22/14 at 11:45 a.m., the Administrator said she performed smoking assessments on all residents who smoked in December, 2013. Review of the facility Smoking Policy, undated, revealed: -The Policy was: "It is the policy of this facility to establish and maintain resident smoking policies." -The Procedure included: -"A smoking assessment will be conducted by the Social Worker for all residents who request to smoke. This assessment is to determine the safety status of the resident in his/her ability to smoke safely." -The time frame for the smoking assessment to be completed included: ---"Upon admission if resident requests to smoke." ---"Residents are NOT allowed to keep any smoking materials on themselves or in their rooms, this includes matches and/or lighters." Review of the Job Description for Administrator, undated, revealed the position summary was: -"Under the direct supervision of the Regional Vice President, the Administrator leads and directs the overall operation of the faiclity in accordance with resident needs, government regulations and company policies so as to maintain excellent care for the residents while achieving the facility's business objectives" Essential position functions included: -"Conducts regular rounds to monitor operations of all departments, cleanliness and appearance of facility, morale of staff and to ensure resident needs are being addressed" Review of the Job Description for Director of Nursing, undated, revealed the essential position functions included: -"Conduct regular rounds and monitor resident activity, assess residents' physical and psychosocial status, and monitor care activities and documentation to ensure the delivery of nursing care according to physicians orders, care plans, and established standards and facility policies" The Administrator was notified on 04/16/14 at 10:03 a.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 04/16/14 and accepted by the Program Manager on 04/16/14 at 2:26 p.m. The facility took the following actions to remove the IJ: -All smokers were immediately assessed for safe smoking and the facility conducted a Care Plan review -The SW conducted an audit of all smokers' rooms for cigarettes and lighters and collected any found. All smoking materials were stored and kept locked in the medication room. -The facility was to begin daily audits of smokers' rooms for smoking materials until full compliance was achieved. Residents who did not agree to comply with the smoking policy were to be given a 30 day notice of discharge. -Residents who smoked were to receive counseling regarding the smoking policy that included instructions to either place unused smoking materials in a storage box for safekeeping or to leave used materials in the proper receptacles in the smoking area. Residents were to sign a copy of the smoking policy to ensure acknowledgement and understanding. -Residents' family members and responsible parties were to be contacted and counseled to bring any smoking materials to the nurses' desk for resident safekeeping. -The code for the door leading to the smoking area was to be changed so that residents wishing to smoke would have to request exit from a staff member. -All staff were to receive in-services regarding the smoking policy. -"No Smoking" signs were placed on walls outside the 100 hall door. -The Medical Director and State Ombudsman were notified of smoking policy procedures. The Ombudsman was invited to meet with all residents who smoked to reinforce the smoking policy for all residents' safety. Interviews with nurses and CNAs on 04/16/14 from 3:00 p.m. to 3:43 p.m. and 04/17/14 from 6:00 to 6:12 a.m. revealed nurses and CNAs had received training on the facility smoking policy and enforcement of the policy. They all listed the designated smoking times as 9AM, 1PM, 4PM, and 7PM. They all said residents were not to keep smoking materials in room, and following passes or having visitors, all smoking items were to be stored in the medication room. Interviews with residents who smoked on 04/17/14 from 8:57 a.m. to 10:55 a.m., revealed they received counseling on the smoking policy. Review of Resident Safe Smoking Assessments revealed all residents who smoked had been assessed/re-assessed on 04/16/14 and signed copies of the Smoking Policy. On 04/16/14 at 2:32 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of potential harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the Plan of Removal were completed. In an interview on 04/22/14 at 9:55 a.m., the Administrator said all staff in-services on the smoking policy and procedure, resident/family counseling, and smoking assessments were completed on 04/16/14 at approximately 4:00 p.m. According to a census list dated 04/15/14 and information provided by the facility on 04/17/14, there were 24 residents living on the 300 hall, including 6 former group home residents who smoked.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 4 of 6 residents (#1, 2, 9 and 12) on 1 of 4 halls (300) whose care was reviewed for safe smoking in that: 1. Resident #9 had not been assessed for safe smoking, per facility policy and procedure, for 20 days after admission and was smoking, unsupervised, in a non-designated smoking area. 2. Resident #2 had cigarettes and a lighter in her possession and was smoking in a non-designated smoking area. 3. Residents #1 and #12 had not been assessed for safe smoking, per facility policy and procedure, for 20 days after admission. 4. Residents #1, 2, and 9 kept cigarettes in their rooms. Resident #1 also had cigarette butts in his room. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 04/16/14. While the IJ was removed on 04/16/14, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to facility not yet completing in-service training for all staff on enforcement of the smoking policy and counseling all residents who smoked and their families regarding rules for smoking at the facility. These failures could result in fire hazard with injury and could affect 24 residents living in the 300 hall of the facility. Findings: 1. Review of Resident #9's Face Sheet, undated, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour with LVN A on 04/16/14 at 7:00 a.m., revealed Resident #9 standing immediately outside the glass door at the end of the 100 hall, smoking, unsupervised, in an non-designated smoking area. LVN A escorted the surveyor outside the 100 hall glass door, around the corner of the building to a covered area that she identified as the smoking area. There were no other residents in the designated smoking area and no staff member at the smoking area to distribute cigarettes and lighters or to supervise residents smoking. In an interview on 04/16/145 at 7:06 a.m., LVN A said RA E was going to go outside and supervise residents smoking. Review of Resident #9's clinical record revealed there was no smoking assessment and there was no Care Plan to address smoking. In an interview on 04/16/14 at 7:43 a.m., LVN B, who was working on the 100 hall, said to determine if a resident was a safe smoker, he would review the resident's clinical record for a smoking assessment. When LVN B reviewed Resident #9's clinical record, he acknowledged there was no smoking assessment filed in the record. LVN B said he would ask the DON if he did not find a smoking assessment for a resident. LVN B said he had not seen Resident #9 go outside to smoke and that the resident might have gone out the door at the same time as another resident who he said had been assessed as safe to smoke without supervision. LVN B said, to his understanding, if a resident was assessed as a safe smoker, the resident was allowed to keep cigarettes and lighters. In an interview on 04/16/14 at 8:12 a.m., LVN C, who was working on the 300 hall, said residents were assessed for safe smoking on admission. LVN C said the smoking assessments were supposed to be in the residents' charts (clinical records). LVN C said if she did not find a safe smoking assessment in a resident's chart, she would perform an assessment herself. LVN C said many residents got out of bed early and went outside by themselves. LVN C said she saw Resident #9 go outside at approximately 7:00 a.m. and she thought there was a staff member outside at that time to supervise smoking. LVN C said she had not seen a smoking assessment for Resident #9. LVN C did not say she had done an assessment for Resident #9 as she thought there was a staff member outside to supervise residents smoking. LVN C said she did not go outside to verify the presence of a supervising staff member for smoking. Observation on 04/16/14 at 9:16 a.m., revealed Housekeeper D was outside in the smoking area supervising residents. In an interview at that time, Housekeeper D said cigarettes and a lighter were stored in a plastic box that she was holding and were kept at the nurses' desk. Housekeeper D said the scheduled smoking times were 9:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m., but that she had seen residents go outside to smoke at other times. Housekeeper D said she had seen residents with cigarettes and lighters in the facility. Observation on 04/16/14 at 4:01 p.m., revealed the DON conducted resident room searches, after an IJ was identified, for cigarettes and lighters and found 6 cigarettes in Resident #9's room. Interviews were attempted with Resident #9. The resident was not in his room. 2. Review of Resident #2's Face Sheet, undated, revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission MDS, dated [DATE], revealed she had a BIMS score of 15 (corresponding to intact cognition). Observation during initial tour with LVN A on 04/16/14 at 7:00 a.m., revealed the designated smoking area was outside the 100 hall glass door, around the corner of the building, and in a covered area. There were no residents smoking in the designated smoking area and no staff member to distribute cigarettes and lighters or to supervise residents smoking. As LVN A and the surveyor approached the glass door to the 100 hall to enter the faciity, Resident #2 stepped outside the door and immediately took out a cigarette and lighter, lit the cigarette, and began to smoke. Observation on 04/16/14 at 7:09 a.m., revealed Resident #2 told LVN A she obtained the lighter she was using from Resident #1. Resident #2 gave the lighter to LVN A. Review of Resident #2's clinical record revealed no smoking assessment and no Care Plan to address smoking. In an interview on 04/16/14 at 7:20 a.m., the DON said Resident #2's smoking assessment might be on the computer. At 7:28 a.m., the DON said she did not locate the smoking assessment in the resident's computer records. In an interview on 04/16/14 at 7:29 a.m., LVN A said the resident's smoking assessment might be in the Social Worker's (SW) office. LVN A said the SW's office was locked but that he was on his way to the facility. In an interview on 04/16/14 at 7:55 a.m., the Administrator said she had unlocked the SW's office and found two smoking assessments. One of the assessments was for Resident #2. Review with the Administrator revealed Resident #2 had been assessed as being a safe smoker. In an interview on 04/16/14 at 8:50 a.m., Resident #2 said she kept cigarettes at all times in her jacket pocket and that she was given a lighter by Resident #1 that morning. Resident #2 took a packet of cigarettes from her jacket pocket but said that she no longer had the lighter. Resident #2 said she told staff on admission that she did not feel safe keeping a lighter. Resident #2 said she kept cigarettes all the time, that she would go out to smoke every 3 to 4 hours, and that she had been told no one had to go out with her. Observation on 04/16/14 at 4:20 p.m. revealed the DON conducted resident room searches for cigarettes and lighters and found a cigarette and a half in Resident #2's room. (The DON said the SW and GVN H had conducted room searches for cigarettes and lighters immediately after an IJ was identified). 3. Review of Resident #1's Face Sheet, undated, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS dated [DATE], revealed he was assessed as having a BIMS score of 11 (corresponding to moderate cognitive impairment). Observation inside the 100 hall on 04/16/14 at 7:04 a.m., revealed Resident #1 approached the glass door leading to the smoking area and attempted to open the door. Resident #1 did not enter the door code prior to opening the door. A door alarm sounded. Staff silenced the alarm. Observation on 04/16/14 at 7:06 a.m., revealed LVN A asked Resident #1 where he was going. Resident #1 said he was going to smoke and indicated he had cigarettes in his pants pocket. Resident #1 said he had given his lighter to Resident #2. Review of Resident #1's clinical record revealed there was no smoking assessment and no Care Plan that addressed smoking. In an interview on 04/16/14 at 7:20 a.m., the DON said Resident #1's smoking assessment might be on the computer. At 7:28 a.m., the DON said she did not locate the smoking assessment in the resident's computer records. In an interview on 04/16/14 at 7:29 a.m., LVN A said the resident's smoking assessment might be in the Social Worker's (SW) office. LVN A said the SW's office was locked but that he was on his way to the facility. In an interview on 04/16/14 at 7:55 a.m., the Administrator said she had unlocked the SW's office and found two smoking assessments for residents other than Resident #1. In an interview on 04/16/14 at 8:12 a.m., LVN C said she had not seen a smoking assessment for Resident #1. LVN C did not say she had done an assessment for Resident #1 as she thought there was a staff member present in the smoking area to supervise residents smoking . LVN C said she did not go outside to verify the presence of a supervising staff member for smoking. In an interview on 04/16/14 at 8:55 a.m., Resident #1 said he kept cigarettes in his room night stand and a lighter on his overbed table. Resident #1 said the lighter was not on the overbed table at the moment and that he obtained the lighter the night before. Resident #1's roommate came around the privacy curtain and said he had given Resident #1 the lighter. Resident #1 said he usually went out to smoke 3 times a day and that he was now supposed to have someone go out with him when he smoked. Resident #1 said a family member brought him cigarettes and lighters. Resident #1 opened the top drawer of his night stand and revealed 2 packets of cigarettes. Resident #1 opened the bottom drawer of his night stand and revealed approximately 5 cigarette butts on a thin metal tray-like object. In an interview on 04/16/14 at 9:02 a.m., Resident #1's roommate said he no longer smoked and that he gave Resident #1 a lighter the night before. Resident #1's roommate said he did not remember what the time was when he gave Resident #1 the lighter. Observation on 04/16/14 at 4:00 p.m., revealed the DON conducted resident room searches for cigarettes and lighters and found cigarette butts from Resident #1's room (the SW and GVN H conducted room searches for cigarettes and lighters immediately after an IJ was identified ). 4. Record review of Resident #12's clinical record revealed an undated Face Sheet that documented her date of admission was 03/27/14. Resident #12's [DIAGNOSES REDACTED]. There was no admission smoking assessment or Care Plan for smoking. Observation and interview on 04/16/14 at 9:20 a.m., revealed Resident #12 was sitting in the smoking area, smoking. Resident #12 said her cigarettes were in the plastic box that Housekeeper D was holding. Review of a list provided by the SW dated 04/16/14, revealed he found and collected cigarettes and lighters from 3 resident rooms that included Resident #12's room. In a telephone interview on 04/16/14 at 2:38 p.m., the Medical Director said resident safe smoking assessments should be conducted on a case by case basis. The Medical Director said the determination of a resident's ability to smoke safely should include a decision by residents' attending physicians, including psychiatric services. In an interview on 04/17/14 at 6:12 a.m., CNA M said she had seen residents going out to smoke without staff accompanying them. CNA M said when she confronted the residents about having cigarettes and lighters, the residents became angry. CNA M said she had seen residents return from the smoking area into the building with cigarettes and lighters in their possession. CNA M said she started seeing residents go outside and return to the building in possession of cigarettes and lighters early this year. CNA M said she did not know who decided residents were safe to smoke without supervision. In an interview on 04/17/14 at 6:21 a.m., LVN B said residents were allowed to keep cigarettes and lighters in their rooms after it was determined they were safe smokers. LVN B said the residents were allowed to keep the cigarettes and lighters to honor their rights. LVN B said he did not see all residents who went out to smoke. LVN B said he did not remember which staff began to allow residents to keep cigarettes and lighters in their rooms. In an interview on 04/17/14 at 6:28 a.m., the Administrator said she was ultimately responsible for enforcing the facility smoking policy. The Administrator said she never decided to allow residents to keep cigarettes and lighters in their rooms. The Administrator said cigarettes and lighters were supposed to be collected when residents were admitted to the facility. After admission, the Administrator said the charge nurses were responsible for day to day enforcement of the policy. The Administrator said she was not supervising the nursing staff to assure that they enforced the smoking policy and ensured residents were supervised when smoking. The Administrator said 9 residents were admitted on [DATE] from a group home that closed. The Administrator said 7 of the 9 residents smoked and that their cigarettes and lighters were collected upon admission. The Administrator said that, since admission, the 7 residents either had gone out on pass and returned with cigarettes or their visitors brought them cigarettes and lighters. The Administrator said the charge nurses on the 300 hall should have been monitoring the residents for cigarettes and lighters in rooms. In an interview on 04/17/14 at 10:28 a.m., the DON said all staff were responsible for enforcing the smoking policy. The DON said the SW was responsible for enforcing the smoking policy with each resident as well as the charge nurses and CNAs. The DON said she did not know who was responsible for assuring residents did not keep cigarettes and lighters in their rooms or who was to supervise staff to assure they monitored residents keeping cigarettes and lighters in rooms. The DON said the facility would have to "figure that out on the plan of correction." In an interview on 04/22/14 at 9:55 a.m., the Administrator said the facility could not define any date in which residents began to keep cigarettes and lighters in their rooms but started sometime after 03/28/14 with the admission of the residents from the group home. The Administrator said CNAs working in residents' rooms should have looked for cigarettes and lighters. The Administrator said the CNAs would not have looked inside residents' dresser or night stand drawers. The Administrator said according to the smoking policy, residents were not supposed to keep cigarettes or lighters in their rooms. In an interview on 04/22/14 at 10:20 a.m., the SW said he was working part-time at the facility, approximately one hour a day, until 04/16/14 when he began full-time employment. The SW said he was present on 03/28/14 and completed a few smoking assessments, but not for Residents #1, 9, or 12. The SW said he completed the assessments by observing residents smoking and would then assess safe habits while smoking. The SW said he collected cigarettes and lighters when he performed the assessments but that residents must have acquired more after admission. The SW said that prior to his full-time employment, GVN H was performing smoking assessments. The SW said he completed smoking assessments on all residents who smoked on 04/16/14 (after surveyor intervention as SW was not present in facility when surveyor noted lack of assessments). In an interview on 04/22/14 at 10:40 a.m., GVN H said he did not know who was supposed to perform assessments for safe smoking when the SW was not in the facility or who should have been doing the assessments when the facility was without a full-time SW. GVN H said he had not been performing the safe smoking assessments. GVN H said there had been no residents who smoked admitted from December, 2013 to 03/27/14. GVN H said residents began keeping cigarettes and lighters in their rooms sometime after 03/27/14 with the admission of the residents from the group home. GVN H said the residents on the 300 hall hid cigarettes and lighters. In an interview on 04/22/14 at 11:45 a.m., the Administrator said she performed smoking assessments on all residents who smoked in December, 2013. Review of the facility Smoking Policy, undated, revealed: -The Policy was: "It is the policy of this facility to establish and maintain resident smoking policies." -The Procedure included: -"A smoking assessment will be conducted by the Social Worker for all residents who request to smoke. This assessment is to determine the safety status of the resident in his/her ability to smoke safely." -The time frame for the smoking assessment to be completed included: ---"Upon admission if resident requests to smoke." ---"Residents are NOT allowed to keep any smoking materials on themselves or in their rooms, this includes matches and/or lighters." Review of the Job Description for Administrator, undated, revealed the position summary was: -"Under the direct supervision of the Regional Vice President, the Administrator leads and directs the overall operation of the faiclity in accordance with resident needs, government regulations and company policies so as to maintain excellent care for the residents while achieving the facility's business objectives" Essential position functions included: -"Conducts regular rounds to monitor operations of all departments, cleanliness and appearance of facility, morale of staff and to ensure resident needs are being addressed" Review of the Job Description for Director of Nursing, undated, revealed the essential position functions included: -"Conduct regular rounds and monitor resident activity, assess residents' physical and psychosocial status, and monitor care activities and documentation to ensure the delivery of nursing care according to physicians orders, care plans, and established standards and facility policies" The Administrator was notified on 04/16/14 at 10:03 a.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 04/16/14 and accepted by the Program Manager on 04/16/14 at 2:26 p.m. The facility took the following actions to remove the IJ: -All smokers were immediately assessed for safe smoking and the facility conducted a Care Plan review -The SW conducted an audit of all smokers' rooms for cigarettes and lighters and collected any found. All smoking materials were stored and kept locked in the medication room. -The facility was to begin daily audits of smokers' rooms for smoking materials until full compliance was achieved. Residents who did not agree to comply with the smoking policy were to be given a 30 day notice of discharge. -Residents who smoked were to receive counseling regarding the smoking policy that included instructions to either place unused smoking materials in a storage box for safekeeping or to leave used materials in the proper receptacles in the smoking area. Residents were to sign a copy of the smoking policy to ensure acknowledgement and understanding. -Residents' family members and responsible parties were to be contacted and counseled to bring any smoking materials to the nurses' desk for resident safekeeping. -The code for the door leading to the smoking area was to be changed so that residents wishing to smoke would have to request exit from a staff member. -All staff were to receive in-services regarding the smoking policy. -"No Smoking" signs were placed on walls outside the 100 hall door. -The Medical Director and State Ombudsman were notified of smoking policy procedures. The Ombudsman was invited to meet with all residents who smoked to reinforce the smoking policy for all residents' safety. Interviews with nurses and CNAs on 04/16/14 from 3:00 p.m. to 3:43 p.m. and 04/17/14 from 6:00 to 6:12 a.m. revealed nurses and CNAs had received training on the facility smoking policy and enforcement of the policy. They all listed the designated smoking times as 9AM, 1PM, 4PM, and 7PM. They all said residents were not to keep smoking materials in room, and following passes or having visitors, all smoking items were to be stored in the medication room. Interviews with residents who smoked on 04/17/14 from 8:57 a.m. to 10:55 a.m., revealed they received counseling on the smoking policy. Review of Resident Safe Smoking Assessments revealed all residents who smoked had been assessed/re-assessed on 04/16/14 and signed copies of the Smoking Policy. On 04/16/14 at 2:32 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of potential harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the Plan of Removal were completed. According to a census list dated 04/15/14 and information provided by the facility on 04/17/14, there were 24 residents living on the 300 hall, including 6 former group home residents who smoked.

Based on observation, interview, and record review, the Administrator and Director of Nursing failed to ensure the facility was administered in a manner which enabled it to use its resources effectively to attain or maintain the highest practicalbe well-being for 4 of 6 residents (#1, 2, 9 and 12) on 1 of 4 halls (300) whose care was reviewed for safe smoking in that: The Administrator did not supervise staff to assure the facility smoking policy was followed. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 04/16/14. While the IJ was removed on 04/16/14, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to facility not yet completing in-service training for all staff on enforcement of the smoking policy and counseling all residents who smoked and their families regarding rules for smoking at the facility. These failures could result in fire hazard with injury and could affect 24 residents living in the 300 hall of the facility. Findings: 1. Review of Resident #9's Face Sheet, undated, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour with LVN A on 04/16/14 at 7:00 a.m., revealed Resident #9 standing immediately outside the glass door at the end of the 100 hall, smoking, unsupervised, in an non-designated smoking area. LVN A escorted the surveyor outside the 100 hall glass door, around the corner of the building to a covered area that she identified as the smoking area. There were no other residents in the designated smoking area and no staff member at the smoking area to distribute cigarettes and lighters or to supervise residents smoking. In an interview on 04/16/145 at 7:06 a.m., LVN A said RA E was going to go outside and supervise residents smoking. Review of Resident #9's clinical record revealed there was no smoking assessment and there was no Care Plan to address smoking. In an interview on 04/16/14 at 7:43 a.m., LVN B, who was working on the 100 hall, said to determine if a resident was a safe smoker, he would review the resident's clinical record for a smoking assessment. When LVN B reviewed Resident #9's clinical record, he acknowledged there was no smoking assessment filed in the record. LVN B said he would ask the DON if he did not find a smoking assessment for a resident. LVN B said he had not seen Resident #9 go outside to smoke and that the resident might have gone out the door at the same time as another resident who he said had been assessed as safe to smoke without supervision. LVN B said, to his understanding, if a resident was assessed as a safe smoker, the resident was allowed to keep cigarettes and lighters. In an interview on 04/16/14 at 8:12 a.m., LVN C, who was working on the 300 hall, said residents were assessed for safe smoking on admission. LVN C said the smoking assessments were supposed to be in the residents' charts (clinical records). LVN C said if she did not find a safe smoking assessment in a resident's chart, she would perform an assessment herself. LVN C said many residents got out of bed early and went outside by themselves. LVN C said she saw Resident #9 go outside at approximately 7:00 a.m. and she thought there was a staff member outside at that time to supervise smoking. LVN C said she had not seen a smoking assessment for Resident #9. LVN C did not say she had done an assessment for Resident #9 as she thought there was a staff member outside to supervise residents smoking. LVN C said she did not go outside to verify the presence of a supervising staff member for smoking. Observation on 04/16/14 at 4:01 p.m., revealed the DON conducted resident room searches, after an IJ was identified, for cigarettes and lighters and found 6 cigarettes in Resident #9's room. Interviews were attempted with Resident #9. The resident was not in his room. 2. Review of Resident #2's Face Sheet, undated, revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission MDS, dated [DATE], revealed she had a BIMS score of 15 (corresponding to intact cognition). Observation during initial tour with LVN A on 04/16/14 at 7:00 a.m., revealed the designated smoking area was outside the 100 hall glass door, around the corner of the building, and in a covered area. There were no residents smoking in the designated smoking area and no staff member to distribute cigarettes and lighters or to supervise residents smoking. As LVN A and the surveyor approached the glass door to the 100 hall to enter the faciity, Resident #2 stepped outside the door and immediately took out a cigarette and lighter, lit the cigarette, and began to smoke. Observation on 04/16/14 at 7:09 a.m., revealed Resident #2 told LVN A she obtained the lighter she was using from Resident #1. Resident #2 gave the lighter to LVN A. Review of Resident #2's clinical record revealed no smoking assessment and no Care Plan to address smoking. In an interview on 04/16/14 at 7:55 a.m., the Administrator said she had unlocked the SW's office and found two smoking assessments. One of the assessments was for Resident #2. Review with the Administrator revealed Resident #2 had been assessed as being a safe smoker. In an interview on 04/16/14 at 8:50 a.m., Resident #2 said she kept cigarettes at all times in her jacket pocket and that she was given a lighter by Resident #1 that morning. Resident #2 took a packet of cigarettes from her jacket pocket but said that she no longer had the lighter. Resident #2 said she told staff on admission that she did not feel safe keeping a lighter. Resident #2 said she kept cigarettes all the time, that she would go out to smoke every 3 to 4 hours, and that she had been told no one had to go out with her. Observation on 04/16/14 at 4:20 p.m. revealed the DON conducted resident room searches for cigarettes and lighters and found a cigarette and a half in Resident #2's room. (The DON said the SW and GVN H had conducted room searches for cigarettes and lighters immediately after an IJ was identified). 3. Review of Resident #1's Face Sheet, undated, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS dated [DATE], revealed he was assessed as having a BIMS score of 11 (corresponding to moderate cognitive impairment). Observation inside the 100 hall on 04/16/14 at 7:04 a.m., revealed Resident #1 approached the glass door leading to the smoking area and attempted to open the door. Resident #1 did not enter the door code prior to opening the door. A door alarm sounded. Staff silenced the alarm. Observation on 04/16/14 at 7:06 a.m., revealed LVN A asked Resident #1 where he was going. Resident #1 said he was going to smoke and indicated he had cigarettes in his pants pocket. Resident #1 said he had given his lighter to Resident #2. Review of Resident #1's clinical record revealed there was no smoking assessment and no Care Plan that addressed smoking. In an interview on 04/16/14 at 7:55 a.m., the Administrator said she had unlocked the SW's office and found two smoking assessments for residents other than Resident #1. In an interview on 04/16/14 at 8:12 a.m., LVN C said she had not seen a smoking assessment for Resident #1. LVN C did not say she had done an assessment for Resident #1 as she thought there was a staff member present in the smoking area to supervise residents smoking . LVN C said she did not go outside to verify the presence of a supervising staff member for smoking. In an interview on 04/16/14 at 8:55 a.m., Resident #1 said he kept cigarettes in his room night stand and a lighter on his overbed table. Resident #1 said the lighter was not on the overbed table at the moment and that he obtained the lighter the night before. Resident #1's roommate came around the privacy curtain and said he had given Resident #1 the lighter. Resident #1 said he usually went out to smoke 3 times a day and that he was now supposed to have someone go out with him when he smoked. Resident #1 said a family member brought him cigarettes and lighters. Resident #1 opened the top drawer of his night stand and revealed 2 packets of cigarettes. Resident #1 opened the bottom drawer of his night stand and revealed approximately 5 cigarette butts on a thin metal tray-like object. Observation on 04/16/14 at 4:00 p.m., revealed the DON conducted resident room searches for cigarettes and lighters and found cigarette butts from Resident #1's room (the SW and GVN H conducted room searches for cigarettes and lighters immediately after an IJ was identified ). 4. Record review of Resident #12's clinical record revealed an undated Face Sheet that documented her date of admission was 03/27/14. Resident #12's [DIAGNOSES REDACTED]. There was no admission smoking assessment or Care Plan for smoking. Observation and interview on 04/16/14 at 9:20 a.m., revealed Resident #12 was sitting in the smoking area, smoking. Resident #12 said her cigarettes were in the plastic box that Housekeeper D was holding. Review of a list provided by the SW dated 04/16/14, revealed he found and collected cigarettes and lighters from 3 resident rooms that included Resident #12's room. In a telephone interview on 04/16/14 at 2:38 p.m., the Medical Director said resident safe smoking assessments should be conducted on a case by case basis. The Medical Director said the determination of a resident's ability to smoke safely should include a decision by residents' attending physicians, including psychiatric services. In an interview on 04/17/14 at 6:12 a.m., CNA M said she had seen residents going out to smoke without staff accompanying them. CNA M said she had seen residents return from the smoking area into the building with cigarettes and lighters in their possession. CNA M said she started seeing residents go outside and return to the building in possession of cigarettes and lighters early this year. CNA M said she did not know who decided residents were safe to smoke without supervision. In an interview on 04/17/14 at 6:21 a.m., LVN B said residents were allowed to keep cigarettes and lighters in their rooms after it was determined they were safe smokers. LVN B said the residents were allowed to keep the cigarettes and lighters to honor their rights. LVN B said he did not see all residents who went out to smoke. LVN B said he did not remember which staff began to allow residents to keep cigarettes and lighters in their rooms. In an interview on 04/17/14 at 6:28 a.m., the Administrator said she was ultimately responsible for enforcing the facility smoking policy. The Administrator said she never decided to allow residents to keep cigarettes and lighters in their rooms. The Administrator said cigarettes and lighters were supposed to be collected when residents were admitted to the facility. After admission, the Administrator said the charge nurses were responsible for day to day enforcement of the policy. The Administrator said she was not supervising the nursing staff to assure that they enforced the smoking policy and ensured residents were supervised when smoking. The Administrator said 9 residents were admitted on [DATE] from a group home that closed. The Administrator said 7 of the 9 residents smoked and that their cigarettes and lighters were collected upon admission. The Administrator said that, since admission, the 7 residents either had gone out on pass and returned with cigarettes or their visitors brought them cigarettes and lighters. The Administrator said the charge nurses on the 300 hall should have been monitoring the residents for cigarettes and lighters in rooms. In an interview on 04/17/14 at 10:28 a.m., the DON said all staff were responsible for enforcing the smoking policy. The DON said the SW was responsible for enforcing the smoking policy with each resident as well as the charge nurses and CNAs. The DON said she did not know who was responsible for assuring residents did not keep cigarettes and lighters in their rooms or who was to supervise staff to assure they monitored residents keeping cigarettes and lighters in rooms. The DON said the facility would have to "figure that out on the plan of correction." In an interview on 04/22/14 at 9:55 a.m., the Administrator said the facility could not define any date in which residents began to keep cigarettes and lighters in their rooms but started sometime after 03/28/14 with the admission of the residents from the group home. The Administrator said CNAs working in residents' rooms should have looked for cigarettes and lighters. The Administrator said the CNAs would not have looked inside residents' dresser or night stand drawers. The Administrator said according to the smoking policy, residents were not supposed to keep cigarettes or lighters in their rooms. In an interview on 04/22/14 at 10:20 a.m., the SW said he was working part-time at the facility, approximately one hour a day, until 04/16/14 when he began full-time employment. The SW said he was present on 03/28/14 and completed a few smoking assessments, but not for Residents #1, 9, or 12. The SW said he completed the assessments by observing residents smoking and would then assess safe habits while smoking. The SW said he collected cigarettes and lighters when he performed the assessments but that residents must have acquired more after admission. The SW said that prior to his full-time employment, GVN H was performing smoking assessments. The SW said he completed smoking assessments on all residents who smoked on 04/16/14 (after surveyor intervention as SW was not present in facility when surveyor noted lack of assessments). In an interview on 04/22/14 at 10:40 a.m., GVN H said he did not know who was supposed to perform assessments for safe smoking when the SW was not in the facility or who should have been doing the assessments when the facility was without a full-time SW. GVN H said he had not been performing the safe smoking assessments. GVN H said there had been no residents who smoked admitted from December, 2013 to 03/27/14. GVN H said residents began keeping cigarettes and lighters in their rooms sometime after 03/27/14 with the admission of the residents from the group home. GVN H said the residents on the 300 hall hid cigarettes and lighters. In an interview on 04/22/14 at 11:45 a.m., the Administrator said she performed smoking assessments on all residents who smoked in December, 2013. Review of the facility Smoking Policy, undated, revealed: -The Policy was: "It is the policy of this facility to establish and maintain resident smoking policies." -The Procedure included: -"A smoking assessment will be conducted by the Social Worker for all residents who request to smoke. This assessment is to determine the safety status of the resident in his/her ability to smoke safely." -The time frame for the smoking assessment to be completed included: ---"Upon admission if resident requests to smoke." ---"Residents are NOT allowed to keep any smoking materials on themselves or in their rooms, this includes matches and/or lighters." Review of the Job Description for Administrator, undated, revealed the position summary was: -"Under the direct supervision of the Regional Vice President, the Administrator leads and directs the overall operation of the faiclity in accordance with resident needs, government regulations and company policies so as to maintain excellent care for the residents while achieving the facility's business objectives" Essential position functions included: -"Conducts regular rounds to monitor operations of all departments, cleanliness and appearance of facility, morale of staff and to ensure resident needs are being addressed" The Administrator was notified on 04/16/14 at 10:03 a.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 04/16/14 and accepted by the Program Manager on 04/16/14 at 2:26 p.m. The facility took the following actions to remove the IJ: -All smokers were immediately assessed for safe smoking and the facility conducted a Care Plan review -The SW conducted an audit of all smokers' rooms for cigarettes and lighters and collected any found. All smoking materials were stored and kept locked in the medication room. -The facility was to begin daily audits of smokers' rooms for smoking materials until full compliance was achieved. Residents who did not agree to comply with the smoking policy were to be given a 30 day notice of discharge. -Residents who smoked were to receive counseling regarding the smoking policy that included instructions to either place unused smoking materials in a storage box for safekeeping or to leave used materials in the proper receptacles in the smoking area. Residents were to sign a copy of the smoking policy to ensure acknowledgement and understanding. -Residents' family members and responsible parties were to be contacted and counseled to bring any smoking materials to the nurses' desk for resident safekeeping. -The code for the door leading to the smoking area was to be changed so that residents wishing to smoke would have to request exit from a staff member. -All staff were to receive in-services regarding the smoking policy. -"No Smoking" signs were placed on walls outside the 100 hall door. -The Medical Director and State Ombudsman were notified of smoking policy procedures. The Ombudsman was invited to meet with all residents who smoked to reinforce the smoking policy for all residents' safety. Interviews with nurses and CNAs on 04/16/14 from 3:00 p.m. to 3:43 p.m. and 04/17/14 from 6:00 to 6:12 a.m. revealed nurses and CNAs had received training on the facility smoking policy and enforcement of the policy. They all listed the designated smoking times as 9AM, 1PM, 4PM, and 7PM. They all said residents were not to keep smoking materials in room, and following passes or having visitors, all smoking items were to be stored in the medication room. Interviews with residents who smoked on 04/17/14 from 8:57 a.m. to 10:55 a.m., revealed they received counseling on the smoking policy. Review of Resident Safe Smoking Assessments revealed all residents who smoked had been assessed/re-assessed on 04/16/14 and signed copies of the Smoking Policy. On 04/16/14 at 2:32 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of potential harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the Plan of Removal were completed. According to a census list dated 04/15/14 and information provided by the facility on 04/17/14, there were 24 residents living on the 300 hall, including 6 former group home residents who smoked.