Every finding on record at The Suites Pasadena

Based on interviews and record reviews the facility failed to ensure residents were free of any significant medication error for 1 of 3 residents (Resident #1) reviewed for medication errors. The facility failed to ensure Resident #1 did not receive insulin without a physician order.The facility failed to ensure the RN adherence to the five rights of medication administration, including resident rights when administering medications to Resident #1. These failures could place residents at risk decline in health, adverse reactions, and hospitalization.Record review of Resident #1's face sheet revealed he is a [AGE] year-old male admitted [DATE], with an original admission date of 11/26/25. The patient has Parkinson's disease (a movement disorder affecting balance and stiffness), dysphagia (trouble swallowing), muscle weakness, and difficulty walking. Medical history also includes metabolic encephalopathy (temporary brain dysfunction causing confusion), emphysema and COPD (chronic lung diseases causing breathing difficulty), and gastroesophageal reflux disease (stomach acid reflux). The patient is PEG tube dependent for nutrition and medications (receives feedings through an abdominal tube). Additional conditions include hyperlipidemia (high blood fats) and a contracted right wrist (permanent tightening that limits movement). Advance directive is documented as Do Not Resuscitate. Record review of Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was unable to complete 10-point ROS (Reactive Oxygen Species) due to cognitive deficit. The resident was nonverbal; requires assistance with ADLs. Nutrition via PEG documented. No care area trigger for diabetes; no insulin dependence indicated in MDS data elements for this assessment period. Record review of Resident #1's Care Plan dated 03/01/2026 revealed a focus on Resident #1's Hospice Care due to a diagnosis of Parkinson's disease. The review showed that, because of his Parkinson's, he experienced muscle rigidity. It noted that after he took his medications, if he did not want to participate in therapy or communicate with staff, he would place himself in a freeze like state. The interventions were to administer medications as ordered. The record also showed that Resident #1 received anti anxiety medications related to an anxiety disorder, with interventions that included educating the resident about the risks, benefits, and potential side effects or toxic symptoms of the anti anxiety medications being administered. Record review of Resident #1's H&P contained no active insulin orders per physician order sheet dated 03/26. In the Record review eMAR for 03/08/2026, there are noted irregularities. a blood glucose reading of 132 mg/dL. Record review of a late entry was added for a medication administered by mouth. The exception notes indicate that staff corrected the entry and notified the Director of Nursing (DON) Record review of Resident #1's Physician Orders revealed the following active orders dated 03/11/26: Bisac Evac Suppository 10 mg - For constipation. 1 suppository rectally daily as needed.MiraLax 17 g - For constipation. 1 scoop via G tube daily mixed with 8 oz water.Hyoscyamine 0.125 mg - Reduces excess secretions. 1 tablet via G tube every 4 hrs as needed.Carbidopa Levodopa 25 100 mg - Treats Parkinson's symptoms. 2 tablets via G tube four times daily.Ibuprofen Suspension - For pain/inflammation. 30 mL via G tube every 8 hrs as needed.Ondansetron 4 mg - For nausea/vomiting. 1 tablet every 8 hrs as needed.Senna Tabs - Laxative for constipation. 2 tablets via PIC tube every 12 hrs as needed.Acetaminophen 650 mg - For pain/fever. 2 tablets via G tube every 4 hrs.ZyrTEC 10 mg (Cetirizine) - For allergies. 1 tablet via G tube once daily.Debrox Ear Drops - Softens and removes earwax. 10 drops in both ears at bedtime for wax for 1min.Esomeprazole 40 mg (Delayed Release) - For GERD/acid reflux. 1 capsule via G tube daily; do not crush.Entacapone 200 mg - Supports Parkinson's medication. 2 tablets via G tube four times daily.Ipratropium Albuterol Nebulizer - Eases breathing for COPD/emphysema/SOB.Inhale 1 vial every 6 hrs as needed. Record review of a The Complaint/Grievance Report was completed by the DON and revealed that a nurse had administered the wrong medication to Resident #1. The physician was notified, the resident was monitored closely for signs and symptoms, and no adverse reactions were noted. The family was informed on 03/09/2026. During an observation on 03/11/2026 at 11:45 a.m., the Blood level chart showed a blood glucose value of 132 mg/dL at the time of the event. No subsequent hypoglycemia or hyperglycemia symptoms were documented during the shift. Resident #1 remained clinically stable, and no ER transfer occurred in connection with the insulin allegation. In an interview on 03/11/2026 at 10:22 a.m., the Administrator stated that she had been made aware of the incident on 03/10/2026 by the resident's family. She explained that the family had observed, through video camera surveillance, that Resident #1 had received insulin, even though he should not have been given that medication. She stated that the DON had spoken with regional leadership regarding steps and protocol to ensure compliance with guidelines. She added that the physician's orders were to monitor the resident for any adverse effects. During an interview on 03/11/2026 at 1:25 p.m., RN (A) stated that he had been employed at the community for three days. He reported that his mistake was not matching the resident's face with the correct client. He explained that his roommate was the individual who had required insulin, not Resident #1. He stated that approximately 0.5 units of insulin had been administered to Resident #1 at around 10:00 a.m., which was near the scheduled medication time.He indicated that once he realized the error, he immediately contacted the physician. The physician asked whether the resident's blood glucose had been checked and instructed that if the level fell below 70 mg/dL, the resident should be given orange juice. The physician then ordered blood glucose checks every 15 minutes, then every 30 minutes, then hourly, and if stable every 2 hours until the end of the shift. RN #1 stated that he informed the incoming staff of the monitoring plan and the medication error.He reported that there were no changes in Resident #1's condition during the shift and no adverse reactions. He notified the DON, who removed him from the floor and assumed his duties for the remainder of the shift. He added that hypoglycemia could occur when a person receives insulin without being diabetic. RN #1 stated that he immediately completed staff re education, one on one competency validation, dual verification for insulin, and leadership rounding. During an interview on 03/11/2026 at 3:42 p.m., the Physician Assistant stated that she did not have any concerns regarding Resident #1's health needs. She reported that the physician's orders had been in place for ongoing monitoring and confirmed that Resident #1's finger stick results had remained normal. She stated that 0.5 units of insulin would not have been a concerning amount for the resident. She further stated that she felt the facility had responded appropriately to the resident's care needs. During an interview with the Director of Nursing (DON) on 03/12/2026 at 2:02 p.m., she stated that resident #1 was always given his medications through his tube. She explained that RN (A) had mistakenly administered insulin approximately 0.5 units and had been immediately removed from the floor and re educated on insulin administration and rights to medication administration. The DON stated that RN (A) acknowledged he had failed to verify resident's #1 identity. She reported that, she contacted the physician and notified the family. The DON stated that the physician's orders were to continue monitoring for adverse reactions, including hypoglycemia and hyperglycemia (Hypoglycemia refers to blood sugar dropping too low, while hyperglycemia refers to blood sugar rising too high), every 15 minutes, then every 30 minutes, then hourly, and then every two hours until the end of the shift. The DON stated that Resident #1 ate lunch and dinner and that his blood sugar levels remained stable throughout. She further stated that death, hypoglycemia, or other adverse reactions could have been potential consequences of Resident #1 receiving the insulin. Record review of the facility's policy and procedure on the Residents Rights stated that Residents have the right to receive the services and/or items included in the Plan of Care. Record review of the facility's policy and procedure on Administering Medications ((2025 Revision) read in part: .Review MAR to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 33 of 33 residents reviewed for accidents, hazard and supervision. The facility failed to ensure adequate supervision of residents to prevent them from entering the construction area that had exposed wooden framing and loose life hanging electrical wiring. This failure places residents, staff and visitors at risk of accidents, electrical shock and fire hazards. Finding included Observation on 01\12\26 at 6:00 AM, revealed part of the facility, hall 100 and the end of 300 had a sign on the door that read do not enter During an interview on 01\12\26 at 7:00AM, the DON said part of the facility was under construction and all residents are on 600, 500 and 400 halls. She said the construction was on 100 and 200. During an interview with interim Administrator on 01\12\26 at 8:00 am, he said he was from another facility, and it was his understanding that construction was approved and the 100 and 200 halls was for a different company Observation on 1\13\2026 at 11:58AM, revealed the door that separated the 100 halls from the general area by the front desk was unlocked. The door by the dining room that separated the 300 halls from the 200 halls was unlocked. The dining room was on one side of the 300 halls next to the 200 halls under construction. The vending machine was next to the 200 hall which made it possible for anyone to go through the construction area that had exposed wooden framing, hanging electrical wiring, nails and wires. Observation of residents in dining area on 1\13\26 at 12:42pm, revealed there were approximately 20 residents eating lunch in the dining room near the construction area. Observation of Resident #34 on 01\13\26 at 1:15PM, revealed he walked into the dining area unsupervised to get a snack. Observation on 01\13\26 at 12:40PM revealed the door between the dining room and the enclosed patio was open. Observation revealed there were 6 beds with electrical cords hanging down on the bed. Two beds had mattress on them and 4 had nothing covering the bed springs. During an interview with the Interim Administrator on 1\13\2026 at 3:00pm, he stated that the only thing that kept the residents from the construction area was the do not enter sign. He admitted that he did not have any plans in place to prevent the residents from entering the restricted area. He said the residents could have been injured by the exposure to the construction. He stated that he had been here since yesterday 01\12\26 to help while they searched for an Administrator. He stated that he was not sure if staff had completed any in-services concerning the hazard of the construction area. In an interview with Resource Manager on 01\13\26 at 3:30PM, she said she started with the corporation in October 2025 to help the new DON. She stated they will implement every 15-minute rounds now that she is aware that the restricted area was an issue. She said she in-serviced the Maintenance Director today after our first meeting with them on the dangers of the unrestricted construction area and would try to keep residents away from the area. In an interview with MA J on 01\13\26 at 4:00pm, she stated she had been employed for two months and that they keep a close eye on the residents, so they do not go into the construction area. She stated that she was not sure what she would do if there was a fire. She denied any in-services concerning fire safety or evacuation changes. In an interview with the DON on 01\13\26 at 5:00PM, she said she had been employed for one month. She stated she did not have any residents that were an elopement risk and with their low census of 34, staff are able to keep a close eye on the residents. She said it was basically wooden framing, but she was not aware of live electrical wiring hanging from the ceiling and on the ground IJPOR Observation and interview on 01\13\26 at 7:30PM, revealed CNA A sitting by the door between the dining room and 200 halls. During an interview, she said she was at the door to prevent Residents from wandering into the construction area. She said she would call for relief if she had to take a break or step out. Observation and interview on 01\13\26 at 8:30PM, revealed CNA B sitting by the door between 100 halls and the therapy room. During an interview, she said she was at the door to prevent Residents from wandering into the construction area. She said she would call for relief if she had to take a break. Observation and interview on 01\14\26 at 8:15AM, revealed CNA B sitting by the door between 100 halls and the therapy room. During an interview, she said she was at the door to prevent Residents from wandering into the construction area. She said she worked the night shift. She said she had an in-service last night, on monitoring the fire exits and fire doors during construction. She said they were told to always be by the doors and to call for relief during lunch and document any resident observed wandering around. Observation and interview on 01\14\26 at 9:30AM, revealed Staff C sitting by the door between 100 halls and the therapy room. During an interview, she said she was at the door to ensure that no one goes through the door to the construction area. She said anyone that desired to go to the 100 hall, and 200 halls had to be one of the construction workers, or the Maintenance Director. She said every other person had to get clearance. Observation revealed the only thing that prevented residents, staff and visitors from going to the construction site was a double door and the staff by the door. The doors were unlocked. Observation on 01\14\26 at 1:15 PM, revealed the patio door to the courtyard was open. Observation revealed there were 6 empty beds outside at the corner of the patio. The beds had bed electrical cord hanging from the beds. Rounds and observation of the patio area on 01/14/26 at 1:20PM revealed 5 doors on the construction side, hall 100 and 200 halls had unlocked and unsupervised doors that opened to the patio which indicated that anyone has access from the dining room, and therapy room to the construction site. During a walk round and interview with facility's interim Administrator on 01\14\26 at 2:40PM, he observed that the doors on 100 and 200 halls to the patio were unlocked. All residents, staff and visitors had access from the patio to the construction site 100 and 200 halls. He said no one had noticed that the doors were open to the patio. He said all doors from the construction site would be locked from inside and the construction site would not be accessible to anyone from outside.He said he would inform the Maintenance Director to lock all doors from inside to secure the doors and would ensure that all equipment on the patio was removed During an interview with interim Administrator on 01\14\26 at 3:00 PM, he said all beds and any equipment outside the patio area had been removed and all doors are secured from the inside, and no one can get into the construction site but would have the door monitor until the facility comes up with a solution. In an interview with Interim Administrator and Resource Manager on 01\14\26 at 4: 00pm, the Interim Administrator said, the recommendation was to get a heavy-duty plastic covering on the door by 01\15\26 until the facility found a permanent solution. He said meanwhile the facility would continue to have the doors monitored. The Resource Manager said she would complete all in-service by the end of the day 1\15\26. Observation and interview on 01\15\26 at 8:15 am revealed Staff G sitting by the door on 100 and halls. In an interview she said she was doing a fire watch to prevent residents, staff and visitors from going through the door because the doors are open to the construction site. She said she had an in-service on fire watch and ensured that all residents were monitored. She said she would call for assistance if she needed to leave her post. She said she came in this morning at 6:00 am to relieve the staff that worked the night shift, Staff G. Observation and interview on 01\15\26 at 8:20 am revealed Staff A sitting by the door on 200 halls and the dining room. In an interview she said she was doing a fire watch to prevent residents, staff and visitors from going through the door because the doors are open to the construction site. She said she would be there until she gets relief. In an interview with Maintenance Director on 1\15\26 at 1:50PM, he said someone had gone to a local hardware store to purchase some heavy-duty plastic covering to cover the doors on both hallways to ensure that Residents, staff and visitors had no access to the construction site. He said staff will continue monitoring the doors until all exits and entrance to the construction site are permanently sealed. Observation on 01\15\26 at 2:00pm, revealed Staff G sitting by the door on hall 100. Observation on 1\15\26 at 2:15pm revealed staff H sitting by 200 between the dining room [ROOM NUMBER] hall. Observation on 01\15\26 at 2:30pm, revealed construction staff were observed attaching a heavy-duty plastic covering on the doors on 100 halls. In an interview, the Maintenance Director said the heavy-duty plastic was a temporary fix and all doors should be completed by 5:00 pm and a permanent wall would be in place on 01\16\26. Observation on 01\15\26 at 4:30pm revealed construction workers placing a heavy duty -plastic covering on the door between the 200 halls and the dining room area. Observation and interview on 01\16\26 at 8:20am, revealed the 2 doors were covered with heavy-duty plastic covering and two staff were observed one on each door. Construction workers were observed removing the double doors behind the heavy-duty plastic covering that connects the 100 halls and the therapy department. In an interview with Construction worker A he said they are from a private company. He said the doors would be removed and a permanent wall would be installed by lunchtime. He said after lunch, he would start on hall 200 door. In an interview with facility Resource Manager on 01\14\26 at 11:45AM, she said the facility had completed in-service on fire exit and fire doors during construction with 60% of the facility staff and was calling all those that were scheduled off. She said she could not get some but will continue trying. In an interview on 01\16\26 at 9:00am, Resource Manager said she had completed in-service training with all staff and the doors between the construction site would be permanently sealed as recommended. Record review of Resident Matrix (facility's census and conditioning) dated 1\13\2026 revealed 26 residents were checked off as having dementia/Alzheimer's Disease diagnosis. Record review of the facility assessment dated 1\12\2026 revealed there were 19 residents that ambulated independently.Record review of the emergency evacuation plan dated 4\22\2025 revealed it did not have any changes due to the construction. On 01\16\26 at 11:00AM, facility was informed that the IJ was lowered while survey team continued to monitor the progress of a permanent solution to ensure the construction site was not easily accessible to Residents, staff and visitors. Records review of facility's policy on accidents and supervision dated 05\16\25 revealedPolicy:The resident environment will remain as free of accident hazards as is possible. Each resident will receiveadequate supervision and assistive devices to prevent accidents. This includes:1. Identifying hazard(s) and risk(s).2. Evaluating and analyzing hazard(s) and risk(s).3. Implementing interventions to reduce hazard(s) and risk(s).4. Monitoring for effectiveness and modifying interventions when necessary. Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazardsto minimize the likelihood of accidents.1. Identification of Hazards and Risks- the process through which the facility becomes aware of potentialhazards in the resident environment and the risk of a resident having an avoidable accident.a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing andidentifying potential hazards in the environment, while taking into consideration the uniquecharacteristics and abilities of each resident.b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident.c. Various sources provide information about hazards and risks in the resident environment. Observation on 01\16\26 at 4:20 pm revealed a permanent wall between all area leading to the construction area were completed. IJ was lifted on 01\16\26 at 4:20PM.

Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions in accordance with professional standards for 3 of 4 medication carts reviewed for medication storage in that: Medication Carts #1, 3, and 4 contained medications that did not have an open date written on the bottles. The failure to date opened medications placed residents at risk for receiving expired, contaminated, or ineffective medications which could result in medication errors, infection, delayed treatment or adverse drug outcome.Observation on 01/13/2026 at 10:15 a.m., of the Medication Carts #1, # 3, and #4 with DON and ADON, revealed the following medications that did not have an opened date written on them. Medication Cart #1Morphine sulphate oral solution 100mg per 5ml(20mg/ml). (Morphine sulphate is an opioid narcotic medication used to treat moderate to severe pain). Medication Cart #3 Three bottles of Levetiracetam 100 mg/ml solution (Levetiracetam is a medication used to treat and prevent seizures).One bottle of magnesia solution (magnesia solution is a liquid form of magnesium, an essential mineral used for medical treatment and supplement)One bottle Lactulose 10 gm/15 ml solution (Lactulose is a medication used primarily to treat constipation and conditions related to liver disease). Medication Cart #4Triamcinolone/acetonide cream (is a cream used to treat moderate to severe skin conditions)Hydrocortisone cream maximum strength (is a cream used to reduce inflammation, skin irritation and itching)Ketoconazole cream 2% (is a medication that is used to treat certain infections caused by fungus - group of micro-organisms).Nystatin and Triamcinolone Acetonide cream USP (Nystatin and triamcinolone topical (for the skin) is a combination medicine used to treat skin infections caused by fungus or yeast)One bottle of Lactulose 10gm/15 ml Solution (Lactulose is a medication used primarily to treat constipation and conditions related to liver disease).One bottle of Chlorhexidine Gluconate oral rinse, USP 0.12% (is an antiseptic that fights bacteria).Zinc Oxide ointment (is used primarily to protect, soothe and heal the skin, also used in the prevention and treatment of skin breakdown)Latanoprost Ophthalmic solution 0.005% (is used in adults to treat certain types of glaucoma - an eye disease that causes vision loss in one or both eyes, and other causes of high pressure inside the eye).Premarin Vaginal cream (Premarin Vaginal Cream is used in the vagina to treat the vaginal symptoms of menopause such as dryness, burning, irritation, and painful sexual intercourse).Magnesium Citrate saline laxative solution (is commonly used to relieve occasional Constipation - is a common condition where you have fewer bowel movements than normal). Olopatadine Hydrochloride Ophthalmic solution USP 0.1% (Olopatadine ophthalmic (for the eye) is used to treat eye itching caused by allergies).Lantus insulin 100 units/ml (Lantus is a man-made form of a hormone (insulin- a hormone that works by lowering levels of glucose (sugar) in the blood.)Two Nystatin cream (is used to treat skin infections caused by yeast).Two Voltaren topical gel (is used to treat joint pain caused by osteoarthritis - occurs when cartilage tissue that cushions a joint wear away slowly and causes the bones to rub together in the hands, wrists, elbows, knees, ankles, or feet).Morphine sulphate oral solution 100mg per 5ml(20mg/ml). (Morphine sulphate is an opioid narcotic medication used to treat moderate to severe pain). Interview with MA J on 1/13/2026 at 10:25 a.m.; She stated that she was not the staff member who opened the medications and reported that she had been off duty. She stated that upon returning to work, she observed the medications in that condition. MA J acknowledged that all medications must be dated upon opening in accordance with facility policy and safe medication administration practices. She stated that the medications had been opened prior to her return to work. When asked about the potential risk to residents if medications are opened and not dated, she stated that without an open date, staff would not be able to determine when the medication has expired. MA J further stated that administering expired medications could cause residents to become ill. She explained that once medications expire, their strength and effectiveness may be reduced, which could result in harm to residents. Interview with DON on 1/13/2026 at 10:38 a.m.; The DON confirmed that all medications are required to be dated upon opening in accordance with CMS regulations and facility policy. She stated that all nursing staff and MA are aware of this requirement. The DON acknowledged that the facility failed to meet this regulatory requirement. She further stated that she would initiate an in-service education immediately for all staff to address the identified deficient practice and reinforce proper medication labeling and handling procedure. Review of the facility policy and procedure titled Medication Labeling and Storage revised on 5/16/2025 revealed: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medication.

Based on observation, interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident's assessment, care planning, and transition of care for 1 (Resident #20) of 4 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within recommended time frame after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in healthFindings included: Record review of Resident #20's face sheet dated 01\13\26 revealed a [AGE] year-old female, admitted to the facility on 06\03\25 and readmitted on 11\25\25. Her diagnoses included: Malignant neoplasm of endometrium neurocognitive disorder with lewy bodies (is a progressive brain disorder caused by abnormal protein clumps), generalized anxiety disorder, iron deficiency anemia, other specified disorders of bone density and structure, neuralgia and neuritis, unspecified intellectual disabilities, dementia, psychotic disturbance, mood disturbance, and anxiety, muscle weakness cognitive communication deficit, difficulty in walking, chronic respiratory failure, pressure ulcer of sacral region stage 4, and chronic kidney disease, unspecified hypertensive heart and chronic kidney disease with heart failure . Record review of Resident #20's MDS annual assessment dated 11\23\25 revealed a BIMS score of 4 indicated her cognition was severely impaired. Record review of Resident #20's care plan dated revision date 12\17\25 revealed Resident #20 was PASRR positive, for intellectual disability. Goal: Resident #20 will receive specialized services/equipment/habilitative, therapies as deemed necessary through assessment and evaluation during their stay Date Initiated: 12\17\2025. Record review of Resident #20's Individualized PASRR Care Plan dated 06\26\25 to 06\26\26 indicated Resident #20 was recommended for habilitative services, Speech therapy and occupational services. Record review of intake revealed several attempts were made by PASRR office to send NFSS form to PASRR office for processing. Record review of PASRR spread sheet revealed phone call was made to the facility on 09\15\25-no answer. E-mail was sent to the facility's Administrator on 09\24\25 no response. During an interview with interim Administrator-A and Resource Manager on 01\12\26 at 10:00AM, the Resource Manager said currently the facility does not have an Administrator. She said the interim Administrator- A was called in to assist and she would talk to the Rehab Manager. During an interview with RM and Rehab Director on 01\13\26 at 11:00AM, she said she was new to the facility and did not know how the PASRR process worked. She said she sent NFSS forms, but the forms were returned several times. She said the last one she sent was returned because the physician's signature did not match due to a change within the agency. She said Resident #20 continued to receive all recommended services. She said Resident #20's services did not stop. She provided therapy notes and documentationObservation on 01\12\26 at 9:00AM revealed Resident #20 was in her room. Attempt was made to have an interview, and she answered as many questions as she could. Her speech was unclear but attempted to answer. She was observed clean. Observation indicated she had a catheter with 200CC of clear urine in the bag. Observation indicated she had a specialized wheelchair. Record review of Facility policy dated 05\05\25 Titled Resident Assessment-Coordination with PASRR Program Revealed- Policy: This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines:1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid manual for screening.a. PASRR Level I - initial pre-screening that is completed prior to admission1. Negative Level I Screen - permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later.ii. Positive Level I Screen - necessitates a PASRR Level II evaluation prior to admission.b. PASRR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs.6. The facility designee shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority.Recommendations, such as any specialized services, from a PASRR level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review.

Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the MDS form specified by the state and approved by CMS for 1 (Resident # 23) of 6 residents reviewed for quarterly assessments. Resident #23's most recent quarterly assessment was completed on 9/29/2025. As of 1/14/2026 at 3:30 pm, the quarterly assessment that was due on 12/30/2025 was not completed. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information.Findings include:Record review of Resident #23's face sheet dated 1/13/2026 showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Type 2 Diabetes mellitus with diabetic polyneuropathy(a type of nerve damage that occurs as a complication of diabetes, primarily due to prolonged high blood sugar levels most commonly affecting the legs and feet, leading to symptoms such as pain, numbness, or tingling) , malignant neoplasm of unspecified site of left female breast (malignant breast cancer of the left breast), unspecified asthma (a disease of the airways that makes it difficult to breathe, often triggered by allergens or irritants) , paranoid schizophrenia (a part of a spectrum of related conditions that involve psychosis), other seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness), and essential hypertension (a type of high blood pressure that has no identifiable cause).Record review on 1/14/2026 at 3:30 pm revealed that Resident #23's last quarterly MDS assessment was completed on 9/29/2025. The next quarterly assessment was due on 12/30/2025 and hadn't been completed as of 1/14/2026 at 3:30 pm.Interview with the DON on 1/14/2026 at 4:45 pm revealed that all comprehensive care plans and assessments are created and updated by MDS A. The DON stated that inaccurate care plans place residents at risk by not receiving needed services or can delay needed services to residents.The DON stated she Resident #23's quarterly MDS is past due and should have been completed in December 2025. Interview with MDS B on 1/14/26 at 1:12 pm revealed the facility was in the middle of a CHOW (change of Ownership), which resulted in the discharge of all residents. The MDS B coordinator reported having many MDS assessments to complete and explained that she is the only staff member responsible for completing them. MDS B stated that she is working as quickly as possible to complete the assessments but acknowledged that she is currently behind. MDS B further stated that once the MDS assessments are completed, they are forwarded to the Registered Nurse (RN) for review and signature. She confirms that when the MDS assessment are not completed in a timely manner, it could result in care plans that are incomplete, inaccurate, or delayed, leading to unmet needs of the residents.Interview with MDS A on 1/15/2026 at 1:26 pm revealed that she began working at the end of October 2025 and is still in training for her role as MDS nurse coordinator. MDS A stated that there was not an MDS nurse coordinator at the facility at the time she was hired at the facility. MDS A stated creating a comprehensive care plan falls under her duties and is aware that some residents do not have accurate comprehensive care plans. MDS A confirmed her understanding that CMS requires comprehensive MDS assessments to be completed within 14 calendar days of admission and the comprehensive care plan is due 7 days after the comprehensive assessment is completed. She further stated that failure to complete the MDS within the required timeframe may result in loss of Medicare reimbursement for the facility. MDS A stated she is aware that Resident #23's quarterly MDS is past due and should have been completed last month in December 2025.Record review of the facility policy titled Conducting an Accurate Resident assessment dated [DATE] reads in part.the appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. This policy did not address the frequencies of MDS assessments.

Based on interview and record review, the facility failed to review and revise the person-centered comprehensive care plan for 1 (Resident #23) of 6 residents reviewed for comprehensive care plan revisions. The facility failed to update Resident #23's care plan to reflect the interventions needed to address Resident #23's medical, nursing, and psychosocial needs.This failure could put residents at risk of not receiving the appropriate care, services, or treatments they need. The findings include:Record review of Resident #23's face sheet dated 1/13/2026 showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Type 2 Diabetes mellitus with diabetic polyneuropathy(a type of nerve damage that occurs as a complication of diabetes, primarily due to prolonged high blood sugar levels most commonly affecting the legs and feet, leading to symptoms such as pain, numbness, or tingling) , malignant neoplasm of unspecified site of left female breast (malignant breast cancer of the left breast), unspecified asthma (a disease of the airways that makes it difficult to breathe, often triggered by allergens or irritants) , paranoid schizophrenia (a part of a spectrum of related conditions that involve psychosis), other seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness), and essential hypertension (a type of high blood pressure that has no identifiable cause). Record review of Resident #23's care plan with an initiation date of 12/1/2025 showed two areas of focus for the resident which were impaired neurological function related to a seizure disorder and the potential for adverse effects related to antianxiety medications. There were no other identified conditions or focus noted on the resident's current comprehensive care plan. Review of the MDS dated [DATE] revealed Resident #23's active diagnoses of Diabetes Mellitus, Schizophrenia, Malignant neoplasm of unspecified site of left female breast. Record review of the MDS dated [DATE] also revealed that Resident #23 was taking diuretic, antiplatelet, hypoglycemic medications. Interview with MDS A on 1/15/2026 at 1:26 pm revealed that she began working at the end of October 2025 and is still in training for her role as MDS nurse coordinator. MDS A stated that there was not an MDS nurse coordinator at the facility at the time she was hired at the facility. MDS A stated creating a comprehensive care plan falls under her duties and she is aware that some residents do not have accurate comprehensive care plans.Record review of the facility policy titled Comprehensive Care Plans with an implementation date of 6/1/2025 and a revision date of 6/2/2025, reflected the Comprehensive Care Plan will describe, at a minimum, the following: The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicablephysical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished, but are not provided due to the resident'sexercise of his or her right to refuse treatment.c. Any specialized services or specialized rehabilitation services the nursing facility will provideas a result of PASARR recommendations.d. The resident's goals for admission, desired outcomes, and preferences for future discharge.e. Discharge plans, as appropriate.f. Resident specific interventions that reflect the resident's needs and preferences and align withthe resident's cultural identity, as indicated. If the resident is non-English speaking, the facilitywill identify how communication will occur with the resident. The care plan will identify thelanguage spoken and tools used to communicate.g. Individualized interventions for trauma survivors that recognize the interrelation betweentrauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used toidentify ways to decrease the resident's exposure to triggers which re-traumatize the resident,as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Interview with the DON on 1/14/2026 at 4:45 pm revealed that all comprehensive care plans and assessments are created and updated by MDS A. The DON stated that inaccurate care plans place residents at risk by not receiving needed services or can delay needed services to residents.

Based on interview and record review, the facility failed to provide services that meet professional standards of quality as outlined by the comprehensive care plan for 1 (Resident #17) of 6 residents reviewed for services. The facility failed to ensure recommendations made by the registered dietician were followed as indicated in Resident #17's comprehensive care plan and the active physician orders. This failure could place residents at risk of not having their individual needs met and not receiving adequate nutritional and medical intervention to maintain their health and prevent worsening health conditions Findings include:Record review of Resident #17's face sheet dated 1/14/2026 revealed a [AGE] year-old female with an initial admission date of 5/21/2021. Resident #17's diagnoses included moderate protein-calorie nutrition (a condition that is characterized by a lack of sufficient energy or protein to meet the body's metabolic demands, often resulting from inadequate dietary intake or malabsorption). Record review of Resident #17's active physician orders revealed an active physician order dated 9/29/2025 that reads, may follow registered dietician recommendations. Record review of Resident #17's current care plan in place initiated on 12/8/2025 revealed an intervention that states Registered Dietician to evaluate and make diet change recommendations PRN and provide and serve supplements as ordered. Record review of Resident #17's progress notes revealed a progress note from the Registered Dietician dated 1/2/2026 that lists recommendations of sugar free shakes twice a day, weekly weights for 4 weeks, zinc sulfate 220 mg twice a day, vitamin C 500 mg twice a day, and a MVI (multivitamin) daily.Record review of Resident #17's active physician orders on 1/12/2026 did not reflect the recommendations given on 1/2/2026 by the Registered Dietitian. Interview on 1/13/2026 at 2:15 pm with Registered Dietician revealed that she emails her recommendations to the DON, ADON, and the Dietary Manager. The Registered Dietician confirmed she emailed her recommendations on 1/2/2026 to the DON, ADON, and Dietary Manager. Interview on 1/13/2026 at 3:32 pm with the DON, revealed that the ADON enters recommendations from the Registered Dietician into resident orders. The DON stated the Registered Dietician recommendations were not entered as orders due to a system email issue. The DON stated there was a change of ownership, and she did not realize that it caused a break in the process of receiving emails. The DON stated the risk to the resident included delayed wound healing, and unintentional weight loss or gain. The DON also stated that skin breakdown could occur which could lead to loss of life. Interview on 1/13/2026 at approximately 3:45 pm with the ADON revealed that she did not realize her email account was not receiving emails timely. The ADON stated that entering recommendations from the Registered Dietician is part of her duties. The ADON stated that the risk to residents of not receiving Registered Dietician recommendations could affect wound healing. Record review on 1/13/2026 at 5:00 pm revealed that recommendations given by the Registered Dietician on 1/2/2026 are now reflected in Resident #17's active orders. Record review of the facility policy on Medication Orders dated 6/15/2025 read in part .documentation of Medication Orders. Enter the new order on the MAR or ensure the new order is in the electronic MAR .

Based on observation, interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission for 3 (Residents #12, #14, #30) of 12 residents reviewed for comprehensive assessment accuracy and timing. The facility failed to complete Residents #12, #14 and #30's admission comprehensive MDS assessments within 14 days following admissions to the facility. This deficient practice could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #12 Record review of Resident #12's face sheet revealed an 81- year- old male, admitted to the facility on 12\18\2025. His diagnoses included congestive heart failure, Diabetes (a condition where the body has trouble controlling sugar in the blood), chronic kidney disease, anemia (a condition in which the body does not have enough healthy red blood cells to carry adequate oxygen to its tissues), hyperlipidemia (Having too much fat in the blood), encounter with attention to tracheostomy (a surgical opening made in the neck to help a person breathe when they cannot breathe normally through the nose or mouth) and generalized muscle weakness. Record review of Resident #12's clinical records indicated Resident Record review of Resident #12's clinical records indicated Resident #12 had a 20-day entry MDS assessment dated 12\18\25 that was not completed. Resident #14 Record review of Resident #14's face sheet dated 1\13\26 revealed a [AGE] year-old female admitted to the facility on 12\24\25. Her diagnoses included Acute and chronic respiratory failure with hypoxia. (condition where the body does not receive enough oxygen due to respiratory failure), chronic pain, pressure ulcer of left heel, infection of the skin and subcutaneous tissue, unspecified essential (primary) hypertension ( High blood pressure), protein-calorie malnutrition, heart disease, type 2 diabetes mellitus with diabetic neuropathy, insomnia ( Lack of sleep), depression, cerebral infarction( Also known as stroke) , dysphagia following cerebral infarction, cerebrovascular disease, dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #14's clinical records indicated Resident #14 had a 5-day entry MDS assessment dated 12\24\25. Record review indicated section A was completed. Record review of Resident #14's admission MDS dated 12\30\25 indicated the admission MDS was not complete as of 01\13\26 which was 20 days after admission. Resident #30 Record review of Resident #30's face sheet dated 1\12\26 revealed an [AGE] year-old female admitted to the facility on 04\09\24 and readmitted on 01\05\26. Her diagnoses included Ankylosing spondylitis of lumbosacral region (inflammation can cause some of the bones in the spine, called vertebrae, displaced intertrochanteric fracture of right femur, closed fracture, history of falling, senile degeneration of brain ( a range of neurological condition) , osteoarthritis, right knee right artificial knee joint, wedge compression fracture of second lumbar vertebra, major depressive disorder, dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #30's clinical records revealed the last Quarterly MDS assessment was dated 08\21\25. Record review revealed an incomplete admission MDS dated 11\26\25 that indicated in progress. During a phone interview on 01\14\26 at 12:57pm, facility MDS coordinator-A said she was new to the facility and still in training. She reported that she has not yet fully acquired the required knowledge to independently complete MDS assessments but has access to resources and support personnel who is assisting her. She acknowledged that she is behind in completing the required MDS assessments and attributed this, in part, to her newness in the role. She stated that she has been employed at the facility since late October 2025 and has completed only two to three MDS assessments so far. She further stated that when she began employment, the facility did not have an on-site MDS Coordinator, and that MDS responsibilities were being managed by a corporate nurse, who is also providing her training. The MDS Coordinator confirmed her understanding that CMS requires comprehensive MDS assessments to be completed within 14 days of admission. She further stated that failure to complete the MDS within the required timeframe may result in loss of Medicare\Medicaid reimbursement for the facility. She also acknowledged that delayed completion of the MDS can negatively impact residents by delaying the identification of needs and the development or implementation of appropriate care. During an interview with Regional MDS Coordinator B she stated that the facility was in the middle of a CHOW (change of Ownership), which resulted in the discharge of all residents. She reported so many MDS assessments to complete was difficult. She said she was the only staff member responsible for completing all the MDS assessments. She stated she is working as quickly as possible to complete the assessments but acknowledged that she is currently behind. She further stated that once the MDS assessments are completed, they are forwarded to the Registered Nurse (RN) for review and signature. She also demonstrated understanding that comprehensive assessments must be completed within a 14-day timeframe from the date of admission. She confirmed that when the MDS assessments are not completed in a timely manner, it could result in care plans that are incomplete, inaccurate, or delayed, leading to unmet needs of the residents. Record review of facility policy dated 05\05\25 titled Conducting an Accurate Resident Assessment revealed, Policy: The purpose of this policy is to ensure that all residents receive an accurate assessment, reflective of the residents' status at the time of the assessment, by staff qualified to assess relevant care areas. Provided MDS Policy did not address timing of MDS assessment. 1. The Administrator will ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. 2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. 4. A registered nurse will coordinate the RAI completion process with the appropriate participation of health professionals. The registered nurse is responsible for certifying that the assessment has been completed. 5. Information provided by the initial comprehensive assessment establishes baseline data for the ongoing assessment of resident progress. 6. The physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon individual resident status and needs. 7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. Whether the MDS assessments are manually completed, or computer generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent the development of pressure ulcers for 1 of 7 (Resident #7) residents reviewed for pressure ulcers. - The facility failed to prevent Resident #7 from acquiring DTIs to both of her heels and from the L heel progressing into an unstageable PU, when she was admitted with only redness to both heels. Resident #7 required hospitalization for the treatment of the injuries to her heels.An Immediate Jeopardy (IJ) was identified on 8/21/2025. The IJ template was provided to the facility on 8/21/2025 at 12:55pm. While the IJ was removed on 8/22/2025 at 4:00pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk for pain, infection, and hospitalization.Findings include:Record review of Resident #7's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes (body does not make insulin or resists it), retention of urine, osteoarthritis (joint disease where cartilage breaks down), neuropathy (nerve pain), and difficulty walking.Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMs score of 15 out of 15 which indicated normal cognition. She had an impairment on both sides of her upper and lower extremities. The resident was partial/moderate (helper does less than half the effort) assistance with ADLs. She had an indwelling catheter and was incontinent of bowel. The MDS revealed the resident had no pressure injuries on admission.Record review of Resident #7's admission and Baseline Care plan dated 6/30/25 revealed the resident had redness to her right and left heel on admission, with no DTIs or open wounds to her heels. Resident #7 admitted with a wound to the sacrum but there was no evidence of it worsening.Record review of Resident #7's care plan dated 6/30/25 revealed a Focus: Resident #7 admitted with DTI of the L heel (Initiated 6/30/25, Revised 7/30/25). The goal was to remain free from further breakdown through the next review. Interventions included floating the heels, heel boots, weekly skin inspection, and treatments as ordered. Focus: Resident #7 admitted with DTI of the R heel (Initiated: 6/30/25, Revised: 7/30/25). The goal was to remain free from further breakdown through the next review. Interventions included weekly skin inspections, float the heels, heel boots, and treatments as ordered.Record review of Resident #7's previous hospital's Initial admission Physical assessment dated [DATE] at 10:19pm, revealed redness to the sacrum (tailbone), but no wounds and no mention of redness or any concerns to the heels.Record review of Resident #7's previous hospital's Wound Care Consult dated 6/24/25 at 12:42pm, revealed she had .sacral blanchable [turns white] redness over intact skin.Bilateral lower extremities with edema [swelling].no open wounds. Bilateral feet had palpable [able to feel] pulses. No other alterations to skin integrity noted.Record review of Resident #7's previous hospital's Shift Physical assessment dated [DATE] at 9:00am, revealed her exception to a normal skin assessment was having swollen bilateral legs. There was no mention of any other skin issues.Record review of Resident #7's Progress Note dated 7/1/25 at 1:14pm by LVN W, revealed the resident had pressure ulcers on her sacrum and Wound Care was consulted. Nothing was noted about the heels having wounds.Record review of Resident #7's Physician Orders revealed the following orders from MD M:- Consult Wound Care. Ordered on 7/1/25.- Wound Care: Cleanse R Heel with NS, Pat dry, Apply skin prep to wound and LOA, QD. Ordered on 7/9/25 at 6:00am.- Wound Care: Cleanse L Heel with NS, Pat dry, Apply skin prep to wound and LOA, QD. Ordered on 7/10/25 at 6:00am.- Use Heel Lift to float heels at all times while in bed, every shift. Ordered 7/10/25 at 2:00pm.- May send to [hospital] for eval and tx, one time. Ordered on 8/3/25 at 8:30pm.Record review of Resident #7's Weekly Head to Toe Skin Check dated 7/7/25 at 12:34pm by LVN C, revealed L heel with no description and no mention of the R heel. Under the weekly heel check questions LVN C answered the L heel was not boggy (mushy), not discolored, did not have an open area, and did not have a blister.Record review of Resident #7's Wound Care Note dated 7/8/25 at 4:39pm from MD O, revealed the resident had a R heel deep tissue injury that was 3cm x 4cm x 0cm. She also had a L heel deep tissue injury that was 3cm x 3.5cm x 0cm.Record review of Resident #7's Weekly Head to Toe Skin Check dated 7/14/25 at 12:38pm by LVN C, revealed R heel DTI and no mention of the L heel. Under the weekly heel check questions LVN C answered the L heel was not boggy, it was discolored, did not have an open area, and did not have a blister.Record review of Resident #7's Wound Care Note dated 7/15/25 at 9:11pm from MD O, revealed the R heel DTI was 3.2cm x 3.5cm x 0cm. The L heel DTI was 4cm x 4.5cm x 0cm.Record review of Resident #7's Weekly Head to Toe Skin Check dated 7/21/25 at 12:38pm by LVN C, revealed R heel DTI and no mention of the L heel. Under the weekly heel check questions LVN C answered the L heel was not boggy, it was discolored, did not have an open area, and did not have a blister.Record review of Resident #7's Wound Care Note dated 7/24/25 at 6:45pm from MD O, revealed the R heel DTI was 3cm x 3.5cm x 0cm. The L heel DTI was 4cm x 4.5cm x 0cm.Record review of Resident #7's Weekly Head to Toe Skin Check dated 7/29/25 at 7:11am by LVN D, revealed R heel pressure and no mention of the L heel. Under the weekly heel check questions LVN D answered the L heel was not boggy, it was discolored, did not have an open area, and did not have a blister.Record review of Resident #7's Wound Care Note dated 8/1/25 at 8:59pm from MD O, revealed the R heel DTI was 3cm x 3.4cm x 0cm. The L heel DTI was 3.5cm x 4.5cm x 0cm.Record review of Resident #7's hospital Wound Care Consult, dated 8/4/25 at 10:49am from MD Q, revealed the resident had a DTI of the R heel and an unstageable L heel ulcer.In an observation and interview on 8/7/25 at 10:55am with Resident #7, she was admitted to the hospital and lying on her left side in bed. She had pressure relieving boots (foam boots for pressure) on both of her feet. She said she did not like the nursing facility she came from because they did not change her frequently but was unable to answer any other questions due to having severe pain in her bottom from her pressure ulcer.In a telephone interview on 8/7/25 at 3:25pm, Resident #7's family member said the resident's mom admitted to the nursing facility with a very small sacrum wound, but nothing on her heels. She said the resident was always calling her and telling her she had to go potty in her diaper because she could not wait anymore for someone to come help her.In a telephone interview on 8/8/25 at 3:28pm, Resident #7's other family member, said the resident would always complain about hitting the call bell and no one would come to help her so she would have to go in her diaper because she could not hold it anymore. She also said every time she went to the facility the resident was on her back in bed. She never saw Resident #7 on her side. The family member said she spoke to the Director of Rehab about the issues many times and nothing got done. She spoke to the Director of Rehab because that was the only phone number she had for Leadership Personnel.Record review of Resident #7's hospital Wound Care Consult dated 8/9/25 at 6:30pm from MD Q, revealed the resident had a DTI of the R heel and an unstageable L heel ulcer.During an attempted telephone interview on 8/12/25 at 9:13am, a message was left for LVN C.During an attempted telephone interview on 8/12/25 at 10:18am, a message was left for LVN W.In an interview on 8/12/25 at 10:50am, LVN G said the weekly head to toe assessment should still be completed by the floor nurse, even if the wound assessment was performed. She said the admitting nurse measured the wounds, consulted the Wound MD, and treated the wounds by getting orders from the doctor.In an interview on 8/12/25 at 11:41am, the ADM said a skin assessment was performed at every admission and documented under the Admission/Baseline Care Plan. She said the weekly head to toe assessments were performed on a schedule by the 3 different shifts. The ADM said the head to toe skin assessment should still be completed along with the Wound Assessment. She said the admitting nurse would identify any wounds and stage them, but not measure them, and then notify the MD to get orders. She said the Wound Care MD would measure the wounds and document the measurements.In an interview on 8/21/25 at 12:53 pm, the ADM said the facility was treating Resident #7's heels and there was no way to avoid the PUs. She said sometimes residents got facility acquired PUs and there was nothing the facility could do.In a telephone interview on 8/21/25 at 2:53pm, NP B said she performed her own skin assessment at admission, but she did not remember if the resident had heel DTIs or not, even though nothing was mentioned in her H&P. She said interventions that would prevent heel wounds would be offloading, pressure relieving boots, heel protectors, and nutritional support. She said she did not know if Resident #7's heels got better or worse because she defers all wounds to the Wound Care MD.In a telephone interview on 8/21/25 at 2:57 pm, MD O said if the staff were using heel cushions, offloading, and repositioning for Resident #7, the heels would have gotten better and not opened into ulcers. She said if the DTIs to her heels opened into an ulcer, it would have been because the pressure was not relieved to her heels. She also said if a resident came to the facility with no wounds, and precautions were put in place to prevent PUs, there would be no reason why a resident would get a pressure ulcer.Record review of the facility's policy and procedure on Pressure Injury Prevention and Management, undated, read in part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.Licensed nurses will conduct a full body skin assessment on all residents upon admission/re­admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record.Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces; Provide non-irritating surfaces; and Maintain or improve nutrition and hydration status, where feasible. The RN Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record.This was determined to be an Immediate Jeopardy (IJ) on 8/21/25 at 12:55pm. The ADM and the DON were notified on 8/21/25 at 12:55pm. The ADM was provided with the IJ template on 8/21/25 at 12:55pm.The following Plan of Removal submitted by the facility was accepted on 8/22/25 at 1:02pm.The plan of removal reflected the following:Name of Facility: [Name of facility]Date: 8/22/2025F686 - Treatment/Services to Prevent Pressure Ulcers1. Corrective Action Taken for the Resident(s) Found to Have Been AffectedResident #7 was admitted on [DATE] with redness to both heels and subsequently developed bilateral deep tissue injuries, progressing to an unstageable ulcer on the left heel The facility failed to prevent Resident #7 from acquiring DTIs to both heels and from the L heel progressing into an unstageable PU, when she was admitted with only redness to both heels.2. Corrective Action Taken for Residents Having the Potential to Be AffectedOn 8/21/25, immediately upon identification of the Immediate Jeopardy, licensed nurses conducted full head-to-toe skin assessments on all residents in the facility completed on 08/21/25. Two new residents were identified with new pressure areas, one new pressure injury to left medial foot and one new pressure injury to sacrum. Repositioning interventions are in place on each newly identified residents care plan and Kardex, both newly identified residents can reposition self. All Resident's Pressure Injury Risk Assessments were completed on 8/21/2025 by DON/Designee. All findings were documented and reviewed by the Director of Nursing, and physician orders were obtained for any new or existing areas of skin alteration. Preventive interventions, including heel elevation, use of heel boots, and use of pressure-relieving mattresses or cushions, were verified to be in place for all residents identified at risk completed on 8/21/2025 by DON/Designee. Kardex and Care plans were reviewed and updated to reflect individualized risk factors and interventions completed on 8/21/2025 by DON/Designee. In-servicing conducted by DON on 08/21/2025 with all full-time licensed staff included review of Kardex for current interventions in place for residents.3. Measures and Systemic Changes Put into PlaceOn 8/21/25, the Director of Nursing and wound nurse re-educated all fulltime/scheduled nursing staff, including registered nurses, licensed vocational nurses, and certified nursing assistants, on pressure ulcer prevention, early identification of skin changes, proper use of preventive devices, and documentation requirements. In-Servicing completed on 08/21/2025. Nursing staff will be in-serviced prior to start of their next scheduled shift, In-servicing will remain on-going for all new hires/PRN prior to the start of their assigned shift. AD HOC QAPI held with IDT Team and Medical Director, Skin assessment and wound management policies were reviewed and updated to include a comprehensive skin assessment conducted by the Wound Care Nurse on the day after admission or readmission to ensure assessments were completed accurately, completed on 08/22/2025. On 08/21/2025 daily meeting board was updated to include an admission tab ensuring all new admissions will receive a complete skin assessment upon admission, will be reviewed daily Monday thru Friday by DON/Designee and preventive interventions will be initiated and documented immediately. The Director of Nursing and Assistant Director of Nursing/Wound Care Nurse will ensure care plans are updated within 24 hours of any identified skin change or physician order. 4. Monitoring to Ensure Ongoing ComplianceBeginning 8/21/25, the Director of Nursing or Designee will perform audit of completed skin assessments of 5 residents daily for five days Monday through Friday, then two times weekly for four weeks, then weekly for two months, then random audit congoing to ensure continued compliance to confirm preventive interventions are in place, to ensure no residents are developing new pressure ulcers, and ensure that completed skin assessments were performed correctly. In addition, the Director of Nursing/Designee will perform direct observation of nursing staff to ensure heel elevation, turning/repositioning and use of pressure relief devices are consistently completed. Any noncompliance identified during audit will require immediate re-education, by DON/designee, with the Licensed Nurse who completed the skin assessment. Audit results are reported to the QAPI committee monthly, and corrective actions are initiated immediately if deficiencies are identified. Any staff found to be non-compliant with pressure ulcer prevention protocols will receive immediate re-education and disciplinary action if necessary. Compliance will be further validated by corporate clinical support during monthly monitoring visits. Starting 08/22/2025 and continuing forward, per updated Skin Assessment policy, the Wound Care Nurse will perform daily audits Monday-Friday of new admissions and re-admissions to ensure skin assessments were completed and correct. Any variance found will result in immediate re-education of Nursing Staff. Starting 08/22/2025, Certified Nursing Assistants will complete shower sheets on scheduled shower days which will be verified by Licensed Nurses and then turned into Wound Care Nurse for review and follow up as needed. The DON/Designee will review these logs daily during daily clinical meetings Monday through Friday to ensure timely follow up and accuracy. Completion Date - 08/22/2025From 8/22/25-8/23/25 a monitoring visit was conducted to ensure the facility was following its POR. The visits revealed:Record review revealed the skin assessments performed on 8/21/25 by the DON, found 2 residents with new pressure ulcers. Resident #8 was found to have an unstageable PU to her L inner foot and Resident #9 was found to have a PU to her sacrum. The facility notified the MDs for both residents and received orders.Record review of Resident #8's chart revealed the Head-to-Toe assessment performed on 8/22/25 that found the new PU, along with the Wound Assessment also performed on 8/22/25. Record review revealed MD orders for the PU found to the L inner foot, entered on 8/22/25. Record review also revealed the Care Plan was updated with the PU.Record review of Resident #9's chart revealed the Head-to-Toe assessment performed on 8/22/25 that found the new PU, along with the Wound Assessment also performed on 8/22/25. Record review revealed the MD orders for the PU found to the sacrum, entered on 8/22/25. Record review also revealed the Care Plan was updated with the PU.In an observation on 8/22/25 at 3:26pm, Resident #8 was asleep on her left side in bed. Her legs were under the covers, so it was undetermined if she had any heel protectors on.In an observation and interview on 8/22/25 at 3:30pm, Resident #9 was sitting up in bed with her heels elevated. She said the staff did find a new wound to her bottom, but it was not bothering her. She said they put new interventions in place like turning and putting her feet up.In an interview on 8/23/25 at 2:37pm, LVN D said she worked the 6am-2pm shift. She said she recently had in-services on wound care and ensuring it was done, assessing for PUs and how to assess for PUs, reporting to the MD and to the Wound MD if any skin issue were found, ensuring accurate skin assessments were done, and ensuring shower sheets were verified by the nurse and then turned over to the Wound Care Nurse if a skin issue was found. She also said the admission assessments were performed by the floor nurse and then the Wound Care Nurse performed them after.In an interview on 8/23/25 at 2:40pm, LVN G, also the Wound Care Nurse, said she worked the 2pm-10pm shift. She said she had in-services on skin assessments, PUs, documenting wounds, and calling the MD for orders. She said there were also in-services on the risk factors for PUs, and interventions for PUs. She said the admission/readmission skin assessment was done by the floor nurse and then re-assessed by the Wound Nurse. She also said if the CNA found skin issues during a shower, the shower sheet was filled out and then given to the nurse then the Wound Nurse.In an interview on 8/23/25 at 2:43pm, CNA I said she worked the 6am-6pm shift. She said she received in-services on ways to prevent PUs like repositioning and floating the heels. She said she also received in-services on ensuring the skin was checked and filling out shower sheets and giving them to the nurse if there were any skin concerns found.In an interview on 8/23/25 at 2:45pm, CNA T said she worked the 6am-6pm shift. She said she received in-services on skin assessments, giving shower sheets to the nurse or Wound Care Nurse if any skin issues were found, and interventions to prevent PUs like floating the heels, and repositioning.In a telephone interview on 8/23/25 at 3:21pm, CNA S said she worked the 6pm-6am shift. She said she received in services on PUs and how to look for them and what to do if she found any on a resident. She said she also received in-services on interventions to prevent PUs like turning, repositioning, and floating heels. She said she was also trained on filling out shower sheets if a skin concern was found and giving them to the supervisor.In a telephone interview on 8/23/25 at 3:50pm, LVN P said she worked the 10pm-6am shift. She said she had in-services on skin assessments, how to do them, what to look for, and that the Treatment Nurse would do the Admission/readmission assessments. She said they also received in-services on interventions to prevent PUs like turning, repositioning, and floating the heels. Also, she had in-services on the CNAs filling out the shower sheets and if they found any skin concerns, they needed to give the sheets to the nurse and then the nurse gave them to the Treatment Nurse.Record reviews performed by the Surveyor on 8/23/25:- Braden Scales (determines risk for skin breakdown) for all residents were completed on 8/21/25 and revealed 17 at risk, 4 at moderate risk, 2 at high risk, and 12 with no risk.- A list of residents whose Kardex and Care Plan had been reviewed by the DON on 8/21/25.- In-services given by the DON on 8/21/25 to the CNAs and Licensed Nurses on Early Identification of PUs with 24 staff signatures.- In-services given by the DON on 8/21/25 top the Nursing Staff on PU Prevention, Skin Audits, and ANE with 23 signatures.- In-services given by the DON on 8/21/25 to the Treatment Nurse, RNs, and LVNs on PU Prevention with 20 signatures.- Ad Hoc QAPI Meeting from 8/21/25-8/22/25 revealed MD M, the Medical Director, the ADM, the SW, the BOM, the HR Director, the Maintenance Director, the AD, the DM, and the Admissions Director were in attendance.- A sheet that said Admissions on the top and had a column starred that said, Skin Issues: Identified on Admission, Assessment with Notification and New Order for Treatment as Applicable. There was another column starred that said, If Skin Issue Identified, Accuracy of Classification/Stage of Wound Confirmed. The log did not have anyone on it yet.- The Skin Assessment Audits log had 3 residents that had been audited on 8/22/25 and were found to have preventative measures in place, the skin assessment was complete and accurate, and no corrective actions needed to be taken.- The Wound Care Nurse Admission/readmission Audits log was blank and did not have anyone on it yet. An Immediate Jeopardy (IJ) was identified on 8/22/2025. The IJ template was provided to the facility on 8/22/2025 at 12:55pm. While the IJ was removed on 8/23/2025 at 4:00pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 5 of 33 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #6) reviewed for quality of care.The facility failed to perform weekly skin assessments on the residents for several weeks.This failure could place residents at risk for skin breakdown and/or wounds without receiving treatment or worsening of skin breakdown or wounds.Findings included:1. Record review of Resident #1's undated face sheet revealed she was a [AGE] year-old female admitted originally on 5/21/21, with the most recent admission being 7/25/25. She had diagnoses of type 2 diabetes mellitus (body does not produce insulin or resists it), stage 3 pressure ulcer (fat is visible, but not bone), cognitive communication deficit (difficulty in communication due to attention or memory), hemiplegia of left side (paralysis), contracture of right lower leg (shortening or tightening of muscles, tendons, or ligaments), contracture of left lower leg, and dementia (decline in mental ability affecting daily life).Record review Resident #1's Quarterly MDS assessment dated [DATE], revealed a BIMs score of 4 out of 15 which indicated severely impaired cognition. The resident had impairment on both sides of her upper and lower extremities and was dependent (helper does all of the effort) with all ADLs. The MDS revealed the resident had a Stage 3 pressure ulcer, and a Stage 4 (exposed bone, tendon or muscle) pressure ulcer. She also had 2 unstageable pressure injuries.Record review of Resident #1's care plan dated 5/22/21 revealed the following: *Focus: Resident had a Stage 3 pressure injury of the L Lateral Knee (outside of the knee) that was now a Stage 4 pressure injury after being readmitted from the hospital on 7/25/25 (Initiated: 9/5/24, Revised: 8/2/25). The goal was for the resident to remain free from further breakdown. An intervention was conducting weekly skin assessment per facility policy. *Focus: Resident had impaired physical mobility r/t decreased ROM to L hand (Initiated: 11/21/24). The goal was to reduce further contraction through next review. Interventions included monitoring R hand skin integrity, circulation, and motion. *Focus: Resident had a pressure ulcer/DTI to the L medial (inside) heel after readmission from the hospital on 7/25/25 (Initiated: 4/23/25, Revised: 8/2/25). The goal was to remain free from further breakdown through the review date. Interventions included skin assessment to be completed per facility policy and conduct a weekly skin inspection. *Focus: Resident had a pressure injury to the L plantar (bottom) foot (Initiated: 8/5/25). The goal was for her skin to remain intact through the review date. Interventions included conducting a weekly skin inspection and diabetic foot monitoring. *Focus: Resident had pressure injury to R Ischium (hip) on readmission 7/25/25 (Initiated: 7/25/25, Revised: 8/2/25). The goal was to show s/s of healing through the review date. Interventions included monitoring for tissue breakdown, monitoring for infection, and notifying MD if necessary. *Focus: Resident had pressure injury to R dorsal great toe (top of big toe) on readmission 7/25/25 (Initiated: 7/25/25, Revised: 8/2/25). The goal was to show s/s of healing through the review date. Interventions included monitoring for tissue breakdown and monitoring for infection.Record review of Resident #1's Physician Orders from 8/12/25, revealed an order from MD J for weekly head to toe skin assessments every night shift on Tuesdays, which was ordered on 7/25/25 to start on 7/29/25. Record review of Resident #1's medical records revealed an initial skin assessment was performed on re-admission 7/25/25 at 11:56am. Record review of Resident #1's assessments on 8/12/25, revealed the weekly wound reports were being performed.Record review of Resident #1's July 2025 MAR-TAR revealed LVN P initialed that she performed the skin assessment on 7/29/25. No weekly skin assessment for 7/29/25 was found in the resident's chart.Record review of Resident #1's August 2025 MAR-TAR revealed LVN P initialed that she performed the skin assessment on 8/5/25. No weekly skin assessment for 8/5/25 was found in the resident's chart.In an observation and interview on 8/12/25 at 2:10pm, a skin assessment was performed on Resident #1 by LVN G and CNA I. No new skin issues were found. There were wounds on the resident's L thigh, L knee, R toe, and R hip. Per LVN G, the wounds were already being treated by wound care. The resident was not interviewable. 2. Record review of Resident #2's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of ESBL (type of multi-drug resistant organism) resistance, prediabetes, paraplegia (paralysis of lower extremities), cognitive communication deficit (difficulty in communication due to attention or memory), bipolar (mood swings ranging from depressive lows to manic highs), and depression.Record review of Resident #2's admission MDS assessment dated [DATE] revealed a BIMs score of 15 out of 15 which indicated normal cognition. The resident had impairment on both sides of his upper and lower extremities and was dependent with almost all ADLs. The resident had a foley catheter (tube into bladder to drain urine) and was incontinent of bowel. The MDS revealed the resident had no unhealed pressure ulcers/injuries.Record review of Resident #2's care plan dated 6/25/25 revealed a Focus: Resident had a Stage 3 pressure injury that he was admitted with, to his sacrum (tailbone) (Initiated: 6/25/25, Revised: 6/29/25). The goal was for the resident to remain free from further breakdown through the review date. An intervention was to conduct weekly skin inspections.Record review of Resident #2's medical records revealed an initial skin assessment that was performed on 6/25/25 at 3:48pm. Further review revealed no additional skin assessments.Record review of Resident #2's Physician Orders from 8/12/25, revealed no orders for weekly skin assessments.In an observation on 8/12/25 at 1:25pm, a skin assessment was performed on Resident #2 by LVN D and LVN G. No skin issues were found, and the sacrum pressure ulcer was gone. The resident was not interviewable. 3. Record review of Resident #3's undated face sheet revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis and weakness) on the right side after a stroke, type 2 diabetes mellitus (body does not produce insulin or resists it), functional quadriplegia (paralysis of upper and lower extremities), epilepsy (seizures), and muscle wasting/atrophy to the right and left lower leg.Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMs score of 15 out of 15 which indicated normal cognition. The MDS revealed she had impairment on both sides of her upper and lower extremities, and she was dependent on staff for all ADLs. The resident was incontinent of bowel and bladder. The MDS revealed the resident had 1 unstageable pressure injury and was receiving care.Record review of Resident #3's care plan dated 2/19/25 revealed a Focus: Resident had a Stage 1 (redness with no open areas) pressure ulcer to the R medial (inside) foot (Initiated: 4/24/25). The goal was for the resident's skin to remain intact through the review date. Interventions included conducting weekly skin inspections, notifying the MD if symptoms worsen, and skin assessments to be completed per facility policy.Record review of Resident #3's Physician Orders from 8/12/25, revealed an order from MD M for weekly head to toe skin assessments every Tuesday evening, ordered on 2/19/25 to start on 2/25/25.Record review of Resident #3's assessments revealed the last weekly skin assessment was performed on 7/22/25 at 8:09pm.Record review of Resident #3's July 2025 MAR-TAR revealed LVN G initialed she performed the weekly skin assessment on 7/29/25. No weekly skin assessment was found in the resident's chart for 7/29/25. Record review of Resident #3's August 2025 MAR-TAR revealed a blank spot for the weekly skin assessment on 8/5/25.In an interview on 8/12/25 at 4:00pm, the ADM said she ensured LVN G performed a skin assessment on Resident #3 and there were no skin issues found. 4. Record review of Resident #4's undated face sheet revealed he was an [AGE] year-old male originally admitted on [DATE], with the most recent admission being 2/11/25. He had diagnoses of atrial fibrillation (irregular heartbeat), type 2 diabetes, COPD (lung diseases that cause airflow blockage and breathing problems), heart failure (heart does not pump blood effectively), cerebral infarction (stroke), and pneumonia (infection in the lungs).Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMs score was unable to be performed. The resident had impairment on both sides of his upper and lower extremities and was dependent for all ADLs. The resident was incontinent of bowel and bladder but had no pressure injuries. She did have some MASD (skin breakdown from moisture).Record review of Resident #4's care plan dated 8/8/24 revealed a Focus: Resident had physical functioning deficit r/t self-care impairment (Initiated: 10/20/24). The goal was that the resident would maintain current level of functioning. The interventions included inspecting the skin and report any redness, rashes, or open areas.Record review of Resident #4's Physician Orders from 8/12/25, revealed an order from MD J for weekly head to toe skin assessments to be done every Tuesday evening, ordered on 2/11/25 to start on 2/13/25.Record review of Resident #4's assessments revealed the last weekly skin assessment was performed on 7/31/25 at 9:29pm.Record review of Resident #4's August 2025 MAR-TAR revealed LVN G initialed she performed the weekly skin assessment on 8/7/25. No weekly skin assessment was found in the resident's chart for 8/7/25.In an interview on 8/12/25 at 4:00pm, the ADM said she ensured LVN G performed a skin assessment on Resident #4 and the only skin issue that was reported to her was redness to his groin. 5. Record review of Resident #6's undated face sheet revealed she was a [AGE] year-old female originally admitted on [DATE], with the most recent admission being 6/2/25. She had diagnoses of respiratory failure (not enough oxygen in the blood), type 2 diabetes (body does not produce insulin or resists it), atrial fibrillation (irregular heartbeat), congestive heart failure (heart is not able to pump the fluid out of the body), and hypertensive heart/chronic kidney disease with heart failure (high blood pressure that caused kidneys/heart to fail).Record review of Resident #6's Significant Change MDS assessment dated [DATE] revealed a BIMs score was unable to be performed. The resident had impairment on both sides of her upper and lower extremities and was substantial/max assist with ADLs. The MDS revealed the resident was incontinent of bowel and bladder and she had a Stage 2 (shallow open ulcer or open/ruptured blister) pressure injury and was receiving care.Record review of Resident #6's care plan dated 1/14/21 revealed a Focus: Resident #6 had potential for pressure ulcer development r/t immobility (Initiated: 4/14/21, Revised: 6/3/21). The goal was to have intact skin through the review date. The interventions included following the facility's policies/protocols for the prevention of skin breakdown.Record review of Resident #6's Physician Orders from 8/12/25, revealed an order from MD M for weekly skin assessments every Tuesday evening, ordered on 5/24/25 to start on 5/27/25.Record review of Resident #6's weekly skin assessments revealed the last weekly skin assessment was performed on 7/22/25 at 7:58pm.Record review of Resident #6's assessments revealed weekly wound assessments were performed until 8/1/25, when her pressure ulcer healed.Record review of Resident #6's July 2025 MAR-TAR revealed LVN G initialed she performed the weekly skin assessment on 7/29/25. No weekly skin assessment was found in the resident's chart for 7/29/25.Record review of Resident #6's August 2025 MAR-TAR revealed a blank spot on 8/5/25 for the weekly skin assessment.In an observation on 8/12/25 at 1:36pm, a skin assessment was performed on Resident #6 by LVN G and CNA T. Redness was found to her L lateral foot, R underarm, and R buttock, but no open areas.In an interview on 8/12/25 at 9:59am, LVN D said the floor nurse performed the weekly skin assessment according to the schedule they had posted at the nursing station. She said if the resident was being treated by wound care, then the wound care nurse would do the weekly skin assessment. She said if a weekly skin assessment was not performed, they could miss skin issues.In an interview on 8/12/25 at 10:50am, LVN G said she was the Wound Care Nurse. She said the weekly skin assessment should still be performed by the floor nurse, even if they had wounds. She said she filled out the Weekly Wound Review and it was based off the measurements the Wound Care MD gave her.In an interview on 8/12/25 at 11:41am, the ADM said a skin assessment was performed at every admission and was documented under the Admission/Baseline Care Plan. She said then weekly, a head-to-toe skin assessment was performed by one of the 3 different shifts, according to the schedule at the nursing station. The ADM said the Weekly Wound Review should be done along with the Weekly Skin assessment. The ADM said the nurses were trained on performing skin assessments and knew the schedule on when to perform them. She said she did not know why the nurses were not doing the skin assessments and had not heard anything from them about the assessments not being done.In an interview on 8/12/25 at 3:15pm, the ADM said she investigated the reason for the skin assessments not being done and Resident #2's weekly skin assessments were never triggered in the EMR. She said she would call the company to see what was going on. The ADM said even though it did not trigger in the system, the nurses should have known to do the assessment, even if they had to do it on paper.In an interview on 8/12/25 at 4:47pm, the ADM said after investigation of the other resident's skin assessments not being done, she thinks they were overlooked. She said the ADON normally would follow up on skin assessments to ensure they got done and she had not had an ADON in a few weeks. She said she also was in between DONs so everyone was stretched thin. She said if skin assessments were not done, they could miss skin issues and residents could get wounds.Record review of the facility's policy and procedure on Skin Assessment, undated, read in part: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management.A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury.Document if resident refused assessment and why.

Based on observations, interviews and record reviews, the facility failed to protect the resident's personal privacy during personal care for 1 (Resident #5) of 7 residents reviewed for privacy.- CNA I failed to provide privacy during incontinence care for Resident #5 whose naked buttocks were completely exposed and seen through the window by Surveyor walking by.This failure places residents at risk for embarrassment and a lack of privacy.Findings included:Record review of Resident #5's undated face sheet revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of atherosclerotic heart disease (blockage in the arteries to the heart), cognitive communication deficit, lack of coordination, muscle weakness, and problems following cerebrovascular disease (disorders affecting the blood vessels/blood supply to the brain).Record review of Resident #5's Annual MDS assessment dated [DATE] revealed a BIMs score of 15 out of 15 which indicated normal cognition. He had an impairment on one side of his upper extremities and an impairment on both sides of his lower extremities. The resident was substantial/max assist (Helper does more than half the effort) with all ADLs and was incontinent of bowel and bladder. Record review of Resident #5's care plan dated 6/24/22 revealed the following care areas: *Focus: Resident #5 had bladder incontinence. The goal was to remain free from skin breakdown due to incontinence through the review date. Interventions included changing the resident every 2hrs and PRN and establish voiding patterns. *Focus: Resident #7 had potential for alteration in bowel function/incontinence and/or constipation. The goal was to not develop any GI complications. Interventions included keeping the resident clean and dry, and keeping the call light in reach. *Focus: The resident had an ADL self-care deficit r/t R BKA. The goal was to maintain current level of function through the review date. Interventions included Personal Hygiene: The resident required staff participation with personal hygiene, the resident required staff participation to reposition and turn in bed, and the resident required staff participation to use the toilet.In an interview and observation on 8/12/25 at 1:56pm, CNA I was providing incontinence care to Resident #5 without the privacy curtain drawn and the Surveyor saw Resident #5's whole backside exposed through the window while walking down the hall. CNA I said the privacy curtain was stuck, and she could not pull it all the way around. She said she should have pulled harder instead of going ahead and changing the resident. She said she would be embarrassed if that happened to her and she had been trained on privacy/dignity.In an interview on 8/12/25 at 2:00pm, Resident #5 said he did not know he was exposed during incontinence care. He said CNA I normally would pull the privacy curtain all the way around. He said, He did not see it when asked if it bothered him that he was exposed during incontinence care.In an interview on 8/12/25 at 4:47pm, the ADM said she expected staff to pull the privacy curtain all the way around and close the door before performing incontinence care for the privacy of the residents.Record review of the facility's policy and procedure on Perineal Care, undated, read in part: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible ' and to prevent and assess for skin breakdown. Provide privacy by pulling privacy curtain or closing room door if a private room.Record review of the facility's policy on Promoting/Maintaining Resident Dignity, undated, read in part: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Maintain resident privacy. Random observations and/or verifications are conducted by the Director of Nursing Services (DNS), or designee, to ensure compliance with this policy.

Based on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 4 residents reviewed for resident rights. -The facility failed to honor Resident #1's request of wearing a mask before entering her room on 02/21/25. This failure could place residents at risk for a lack of self-determination and quality of life. The findings included: Record review of Resident #1's Admission Record, dated 02/21/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included multiple sclerosis (autoimmune disease resulting in damage to the insulating covers of nerve cells in the brain and spinal cord), bipolar disorder (mental health condition that causes extreme mood swings), and muscle weakness. Record review of Resident #1's MDS Quarterly Assessment, dated 12/08/24, revealed a BIMS score of 13, indicating she was cognitively intact. Further review revealed resident required substantial/maximal assistance (helper does more than half the effort) with toileting, shower/bathe, and lower body dressing. Resident was dependent (the assistance of 2 or more helpers was required for the resident to complete the activity) with upper body dressing. Multiple sclerosis was checked under Section I - Active Diagnoses, Neurological. Record review of Resident #1's Care Plan Report, undated, revealed the resident had ADL self-care performance deficit related to multiple sclerosis. Observation on 02/21/25 at 9:56 a.m., revealed Resident #1 had a red sign posted on the outside of her room door that read Do Not Enter Without A Mask - [Family Name]. Nurse A was observed exiting resident's room without a mask. Observation on 02/21/25 at 10:27 a.m., revealed MA A entered resident room without a mask, did not ask if she needed to wear a mask, administered resident's medications, and then left the room. During an interview on 02/21/25 at 10:14 a.m., Resident #1 said Nurse A was not wearing a mask when she entered her room and neither do other staff members (names unknown). She said her reason for wanting everyone entering her room to wear a mask was because her immune system was already shot, and they have been having COVID-19. She said it had been months since they had COVID-19 in the building, but she still wants masks to be worn. She said she did not tell Nurse A anything about not wearing a mask because it is posted on the door and feels she does not need to tell her or staff to wear one every time they enter her room. During an interview on 02/21/25 at 10:29 a.m., MA A said Resident #1's request to wear a mask when entering her room was being honored. She said the resident told her she did not have to wear a mask. She said she would ask the resident if she needed to wear a mask. MA went to resident's room, opened door, and asked Resident #1 while standing at the entrance to the room if she wanted her to wear a mask when she entered her room. Resident told MA A she wanted her to wear a mask. During an interview on 02/21/25 at 11:50 a.m., Nurse A said Resident #1 picked and chooses who she allows to enter the room with a mask, and who she does not want to enter the room without a mask. She said the resident gave her permission to enter the room without a mask. She said she was in her room because the resident wanted her television remote. She said the resident always allows her to go into her room without a mask. She said when the resident explained the sign to her, she said it was for the staff, and she was ok with the same staff going in and out of the room without a mask, but was not okay with it during COVID-19. She said she asked the ADON about the sign on Resident #1's door and was told it was the family's preference as the sign indicated. She said when she first started working at the facility, she would wear a mask, but there came a time when she was in the hall and the resident asked for her PRN medication. She said ok, but she needed to go get a mask, but the resident said it was okay she did not need one and so she went in and gave her medication . She said it was the resident's own preference that a mask be worn and that she was able to consult with the resident if she could enter without a mask. She said the resident gave her permission to enter without a mask earlier that day because she just needed her television remote. She said not honoring a resident's right could cause or be like mental abuse. During a follow-up interview on 02/21/25 at 12:35 p.m., Resident #1 said staff just came in her room and do not ask her if it is okay to enter without a mask. She said everyone comes in without a mask. She said staff have never asked her if it was okay for them to enter without a mask. She said she should not have to say anything because the sign in posted in their face on her room door. She said staff do what they want. She said her parents come and visit on Sundays and always wear a mask. She said it makes her feel disrespected when they go in her room without wearing a mask. During an interview on 02/21/25 at 11:34 a.m., the DON said if a resident wanted nursing staff to wear a mask when entering their room, the expectation was for the staff to meet their request. When asked about the consequence of not honoring a resident's request, she said she guessed it would affect them psychologically. She said if she were the patient, she would be upset. She said she was aware that Resident #1 had a sign posted on her room door saying something about asking to wear a mask upon entering. She said she was pretty sure the nursing staff was aware because there was a sign posted on the door. Record review of the facility's Statutory of Patients' Rights policy, dated 08/2024, read in part .Statement of Resident's Rights in Texas .The facility must encourage and assist you to fully exercise your rights .You have a right to .4. Be treated with courtesy, consideration, and respect .

Based on observation, interviews, and record reviews, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #1) of 4 residents reviewed for dietary services. -The facility failed to honor Resident #1's food preference according to her meal ticket by serving her pork, which her meal ticket reflected she disliked. This failure could place residents at risk for possible weight loss, and a diminished interest in meals and quality of life. The findings included: Record review of Resident #1's Admission Record, dated 02/21/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (autoimmune disease resulting in damage to the insulating covers of nerve cells in the brain and spinal cord), bipolar disorder (mental health condition that causes extreme mood swings), and muscle weakness. Record review of Resident #1's MDS Quarterly Assessment, dated 12/08/24, revealed a BIMS score of 13, indicating she was cognitively intact. Further review revealed resident required set up or clean up assistance (helper sets up or cleans up) with eating. Record review of Resident #1's Care Plan Report, undated, revealed the resident was on a regular diet with thin liquids. Observation on 02/21/25 at 10:14 a.m. of Resident #1's meal ticket, dated February 2025, revealed pork was listed as one of the resident's dislikes. During an interview on 02/21/25 at 10:14 a.m., Resident #1 said she did not eat pork because she was Muslim. She said the facility had been serving her pork and the last time it happened was that past Tuesday, 02/18/25. She said sometimes she would have them bring her something different or family will bring her food to eat. She said it makes her mad when she was served the wrong food. During an interview on 02/21/25 at 11:50 a.m., Nurse A said she had been working at the facility for maybe a week. She said Resident #1 has complained about something that was on her meal tray (item unknown) that should not be on there. She said she offered the resident a substitute and the dietary manager did as well, but she refused. During a telephone interview on 02/21/25 at 2:40 p.m., CNA A said she checked all the meal tickets. She said she knew Resident #1 did not eat pork. She said resident was served pork because she did not look under the food cap cover that was over the plate. She said she took the tray into the resident's room, lifted the top, asked if she wanted it, because she refuses a lot. She said she saw it was pork and took the tray back. She said the resident called her back to her room and gave her a note. She said she does not remember what the note said. She said Resident #1 told her she was not going to eat the meal. During a telephone interview on 02/21/25 at 2:22 p.m., Dietary Aide A said they prepared the food in kitchen, rolled carts out, and the CNAs delivered the meals. She said meal tickets were printed out every day which told them the resident's name, diet, allergies, likes, and dislikes. She said the cook made the plate and they checked the meal ticket against the meal as they put them on the cart. She said if she sees the ticket and they were having something they do not like, they will try to accommodate with something they like. She said approximately a couple of weeks ago, Resident #1 wrote a note and had a CNA bring the note to the kitchen. She said the note said something about what she did not fucking eat. She said she went and spoke to Resident #1, told her they made a mistake, and asked her what she could get her to eat. She said the resident said she did not want anything and said she would not eat it if the President brought it there. During an interview on 02/21/25 at 1:27 p.m., the Administrator said she knew the serving of the wrong food items had been happening. She said staff would get the ticket, put it on the tray, and then deliver the meal without verifying if the meal was correct. She said the aides would say they knew by memory what residents ate what, but she told them no, they did not know by memory. She said Resident #1 received a pork chop for dinner about 2 1/2 weeks ago and wrote a nasty note saying, I do not eat fucking pork, can't you read. She said on resident's meal ticket it said in two different areas, no pork. She said staff were now looking at the tickets. She said she did not know how it affected Resident #1 when she is served the wrong food item, as it is just a preference. She said she also moved pork over to the allergy area on the resident's meal ticket so she would not get pork. She said the Dietary Manager was on leave.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 for 1 kitchen. Food item was not sealed in the facility pantry . This deficient practice could place 25 residents who received meals from the main kitchen at risk for food borne illness. Findings included: Observation on 10/29/24 at 08:57 am revealed one 13.7-quart clear full-size container of brown sugar was left open to air. In an interview with the Dietary Manager on 10/30/2024 at 10:00 am, she said she noticed the brown sugar lid and the plastic wrapping was not covered on the container. She said when the workers leave the brown sugar uncovered it could cause the sugar to get hard and go bad fast. She said when the workers leave the container of brown sugar uncovered anything can crawl inside of it. She said anything at the top shelf can fall into the sugar which can cause cross contamination. She said she expected her workers to follow policy and procedures. In an interview with the [NAME] on 10/30/24 at 1:03 pm, she said she had been working at the facility for 6 years. She said when the brown sugar was left uncovered, she was moving fast and forgot to close it. She also said when the brown sugar was left open and uncovered with the lid off the container sugar could become contaminated because bugs can get into the sugar. She said moving forward she would slow down and make sure all the lids of the containers were properly stored which would prevent contamination. She said by properly storing the items it would prevent her from needing to throw away the food as well. In an interview with the Administrator on 10/31/2024 at 1:34pm, she said the cook informed her that she took out the brown sugar and forgot to replace the plastic wrapper and lid to cover the container. She said by the cook not covering the container bugs could get inside of it. She said once bugs get into the brown sugar it would become contaminated. She said the cook was in-serviced on properly covering and labeling items in the kitchen. Record review of the facility's Food Receiving and Storage Policy Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use . Dry foods that are stored in bins are removed from original packaging, labeled, and dated (use by date). Such foods are rotated using a first in - first out system. Record review of the U.S. Food and Drug Administration dated 1/18/23 under Chapter 3 read in part . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act.

Based on interviews, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #19) reviewed for resident rights. The facility failed to obtain a signed consent for antipsychotic medication, Wellbutrin XL Oral Tablet Extended Release 24-hour 150 MG, administered to Resident #19. The failure affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Findings included: Record review of Resident # 19's face sheet provided by the facility on 10/31/2024 revealed that Resident # 19 [NAME] a 61 -year-old male who admitted to the facility on [DATE] and had an active diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) with an onset documented as of 09/05/2024. Record review of the comprehensive MDS assessment revealed Resident # 19's Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was able to complete the interview. The MDS assessment for Resident #19 revealed had an active psychotic disorder of bipolar disorder and had received an antipsychotic. Record review of Resident #19's physician's order summary report revealed the following order: Wellbutrin XL Oral Tablet Extended Release 24-hour 150 MG give one ablet by mouth one time a day for depression with a start date of 09/17/2024. Record review of Resident #19's MAR revealed Wellbutrin XL Oral Tablet Extended Release 24-hour 150 MG was administered by the facility's nursing staff on 09/17/2024 thru 09/25/2024 to Resident #19. Interview om 10/30/2024 at Nurse P stated that the provider is responsible for ensuring the resident is informed of the medications prescribed. He stated the nurse is responsible for ensure that a signed consent is obtained prior to administering medication. He stated the resident have the right to be informed of the treatment and medication provided. He stated that when a resident was not informed it deprived the resident of their right to understand the treatment plan, including potential risks, benefits, and alternatives. Interview on 10/30/2024 at 3:00 PM, the DON stated that the nurses were required to confirm that there [NAME] a signed Form 3713 consent for Wellbutrin XL Oral Tablet Extended Release 24-hour 150 MG. The DON stated the facility failed to obtain a consent on 09/17/2024. She stated the nurse is responsible for ensure that a signed consent is obtained prior to administering medication The DON stated she was made aware by Resident #19 that he was taking the medication. She stated that once she was made aware the provider was notified and the medication was discontinued on 09/25/2024, the day she was notified. The DON stated the failure placed the resident at risk for not being informed about his mediation and treatment he was receiving. The Medication Administration and Antipsychotic Medication Use/Consent Policy was requested. Interview on 10/31/2024 at 4:45 PM, the Administrator stated that the nurses [NAME] required to ensure that there was a signed consent for Antipsychotic Medication prior to administering. The Administrator stated the failure placed the resident at risk for not being informed about his mediation and treatment he was receiving. Interview on 10/30/2024 at 3:30 PM, Resident #19 stated the facility did not inform him he was taking Wellbutrin and he did not provide consent for the medication. He stated that he received antipsychotic medication but did not know the medications dosage and side effects associated with medications. He stated he learned he was taking the medication after he requested his medication record on 09/25/2024. He stated that he informed the DON that he did not consent to taking Wellbutrin and the medication was then discontinued. The facility failed to provide the facility policy for Psychoactive Medication Informed Consent.

Based on observations, interviews, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program to the maximum extent practicable for 1 of 5 residents (CR #236) reviewed for PASRR. The NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the CR #236 This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility. Findings included: Record review of CR # 236's face sheet provided by the facility on 10/28/2024 revealed that CR # 236 [NAME] a 45 -year-old female who admitted to the facility on [DATE] and had an active diagnosis of Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) with an onset documented as of 01/29/2021. CR #236 discharged from the facility on 06/04/2024. Record review of the PASRR Level 1 Screening for CR #236 dated for 12/04/2023 indicated no mental health illness, intellectual disability, and developmental disability. It was determined that resident was eligible for PASRR specialized services. Record review of CR #236's care plan dated 08/19/2024 read in part CR #236 is dependent on staff for activities, cognitive stimulation, and social interaction related to cognitive deficits, physical limitations. Care Plan revealed no documentation of PASRR Specialized Services (Therapies and Assessments OT and PT) by 1/29/2024, DME for Mattress and CMWC (Customized Manual Wheelchair). Record review of email dated, 02/23/2024, HHS PASRR Program Specialist informed the facility of non-compliance with the requirements outlined in the Texas Administrative Code, Chapter 19, Subchapter BB, section S19.2704(i)(7)(A), which states facility must initiate nursing facility specialized services within 20 business days after the date that the services are agreed to in the IDT meeting for the resident we spoke about. The facility was instructed to submit a NFSS request form for PASRR Specialized Services (Therapies and Assessments OT and PT) by 1/29/2024, DME for Mattress and CMWC (Customized Manual Wheelchair) by 1/31/2024 through the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Portal found. On 10/30/2024 at 11:00AM in an interview with DON, the DON stated that the MDS Coordinator is responsible for ensure that PASRR are completed. She stated that when the PASRR is not completed and submitted timely it could impact the resident's ability to receive PASRR specialized services and overall affect the resident's wellbeing. On 10/30/2024 at 11:20AM in an interview with the facility's Administrator, the Administrator stated that she was not aware of who was responsible for completing PASRR as she had only work at the facility for three days. She stated that PASRR should be completed timely and submitted to aid in the resident's ability to receive PASRR. She stated when PASRR wasn't completed and submitted for resident's who required specialized services the resident was at risk for not receiving the services needed. On 10/30/2024 at 1:00 PM in an interview and record review with MDS Coordinator revealed that she completed an updated PASRR Level 1 screening on 12/04/2023 prior to her employment with the facility. She stated that Resident #36's PASRR Level 1 screen was completed on 12/04/2024 but services were not provided. The MDS Coordinator stated she did not know why the NFSS follow up request was not submitted for CR #236. She stated that after speaking with the facility's corporate MDS she was informed that the NFSS Request was not submitted because CR #236 was identified as Medicaid Pending. She said that it would be important for a resident to receive PASRR services if they qualified. The MDS Coordinator said that the potential risk to a resident for not having the NFSS Request submitted, would be that the resident would not receive the necessary services the resident qualified for. Record review of the facility's Resident Assessment-Coordination with PASRR Program policy dated implemented 06/2023 and Date Revised: 06/2023 revealed 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASRR.

Based on observations, interviews, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 12 residents (Resident #132) reviewed for significant medication errors. The facility failed to ensure Metoprolol Tartrate (a blood pressure (BP) medication given to lower (high blood pressure) and treat heart failure) was administered on 10/28/2024 and 10/29/2024 to Resident #132 as ordered on 10/25/2024 by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings included: Record review of Resident #132's admission face sheet, undated, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: hypertension (high blood pressure), heart failure (a chronic condition in which the heart not pumping blood as well as it should), and respiratory failure. Record review of Resident #132's baseline care plan dated 10/25/2024 reflected: Baseline Care plan summary: Resident #132 was alert and oriented. The resident's cognition was intact. Resident #132 received antihypertensives (medications used to treat high blood pressure). Resident #132's medication reconciliation (the process of ensuring a resident's hospital medications were reviewed and up to date) was completed. Resident #132's baseline summary reflected baseline care plan and medication list was reviewed with the resident and/or resident representative. Record review of Resident #132's Order Summary report active orders dated as of 10/30/2024 revealed Metoprolol Tartrate Tablet 25Mg. Give one by mouth in the morning for hypertension. Hold for SBP less than 110 and heart rate (HR) less than 60. Order dated 10/25/2024. Record review of Resident #132's October 2024 Medication Administration Record (MAR) dated 10/01/2024 -10/31/2024 reflected, the resident was not administered Metoprolol Tartrate 25 Mg when the physician's set parameter of SBP less than 110 and HR less than 60 were within parameters. The medication was held on: 10/28/2024 6:00-10:00 AM with BP 142/50 and HR 70 by MA A 10/29/2024 6:00-10:00AM with BP 115/50 and HR 72 by MA A Continued review of Resident #132's MAR revealed MA A coded 7 on 10/28/2024 and 10/29/2024. Review of the chart code revealed 7 indicted SBP below set parameters. Hold medications. Effective. In an observation and interview on 10/30/2024 at 9:22 AM revealed Resident #132 in bed. Resident #132 was awake, alert, and oriented. Resident #132 stated she was getting her medicine good. Resident #132 stated they take good care of her, and she felt good. In a phone interview on 10/30/2024 at 11:35 AM the facility pharmacy representative stated the purpose of Metoprolol was to lower high blood pressure. The pharmacy representative stated the physician ordered the SBP and HR parameter because we do not want the BP to go too low. The pharmacy representative stated based on the ordered parameters and the resident's SBP and HR the medication should not have been held for those two days. The pharmacy representative stated the risk was they would not be treating the resident's condition and over time it could be a problem. In a phone interview on 10/30/2024 at 12:56 PM MA A stated she administered Resident #132's medications on 10/28/24 and 10/29/24. MA A stated she did not administer the Metoprolol because either the SBP or DBP was too low. MA A stated she believed she held it due to the resident's DBP being low, in the 50's. MA A stated she coded the dose as 7 due to her holding the medicine. The MA stated the risk of not giving the medication was the BP could go too high. In an interview and record review on 10/31/2024 at 11:21 AM the DON stated after review of Resident #132's physician's order, the Metoprolol should not have been held. The DON stated the DBP was low but there was no parameter set for the DBP. The DON stated she expected the physician's order and the ordered parameters to be followed. The DON stated the physician should have been called and asked if the medication should be held or administered. She stated to prevent this, they would reeducate staff on medication administration . In an interview on 10/31/2024 at 1:00 PM with the Administrator , she stated she expected the person administering the medications to be licensed or a trained MA. The Administrator stated she expected the physician's order to be followed. She expected the job to be done correctly. The Administrator stated the risk of not giving the blood pressure medication could cause the blood pressure to go high. The resident was at risk of a complication from high blood pressure like a stroke. She stated to prevent this again, they would retrain on medication administration. Record review of the facility policy titled Administering Medication revised dated April 2019 read in part . Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frames .

Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for two residents (Resident# 14 and Resident #18) of five residents reviewed for pharmacy services. -The office of the ADON was open and accessible to staff and residents. There were two blister pack cards of controlled medications. Staff were within sight of the open door. The deficient practice placed the facility at risk for drug diversion. Findings included: Observation on 10/31/24 at 3:25 p.m. revealed the DON and the ADON left the ADON's office. They walked down Hall 300 and exited the facility. Observation revealed the office was adjacent to the nurses' station. Observation on 10/31/24 at 3:30 p.m. revealed there were five unidentified staff within sight of the open door. Continued observation from outside of the doorway revealed there was an over-bed table just inside the office. On the over-bed table was a laptop computer and two medication cards with count sheets secured around them with rubber bands. There was no staff in the office. The State Surveyor asked LVN G to accompany him into the office. Continued observation revealed the first card consisted of 77 tablets of Acetaminophen with Codeine for Resident #18. The second card consisted of 21 tablets of Norco 7.5/325 mg for Resident #14. LVN G verified the contents. Observation and interview on 10/31/24 at 3:33 p.m. revealed the DON and the ADON returned to the ADON's office. The DON said she had just left the room briefly and did not realize the door was not locked. The DON said the Acetaminophen with Codeine tablets were for Resident #18, who was just discharged from the facility. She said the Norco 7.5/325 mg tablets were for Resident #14, but the medication order was discontinued. The DON gathered the medications and took them to her office. In an interview on 10/31/24 at 3:50 p.m. the DON said a nurse (RN L) had brought her the medications. She said she was working on something else and got called away. She said she was away for three minutes. She said the two medications were controlled and should have been locked up. She said that anyone there could have taken them and created a drug diversion. In an interview on 10/31/24 at 3:56 p.m., the ADON said she was not aware that the medications were in her office. She said she would have locked the door had she known. She said someone could have taken one tablet or both of the cards. The person could have overdosed or had a negative health effect. Review of the National Institute of Health information sheet revealed Acetaminophen with Codeine was a Schedule III controlled medication. Review of the National Institute of Health National Library of Medicine information sheet revealed Norco 7.5/325 mg was a Schedule III controlled medication. The facility policy Storage of Medications (revised November 2020) read, in part, .1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.

Based on interviews and record review, the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for the purpose of discipline or convenience for one (Resident #1) of five residents reviewed for chemical restraints. 1. The DON changed the medication order from Seroquel Oral Tab 100 MG to be administered at bedtime to be administered in the morning. Resident #1 slept all day until 7-8pm for 3 days. 2. The DON failed to attain verbal consent from a physician or Resident #1, who was her own responsible party. This failure could place 21 residents who receive medications at the facility at risk for adverse medication effects and potential harm. Findings included: Record review of Resident#1's face sheet dated 03/28/24 revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were bipolar disorder (extreme mood swings), multiple sclerosis (immune system attacking the brain and spinal cord-central nervous system), insomnia (cannot sleep), anemia, obesity, lymphedema (swelling due to build up of lymph fluid), and mood disorder with depressive features. Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS Summary Score of 15 indicating her cognition was intact. The functional limitation in range of motion revealed impairment on both sides of lower extremity. She required substantial/maximal assistance for toileting hygiene, personal hygiene, and she required partial/moderate assistance for lower body dressing. Record review of Resident #1's care plan, last review dated 10/18/23 revealed she was at risk for adverse reactions related to polypharmacy. Interventions and tasks included to: a. discuss with resident and family the number and type of medications resident was taking and the potential for drug interactions and side effects for over medication, b. monitor for possible signs and symptoms of adverse drug reactions (fatigue, lethargy, confusion, poor appetite .), c. request physician to review and evaluate medications, and d. review pharmacy consult recommendations, and follow up as needed. The care plan stated Resident #1 used psychotropic medications such as Seroquel, related to bipolar disorder and depression. Intervention and tasks included a. to administer psychotropic medications as ordered by a physician at bedtime. Monitor for side effects and effectiveness q-shift, b. consult with pharmacy, MD to consider dosage reduction when clinically appropriate, c. monitor and report PRN any adverse reactions to psychotropic medications (fatigue, loss of appetite .). Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] documented that Resident #1 denied symptoms of sad moods, fatigue, loss of appetite, excessive worry/ restlessness, hallucinations, and symptoms of delayed sleep symptoms. It stated that per staff patient continued to refuse to leave room, patient is receptive with care, pleasant with most staff, and no recent behavioral changes. Her mental status was described as oriented to person, place, day, month, and year, her mood was neutral, and her thought process was logical linear. Her current medications were Eskalith (used to treat bipolar disease) 2 300 mg capsules QHS, temazepam 2 15 mg capsules QHS, sertraline 1 50 mg tablet daily, and Seroquel 1 100 mg tablet QHS to treat bipolar disorder. Record review of Resident #1's MAR (medication administration record) revealed that she was ordered to take 1 100 MG tablet of Seroquel by mouth at bedtime related to bipolar disorder. This order was started on 09/13/23 at 2100 (9pm) and discontinued on 03/12/24 at 1006 (10:06 am). On 03/13/24 at 0900 (09:00 am), a new order of 100 MG tablet of Seroquel was ordered to be given by mouth one time a day but was discontinued on 03/16/24 at 1205 (12:05 pm). On 03/16/24 at 2100 (9pm), the order for 1 100 MG tablet of Seroquel was changed back to be given at bedtime. Record review of an Order Audit Report for Resident #1 dated 03/12/24 revealed that the DON changed the order for Seroquel Oral Tablet 100 MG administration from bedtime to the daytime. Record review of an Order Audit Report for Resident #1 dated 03/16/24 revealed that the DON changed the order for Seroquel Oral Tablet 100 MG administration from daytime back to its original bedtime order. Record review of Resident #1's weights and vital from 03/13/24- 03/16/24 did not reveal any changes or adverse reactions. Record review of Resident #1's progress notes showed no notes related to changes in behaviors. -On 03/16/24 at 04:18 pm, LVN A documented the Resident #1 inquired about order for Seroquel Oral Tablet 100 MG being changed from original order that was scheduled during 11pm now changed to 9am. There was no previous documentation regarding medication scheduled change. The medication schedule was changed on 3/12/24 at 9am by the DON. Resident #1 was very angry because she never requested medication change and stated that she was never informed or consented to the change. The DON and Administrator were made aware. -On 03/16/24 at 12:08 pm, the DON documented that the patient was informed of medication time change. Patient was own RP. Original order to be reinstated per resident request. MD notified and was in agreement with change. Record review of the DON's employee file revealed that on 03/27/24, she was involuntarily terminated due to job performance. In an interview on 03/28/24 at 11:19 am, Resident #1 stated that things have been horrible at the facility since the last state visit. She explained that she was bipolar and was prescribed pills for major depression. For a few days, she stated that she was sleeping until 7-8 pm at night. After a few days, she realized that her night dose of Seroquel had been switched so that she would receive it in the daytime. She said this started on 03/13/24 and she found out that it was switched by the DON on 03/16/24. This medication made her sleepy and that explained why she was sleeping throughout the day. She brought her concerns to the weekend LVN when she noticed her giving her the Seroquel medication in the daytime. The weekend nurse looked into Resident #1's concerns and confirmed to Resident #1 that the DON had switched her medication administration time without her consent although Resident #1 was her own responsible party. In an interview on 03/28/24 at 03:26 pm with CNA A, she stated that she had worked at the facility for three years as a medication tech until the facility did staffing adjustments and pulled her to the floor to be a CNA. She explained that nurses had the ability to change orders, but they must receive a verbal or written order from the physician to change it. She described Seroquel as a tranquilizer for behaviors and anxiety, dependent on the resident. CNA A stated that a side effect that she had witnessed from Seroquel was sleepiness. She also recounted that in her time of working as a medication aid for the facility, Resident #1 had always received her Seroquel medication at bedtime. In an interview on 03/28/24 at 03:33 pm with the Admin, she stated that when LVN A called her regarding Resident #1's medication order, she called the DON and asked her why it had been changed. The DON stated that she called Dr. T and he said that it was ok to do so. The Admin explained that with the resident being cognitive, she was not allowed to change it. She stated that to her knowledge, Dr. T did not tell her she could change the order and she felt that she was causing all types of trouble. In an interview on 03/28/24 at 04:49 pm with Dr. T, he said that when he spoke with the DON regarding Resident #1's Seroquel order, the DON made it seem like the order request came from the resident. Resident #1 had resided at the facility for a long time, and he could not remember if he authorized anything for this change. He stated that to make adjustments to orders, there has to be some sort of issue or behaviors. He described Resident #1 as pretty simple and noted that he saw her once a month. He could not recall having any issues with her that would cause him to come in to check on her or want to change the order. If he did have a reason, he would give the order change verbally, but the nurse would document that he was called and gave permission to change the order. In an interview on 03/29/24 at 10:14 am with the DON, she stated that as a result of the last investigation completed with the state (exit date 03/12/24), she had been terminated, and was no longer a part of the facility. She explained that the reason that she was terminated was because of Resident #1 and Resident #2 (will be introduced in additional tags) and she expressed the behaviors noted were not her. When asked about the medication order of Seroquel being switched, she stated that Resident #1 was having lots of behaviors but as a result of the last survey I was terminated, and I do not have a response. Thank you. She ended the call. In an interview on 03/29/24 at 10:20 am with LVN A, she stated that she normally did skin assessments and wound care, but she worked as a medication aid about a week ago. Resident #1 was described as alert and oriented x4 (cognitively intact) and knew all of her medications. When she arrived to her room to provide wound care and administer her medication, Resident #1 stated Oh my god you're here, I need to tell you something. Resident #1 told LVN that she had been feeling really sleepy throughout the day and she believed her medication was wrong or different. Resident #1 was her own power of attorney and she requested that LVN check medications placed in her cup and she informed the resident that her Seroquel order had been changed from bedtime administration to the day time. LVN stated that she sent a text message to the DON and told her Resident #1 had requested to know why the order had been changed because no one informed her, nor did they ask. The DON responded to the LVN that she thought the change in the order would be better for her. After that conversation, she called the Admin and let her know what was going on and she also gave Resident #1 the Admin's phone number. The DON changed the order back to 1 tablet 100 MG Seroquel QHS and the LVN documented this in the progress notes. She explained that in the past 8 months that she had worked at the facility, she had never known the resident to have any behaviors, and if she did, it must be documented in her progress notes. Resident #1 only wanted to sit in her room and would only use her call light if she needed pain medication or needed to be changed. The doctor was could not remember Resident #1's complete medication list and did not note any adverse reactions. In an interview on 03/29/24 at 10:40 am, Med Aide A stated that he no longer worked at the facility as of March 15th, but he had worked with Resident #1 often. He described her as a good person and said that she was always very chill but would be vocal if she needed something. He was not aware of the medication order change; he just administered them as he saw listed on the MAR. In an interview on 03/29/24 at 11:52pm with the Admin, she stated that the risk of falsifying records could put the resident at harm. If staff did not follow physician orders, there could be behaviors with Resident #1's medication or she could be at risk for medication interactions. After the incident with Resident #1, Admin requested a psychiatric referral and they should be coming to the facility soon. Record review of the facility's Medication and Treatment Policy revised July 2016 revealed that: 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized licensed practitioners or individuals authorized to take verbal orders from practitioners shall be allowed to write orders in the medical record. 3. Drugs and biological orders must be recorded on the physician's orders sheet and the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. 4. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. 5. The signing of orders shall be by signature or a personal computer key. Signature stamps may not be used. 6. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescribers last name, credentials, and the date and time of the order. 7. Verbal orders must be signed by the prescriber and his or her next visit. Record review of the facility's Coordinating/Implementing Abuse, Neglect, and Exploitation Policies and Procedures revised April 2021, revealed that the administrator is responsible for the overall coordination and implementation of our facilities policies and procedures against abuse, neglect, exploitation, and misappropriation of resident property.

Based on interviews and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for two (Resident #1 and Resident #2) of five residents reviewed for quality of care. 1. The DON falsified documentation that wound care was given to Resident #1 on 03/15/24 and 03/18/24. 2. LVN B failed to provide wound care services to Resident #2 everyday per physician orders. These failures could place 2 residents who receive wound care at risk for infections, healing regression, and pain. Findings included: 1.Resident #1 Record review of Resident#1's face sheet dated 03/28/24 revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were bipolar disorder (extreme mood swings), multiple sclerosis (immune system attacking the brain and spinal cord-central nervous system), insomnia (cannot sleep), anemia, obesity, lymphedema (swelling due to build up of lymph fluid), and mood disorder with depressive features. Record review of Resident #1's care plan, last review dated 10/18/23 revealed she had bladder/bowel incontinence r/t impaired mobility and MS. Interventions were Clean peri-area with each incontinence episode, incontinent: check the resident every 2 hours and as required for incontinence care and PRN. Resident #1 has Multiple sclerosis and interventions/tasks were Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments .Monitor/document/report to MD PRN: S/SX of damage to motor and sensory control centers: urinary frequency, urgency or retention, urinary or fecal incontinence, constipation. She had an ADL Self Care performance deficit r/t MS, limited mobility with interventions to praise all efforts at self-care, transfer. Resident required extensive assist x 1 staff participation to reposition and turn in bed, encouraged to participate to the fullest extent possible with each interaction. For personal hygiene/oral care, the Resident #1 required an extensive assist x1 staff participation with personal hygiene and oral care. Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIMS Summary Score of 15 indicating her cognition was intact. The functional limitation in range of motion revealed impairment on both sides of lower extremity. She required substantial/maximal assistance for toileting hygiene, personal hygiene, and she required partial/moderate assistance for lower body dressing. Record review of Resident #2's Clinical Orders reflected that a wound care order on the big toe had begun on 02/17/24. Orders stated to clean wound on right big toe with wound cleanser, pat dry, apply TBA Ointment, cover with dry dressing every day until healed. Once healed start on Clotrimazol solution for nail fungal infection. DC this order when wound care from ingrown toenail heals. One time a day for Wound healing. Resident #2 also had an order to complete the Braden scale weekly assessment started 11/13/23. Record review of Resident #1's WAR (wound administration record) revealed that on 03/15/24 the DON signed off that she performed wound care for the resident. On 03/18/24, the DON signed off that she completed wound care, and that she completed the Braden skin weekly Assessment. Record review of the DON's employee file revealed that on 03/27/24, she was involuntarily terminated due to job performance. In an interview on 03/28/24 at 11:19 am, Resident #1 stated that she had a wound on one of her toes and it was bandaged. She stated that the DON would lie and say that she provided wound care, and it would display that on the computer. She stated the DON was not allowed in her room and expressed so how was she going to take care of it. She described the DON as a bully ass lady and believed that staff were afraid to talk about it. Resident #2 stated to check 03/15/24 and 03/18/24 or 03/19/24 and it would reflect that the DON signed off on care because she was the nurse on the floor. In an interview on 03/29/24 at 11:52pm with the Admin, she stated that the risk of falsifying records could put the resident at harm. If staff do not follow physician orders, there could be behaviors with Resident #1's medication or she could be at risk for medication interactions. She stated that the DON was not allowed in Resident #1's room so there was no way she could have completed wound care. She explained that the facility made the right decision with terminating her employment. 2.Resident #2 Record review of Resident #2's facesheet revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were type 2 diabetes (affects your body's ability to use insulin and causes high blood sugar levels), heart failure, morbid (severe) obesity, chronic kidney disease, and peripheral vascular disease (a condition that narrows the arteries and reduces blood flow to the arms or legs). Record review of Resident #1's comprehensive MDS assessment dated [DATE] reflected a BIMS score a 05, moderately impaired. Record review of Resident #2's care plan showed that there was not a completed care plan as of 03/29/24. Record review of Resident #2's Clinical orders revealed that she had 3 wound care orders. a. (revised 01/24/24) ordered non-surgical cleansing or right lower leg. Wound spray-collagen -ABD pad- kerlix/ coban (elastic bandage wrap) daily. b. (revised 01/24/24) ordered mid abdomen- nonsurgical cleansing/ wound spray- collagen- pat dry apply- mupirocin ointment. Cover with dry sterile dressing. c. (revised 01/22/24) ordered non-surgical cleansing to wound bed then cover with xeroform then cover with dry dressing. Clean wound to left calf with NS (normal-saline), apply collagen powder and xeroform to wound base, cover with ABD pad and wrap with kerlix dressing and ace bandage every day and as needed. Record review of Resident #2's WAR (wound administration record) for March 2024 reflected that Resident #2 did not receive wound care services for her three wounds on 03/12/24, 03/20/24, 03/21/24, 03/22/24, and 03/27/24. Record review of Resident #2's progress notes from 03/04/24 through 03/29/24 did not display any notes that indicated why the resident did not receive wound care on dates 03/12/24, 03/20/24, 03/21/24, 03/22/24, and 03/27/24. Progress note written by CNA B on 01/22/24 displayed: Note Text: Resident AOx4 (alert and oriented, cognitively intact), stable and able to make her needs known. Resident stating that she is to receive wound care treatment daily to the left leg and abdomen. She stated that the last wound treatment she received was on Wednesday 1/17/24 by wound care physician. There were no wound care orders on PCC (online resident portal) for resident. ADON (ex- employee) notified via text message regarding this matter. She replied that she would follow up on matter tomorrow 1/22/24. Record review of the March 2024 Staff Schedule reflected that LVN B was the floor nurse on 03/12/24, 03/20/24, 03/21/24, 03/22/24, and 03/27/24. In an interview on 03/28/24 at 12:03 pm with Resident #2, she stated that she had a wound on her leg and an outside lady from another place came in once a week to perform wound care. She recalled that the last time her wound was changed was on Tuesday and it was supposed to be changed every day, although they do not change it like they were supposed to. She stated that on 03/25/24, an aid was changing her, and they could smell an odor coming off of the wound. She described the wound as smelly. In an interview on 03/28/24 at 01:06 pm with LVN B, she expressed that she was the nurse and her duties included wound care and as of 03/25/24, medication passes. She felt that this change made it difficult for her to complete her daily tasks and that it put too much on her. She stated that management explained the reason her duties were expanded was due to the census being low (currently 21). LVN B was asked about the wound care orders for Resident #2 and she logged into PCC to review. She stated that as of 01/24/24, Resident #2 was supposed to receive wound care every day. She asked, how am I going to do that every day? and stated that she would be working until 03/30/24. LVN B stated that nurses were supposed to do wound care on Wednesday's, even if the wound care company came in. She was told that the nurses still needed to try but stated that sometimes it didn't get done. She stated that if she did not complete her tasks, she should notify the DON but she was unsure if she was still employed at the facility. When asked when the last time she treated the wound, she said that she would have to check the WAR but she knew it was done over the weekend by LVN A. In an interview on 03/28/24 at 04:43 pm with the Admin, she stated that wound care came to the facility every Wednesday and they were there on 03/27/24. The wound care company progress notes were requested, and they were sent that evening after 5pm. Record review of the wound care company's provider notes reflected that on wound care was provided to Resident #2 every Wednesday. Wound description listed the following measurements on service dates: 1/31/2024-4.5x4.8x0.2 2/7/2024-6.0x4.8x0.1 2/14/2024-6.0x4.8x0.1 2/21/2024- 5.8x4.6x0.2 2/28/2024-5.6x4.5x0.2 3/6/2024-5.6x4.5x0.2 Dates of services in March were 03/06/24, 03/13/24, 03/20/24, and 03/26/24. Progress note on 03/13/24 noted that the wound on the left posterior lower leg had a distressing pain level of 4, no odor, and heavy exudate (fluid that leaks out of blood vessels into nearby tissues). Progress note on 03/20/24 noted that the wound on the left posterior lower leg had a distressing pain level of 4, mild odor, and heavy exudate. Review of wound care note on 03/26/24 measured the wound at 5.2x4.2x0.3 cm and was without odor with moderate exudate. Each progress note documented that the wound had a poor wound progression due to immobility, comorbidities, and age determinants. In an interview on 03/29/24 at 11:52 am with the Admin, she stated that the duties of nurses were expanded to include medication administration on top of normal duties, but the facility had a census of 21 and they had not received any new admissions or doctor's since she had been hired on 03/03/24. She explained that the facility was fully staffed and pulled up the staffing schedule per shift which included two aides who worked with 11 residents a piece and 1 nurse. She stated that she asked LVN A to come in today to assist LVN B so that she could assure all of her tasks were completed. Admin further explained that each nurse worked a 12 hour shift (6am- 6pm) and that completion of daily tasks boiled down to time management. She stated that if she did not have time to complete wound care, she should have let the DON, who oversees nursing staff, and the night shift nurse know so that it could be completed. Admin explained that not following physician orders could lead to harm and if there was a problem, the facility could miss it, and the problem could be caught too late. Record review of the facility's Charting and Documentation Policy revised July 2017, revealed that documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The following information is to be documented in the resident medical record: a. Objective observations b. Medications administered c. Treatments or services performed d. Changes in the resident's condition e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives.

Based on observation and interview, the facility failed to ensure each resident had a right to be free from abuse and neglect for 2 (Resident #1 and Resident #2) of six residents reviewed for abuse and neglect. -The DON caused emotional abuse to Resident #1 who was diagnosed with bipolar disorder and still had menstrual cycles when she cursed at Resident #1 and stated she could not have any more than 8 adult briefs for 2 days. -The DON caused emotional abuse to Resident #2 when she stated that Resident #2 got on her nerves when she used her call light multiple times. Findings included: Record review of Resident#1's face sheet dated 3/8/24 revealed she was admitted on [DATE] with diagnoses of bipolar disorder (extreme mood swings), multiple sclerosis (immune system attacking the brain and spinal cord-central nervous system), insomnia (cannot sleep), anemia, obesity, lymphedema (swelling due to build up of lymph fluid), and mood disorder with depressive features. Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS Summary Score of 15 indicating her cognition was intact. The functional limitation in range of motion revealed impairment on both sides of lower extremity. She required substantial/maximal assistance for toileting hygiene, personal hygiene, and she required partial/moderate assistance for lower body dressing. Toilet transfer was not attempted due to medical condition or safety concerns. She was always incontinent of urine and bowel and was at risk of pressure ulcers/injuries. Record review of Resident #1's undated care plan dated 10/18/23 revealed resident had bladder/bowel incontinence r/t impaired mobility and MS. Interventions were Clean peri-area with each incontinence episode, incontinent: check the resident every 2 hours and as required for incontinence care and PRN .Resident #1 has Multiple sclerosis and interventions/tasks were Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments .Monitor/document/report to MD PRN: S/SX of damage to motor and sensory control centers: urinary frequency, urgency or retention, urinary or fecal incontinence, constipation. She has an ADL Self Care performance deficit r/t MS, limited mobility with interventions to praise all efforts at self-care, transfer: the resident requires extensive assist x 1 staff participation to reposition and turn in bed, encourage the resident to participate to the fullest extent possible with each interaction .personal hygiene/oral care: the resident requires extensive assist x1 staff participation with personal hygiene and oral care. In an interview on 03/8/24 at 11 a.m., Resident #1 stated that she was out of diapers, and she drinks 6 or 7oz cups of water a day. She stated that on the daily, she urinated a lot and the DON passed diapers on Tuesday and Thursday. Resident #1 stated the CNA had to get diapers from another resident's room so that she could be changed. Resident #1 stated the size 3X diapers came with 8 in a pack. She stated the DON kept the diapers locked up in her room and if the DON was gone, Resident #1 needed diapers. Resident #1 stated the DON was not allowed in her room anymore because they had gone back and forth in conversation regarding the diapers (unknown date). She explained that the DON said I ain't giving you shit, you got diapers and I knew I should not have went in there (Resident#1's room) wasting my got damn time. Resident #1 described the DON as raw and stated the staff were scared and did not want to say anything. Resident #1 stated the DON made her feel bad and the DON should not talk down on anyone. She expressed that she had bipolar disorder, and it got her frustrated where she called her family member hollering, screaming, and crying because the DON had thrown her into a [NAME]. Resident #1 stated the 3X diapers came with 8 to a pack. She stated the DON kept the diapers locked up in her room and when the DON was gone Resident #1 needed diapers. In an interview on 03/8/24 at 11:40 a.m., CNA A described the DON's communication style as someone who would talk to her crazy. She stated she saw the DON leave Resident #1's room and talk badly about Resident #1 after the DON told Resident #1 about the number of diapers she was given and the DON stated that was all Resident #1 was getting. CNA A stated on 02/23/24 while she was in the room with Resident #1 and the DON, while Resident #1 was talking to the DON, the DON walked out during the middle of her conversation and continued doing what she was doing. CNA A stated that CNAs did not have access to supplies, did not get trash bags anymore, and had to use what supplies the DON put in the rooms. CNA A also stated that she worked Friday, Saturday, and Sunday when Resident #1 was short on diapers. She explained that Resident #1 received 2 packs of diapers on Fridays with only 8 diapers in them (16 total) until Monday. She explained when Resident #1 had her menstrual cycle, she would go through a whole pack on her 12-hour shift. In an interview on 3/8/24 at 12:10 p.m. with CNA B she stated she has heard the DON say to Resident #1, who still had a menstrual cycle and she needed diapers to tell the family to bring Resident #1 pads because she was on her cycle and that was not her business. CNA B stated the DON limits Resident #1's diapers. CNA B stated she asked the DON for more diapers for Resident #1 and the DON told her that she could not bring more diapers to Resident #1 and she was about to be out of them. CNA B stated she was in the room when the DON said Resident #1 was not getting more diapers. CNA B stated Resident #1 was stressed and worried because she said she did not know what to do and that she needed diapers right then and she did not know what to do. CNA B stated Resident #1 needed to be changed right then and Resident #1 said she needed to wait until tomorrow to get a diaper change. CNA B stated Resident #1 was worried. CNA B stated she went and found diapers for Resident #1 from another resident because the DON refused to give Resident #1 diapers and that was the 2nd time she did that. CNA B stated the previous facility Administrator had to help Resident #1 with diapers because the DON does not go into Resident #1's room. CNA B stated the diapers were not accessible to the CNA's. In an interview on 3/8/24 at 1:59 p.m., the Administrator stated there was no certain number of supplies a resident could have. She stated the residents were able to request more supplies if they need it. She stated the staff round every 2 hrs. and they change the residents if they need to be changed. The Administrator stated the CNAs worked 12 hour shifts and if a resident has urinated or had a bowel movement that would be 6 diapers per shift. The Administrator stated the DON was a brand new DON and never been a DON before and she does not know if she had been trained yet. The Administrator that today was the Administrators 2nd day working at the facility. She stated she had not heard that the DON told a resident that she was getting on her nerves and that customer service was number 1 for her. In an interview on 03/8/24 at 6:57 p.m., with Resident #1's family member, she stated she was so furious she thought she was going to pass out and she did not know how to handle it. She stated the DON had such a bully attitude, a real nasty attitude. Resident #1's family member stated how is she going to use 8 diapers until she gets more on Friday and the DON would not give her [Resident #1] any diapers. She stated she thought it was so ridiculous that the DON could not give Resident #1 more diapers. Resident #1's family member stated she was furious and thought it was very wrong to tell her that and for the DON to have the position she has; she is very rude and has a bully attitude and it really upsets her. She stated she thought the DON was extremely rude and that is totally neglect. She explained, What was she to do, she needed to be changed and she could not get a diaper. She stated the DON just walked out of the room while Resident #1 was trying to explain to her, and she would not allow her to explain. She stated the CNA was in the room when she was talking to Resident #1 and she asked the DON if she could get a diaper to change Resident #1 and was told no. She stated, it was extremely, extremely neglectful to have somebody laying needing a diaper change and could not get it. Record review of Resident#2's face sheet dated 3/8/24 revealed she was admitted on [DATE] with a diagnosis of bipolar disorder current episode depressed (extreme mood swings), hemiplegia and hemiparesis (severe or complete loss of strength in the arm, leg and/or the face on one side of the body), cerebral infarction (stroke-damage to the issue in the brain due to a loss of oxygen), asthma, type 2 diabetes (high blood sugar), congenital malformation of esophagus (birth defect where the tube that connects the mouth to the stomach does not develop properly), osteoarthritis (degenerative joint disease), major depressive disorder, obstructive sleep apnea, overactive bladder, and right upper quadrant pain. Record review of Resident #2's MDS assessment dated [DATE] revealed a BIMS Summary Score of 11 indicating moderate cognitive impairment. Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's undated care plan revealed resident had chronic pain r/t cerebral vascular accident, uses antidepressant medication r/t depression, communication problem r/t neurological symptoms with interventions to anticipate and meet needs, be conscious of resident position when in groups, activities, dining room to promote proper communication with others, discuss with resident/family concerns or feelings regarding communication difficulty, Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. Monitor for/record confounding problems: decline in cognitive status, mood, decline in ADL, deterioration in respiratory status, oral motor function, hearing impairment (ear discharge and cerumen (wax) accumulation, poor fitting/missing dental appliances etc. Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. Monitor/document/report to MD PRN changes in: Ability to communicate, Potential contributing factors for communication problems, Potential for improvement. OT/PT/Nurse to evaluate resident dexterity/ability to use communication board, writing, use computer or use of sign language as alternate communication to speech. Refer to speech therapy for evaluation and treatment as ordered. Use communication techniques which enhance interaction: Allow adequate time to respond, Repeat as necessary, Do not rush, Request feedback, clarification from the resident, to ensure understanding, Face when speaking and make eye contact, Turn off TV/radio as needed to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures and validate resident's message by repeating aloud. In an interview on 3/8/24 at 10 a.m. with Resident #2 she stated the DON says sometimes she get on their nerves .Resident #2 explained that the DON stated that she [Resident #2] was getting on her nerves and said it in a mean way. Resident #2 stated she told the DON you know I don't appreciate it, and don't talk to her like that. Resident #2 stated the DON gets upset. Resident #2 stated that it made her feel bad and that it was serious to her. She stated the DON told her more than one time that she was getting on her nerves (unknown dates) and she told the DON don't treat her like that. In an observation and interview on 3/8/24 at 12:50 p.m. with the DON of the diaper supply in the central supply room she stated the residents received 2 bags of diapers for the weekend and she puts in gloves, wipes, and chucks. She stated she ordered weekly or biweekly what she needed, but this was her first time putting an order in. The DON stated she passed out 1 pack of diapers on Mondays and Wednesdays and 2 packs of diapers on Fridays. The DON stated on Wednesdays she gave out diapers only as needed. The DON stated everyone received 2 packs of whatever size diapers they wear, and the residents receive diapers according to weight and Resident #1 wore a size 3x. The DON stated size 3x had 8 diapers in it, large had 18 diapers, 4x and 5x had 8 diapers in a pack, and medium had 24 diapers in a pack and the residents receive 2 packs so that they do not run out. The DON stated she was giving Resident #1 diapers (to last from Friday to Monday) because the diapers were more absorbent than the large ones. The DON stated she did not tell Resident #1 she was not giving her any more diapers because she did not even go in her room anymore. The DON stated she gave the same number of packs of diapers to each resident more than once and double on the weekends. The DON stated on Monday Resident #1 received 1 pack and sometimes Resident #1 did not need any diapers on Monday. The DON denied telling Resident #1 that she was not giving her any more diapers because she did not go into her room anymore, per Resident #1's request. The DON stated since she had been there, Resident #1 had not run out of diapers because she passed them out herself and she denied telling Resident #2 that she got on her nerves, exclaiming wow, absolutely not. The DON stated she had only made 1 order for Central Supply and she did not keep a record of it at all. She stated on February 7, 2024 the facility changed owners. She stated she made her first order last week In an interview on 03/8/24 at 3:12 p.m. with the DON, she explained that the residents probably got changed before breakfast and every 2 hours so there was a diaper change at least 4-6 times per shift and Resident #1 had 8 adult diapers. The DON stated that in one 12-hour shift, Resident #1 would use at least 6 diapers. The DON stated there was no changing diapers during meals, so 6 diapers is the math of it. She stated they did morning care, after breakfast at around 10 am, after lunch that's a change around 1pm, between 3 and 4 before dinner they will change Resident #1. The DON stated if the CNA did their last round before dinner, they go home at 6 pm and the next shift comes in. She stated the CNA would change Resident #1 at around 8 pm, and with Resident #1 she asks to be changed if they do not change her. She stated they would change Resident #1 in the middle of the night 2 times and between midnight and 4 a.m. Resident #1 was asleep. There are 3 meals in morning shift so there is no change during meals. The DON stated there was a diaper change at least 4 times in a 12-hour shift. She explained that when Resident #1 was on her cycle, a CNA would give Resident #1 a white brief (small), because she liked to line the diapers in her brief. The DON explained that she ordered chucks (bed pads that protect beds and other surfaces from bodily fluids) to benefit Resident #1. In an interview with the Administrator and record review of the DON's employee file on 03/12/24 at 2:05 pm. revealed that there was not a signed Abuse and Neglect document for the DON. The Administrator stated she called the corporate HR to check if there was an electronic copy but was informed that the company did not require that documentation at that time. The Administrator stated she would be implementing that for all current staff and new hires going forward. Record review of in-service for abuse and neglect titled staff development/ Inservice Attendance sheet dated 3/11/24, revealed the DON was present. Record review of in-service for Resident Rights titled staff development/ Inservice Attendance sheet dated 3/11/24, revealed the DON was present. Record review of the facility's policy titled Coordinating/ Implementing Abuse, Neglect, and Exploitation Policies and Procedures, revised April 2021, stated that: -The administrator is responsible for the overall coordination and implementation of our facility's policies and procedures against abuse, neglect, and misappropriation of resident property. -Any identified deficiencies in process that may lead to abuse, neglect, or exploitation or residents are addressed by the QAPI committee. Record review of the facility's policy titled Resident Rights revised February 2021, stated: -Residents have the right to a dignified existence, to be treated with respect kindness, and dignity, and to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent elopement.for 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 walked out of the facility unattended and was missing for 2 hours on 2/08/24 around 8:00 PM, until hospital staff contacted the facility. This failure could affect residents with diagnose of dementia at risk of elopement thus placing themselves at risk of physical harm, pain and mental anguish or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 2/16/24 at 1:00 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 2/16/24 at 1:00 PM. While the IJ was removed on 2/19/24 the facility remained in violation at a scope of Isolated at a severity level of no actual harm with potential for more than minial harm because all staff had not been trained on the facility's newly developed implementation and effectiveness of their Plan of Removal. Findings Included: Record review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of depression, hearing loss, fall, osteoarthritis, morbid obesity, muscle weakness and abnormalities of gait. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 6 cognitively impaired. She required assistance for ADL's, Ambulation and Cognition. In the care assessments interviewed done on 11/21/23 the following care area triggered were Cognitive loss/dementia, communication, ADL functional rehab potential and psychotropic use. Record review of Resident's Wandering and Elopement Risk assessment dated [DATE] revealed score of Nil minimum risk and no current observable evidence of wandering. Record review of Nursing admission assessment dated [DATE] section N wandering and elopement risk assessment revealed that Resident #1 did not have a history of being a regular walker, therefore, Resident's #1's wandering and elopement risks assessment dated [DATE] revealed a score of Nil minimum risk. Record review of Nurses Progress Notes dated 2/08/24 at 9:39 PM revealed: patient left facility and was found at the hospital. Ambulance was called to go to hospital to bring Resident #1 back to the facility. Resident brought back to facility by City Ambulance, awake and alert. First reading vitals: BP 204/78 O2-99, RR 16. On second reading BP 194/84, HR 75 Temp. 99.9, RR16. In an interview with RN A on 2/10/24 at 10:45 AM she stated that on 2/08/24 at 9:00 PM she got a call from the hospital ER Charge Nurse asking was resident #1 in the facility. RN A thought Resident #1 was in her room but when she went to check Resident #1 was gone. She stated that she had arrived at work at 6:00 PM and was helping other residents. She stated that she had seen Resident #1 during the start of her shift. She also stated that Resident #1 requested that she wanted to go to her room and lie down. RN A took Resident #1 to her room and assisted her in bed. RN A stated that she put Resident #1 to bed at around 7:15 PM. Around 9:00 PM she got a call from the hospital. In an interview and observation with Resident #1 on 2/10/24 at 10:10 AM revealed she was in her room, and she was alert and oriented to self. She was confused. She acknowledged and stated that she went out for a walk and did not tell anyone. She stated that she walked outside the back (did not know which door she exited) into the parking lot. She said she did not have her car, so she kept walking towards the hospital where she works. She stated that she did not get hurt and she walked at a steady pace. In an interview with Resident #1's ROP on 2/10/24 at 10:30 AM he stated that last Sunday 2/04/24 he was visiting Resident #1. He stated that Resident #1 was walking all over the facility and he stated that he can't keep up pace with Resident #1. In an interview and observation walk through with the Administrator and Maintenance Director on 2/13/24 at 11:30 AM she stated that Resident #1 must have exited at the door closed to where the slot machines were adjacent to the dining room. She exited the side door and opened gate that was locked in the outside but for safety reason the gate can be open from the inside and makes alarm. It took us eight minutes from the parking lot to the ER . The street was not very busy when we crossed it. There were no cars observed going through the street. Observed the alarm go off and then stop once the gate closed again. The Maintenance Direcror stated that alarms were working; but once the door closes the alarm shuts off automatically. The Maintenance Director stated that he will in-service the staff to check the exit doors when the alarm goes on to make sure that no resident had exited and all residents are accounted for. In an interview with RN A on 2/13/24 at 3:30 PM she stated that she heard the alarm door, but she ignored the alarm because she stated that someone opened the door and when they came in and closed the door, the alarm shut off. Record review of google maps revealed the local hospital was about .3 miles from teh facility, an around a 6 minute walk along the feeder road to a major highway. In an interview on 2/13/24 at 4:10 PM the DON stated that the facility did not have a policy on supervision. An Immediate Jeopardy was identified on 2/16/24 at 1:00 PM. The IJ Template was provided to the facility on [DATE] at 1:00 PM. The following Plan of Removal submitted by the facility was accepted on 2/17/24 at 10:45 AM. Date:2/17/2024 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 2/16/2024 an investigation on a self-report was initiated at [Facility] at 1:00 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F689 - Accidents and Supervision The facility failed to ensure Resident #1 received adequate supervision to prevent Resident #1 from eloping from the facility. Immediate action: Immediate assessment of Resident #1 was completed for any bruising and or skin issues, none noted or observed. Family notified. MD notified. Inservice to all nursing and C.N.A staff was completed on 2/16/2024 by DON, regarding rounding on every patient, especially those that like to walk around. Resident #1's care plan was updated on 2/17/2024 by the Director of Nursing to reflect elopement risk with resident specific focus, goals and interventions including 1:1 supervision. Any staff not attending will be in-serviced upon their return to work, before their next shift. Identification of Others The Director of Nursing/Designee completed an elopement risk assessment of all residents to determine which residents were an elopement risk. Elopement risk assessment was completed on 2/17/2024. No other resident had any risk of elopement. Resident#1 was the only identified elopement risk and as stated above, her care plan was updated to reflect associated focus, goals and interventions to protect her from elopement by the DON. Systemic Change Hourly rounding orders implemented into system by Director of Nursing on 2/16/2024. Nurses ensured that Resident#1 is in the building every hour during each shift and record the documentation into PCC system until Resident can be transferred to a facility with a memory care unit as per the request of the responsible party. Hourly rounding to be done by CNA and Nurse and recorded on nurse MAR. The patient's responsible party states his mother needs a more secure unit such as memory care, due to wandering. Patient is being transferred to facility with locked memory care unit. Patient evaluated 2/16/2024 by receiving staff. Currently awaiting discharge date from receiving facility. Resident is up and out of bed daily and in communal area where she can be always supervised by nurse and CNA staff, any elopement attempts are redirected by activities and snacks and staff members she can walk around with and will be supervised at all times. Education was provided to all Nurses and CNA's, by the Director of Nursing/Designee regarding the plan to complete and verify accurate head count on each patient by round every two hours and as needed. Education included that the whereabouts of each patient having elopement risks will be documented as needed per shift. All future staff to be in-serviced at time of hire regarding elopement and rounding. The above education was completed on 2/16/2024 by the Director of Nursing/designee Any staff not in attendance l for this Training will be educated upon their return prior to the next shift worked. Monitoring The Director of Nursing/designee will conduct monitoring daily Monday- Friday for 4 weeks then weekly 8 weeks to verify that rounding is being completed and documented as well as head counts and whereabouts of residents at risk for wandering. Any concerns identified through these audits will be addressed and corrected immediately and staff education and resident interventions implemented as needed. Monitoring/one on one begin 2/17/2024 as stated above. Ad hoc QAPI meeting held with the IDT and Medical Director to review policy associated with wandering and elopement risk as well as this Plan of removal/response to Immediate Jeopardy Citation 2/16/2024 @1445. The surveyor confirmed the facility implemented their plan of removal sufficiently from 2/17/24 through 2/19/24 to remove the IJ by: 1. Record reveiw of immediate assessment of Resident # 1 was completed on 02/09/24 at 1:23PM for any bruising and or skin issues, none noted or observed. Family notified and Physician notified. 2. Record reveiw of inservice to all nursing and CNA staff was completed on 2/16/2024 by DON regarding rounding on every resident, especially those that like to walk around. 3. Record review of Resident #1's care plan was updated on 2/17/2024 by the Director of Nursing to reflect elopement risk with specific focus, goals and interventions including 1:1 supervision. 4. The Director of Nursing/Designee completed an elopement risk assessment of all residents to determine which residents were on elopement risk. Elopement assessment risk was completed on 2/17/2024. No other resident had any risk of elopement. Resident #1was the only identified elopement risk and as stated above, her care plan was updated to reflect associates focus, goals and interventions to protect her from elopement by DON. 5. Record review of hourly rounding orders implemented into system by DON on 2/16/2024. 6. Record reviewed of documentation of Nurses ensured that Resident #1 is in the building every hour during each shift record the documentation into the PCC System (Electronic Medical Record) until resident can be transferred to a facility with memory care unit as per the request of the responsible party. 7. Record review of Hourly rounding completed by CNAs and Nurse and recorded on nurse's MAR. 8. Resident #1's responsible party stated that Resident #1 needs a more secure unit such as memory care due to wandering. 9 Resident #1 is being transferred to facility with locked memory care unit. Resident evaluated on 2/16/2024 by receiving staff, currently awaiting discharged date from receiving facility. 10. Observation of Resident #1 is up and out of bed daily and in communal area where nurse and CNA staff can always supervise her. Activities, snack, and staff member redirect any elopement attempts. Resident #1 can walk around with and will be always supervised. 11. Education was provided to all nurses and CNAs by the DON/designee regarding the plan to complete and verify accurate head count on each resident by round every two hours and as needed. 12. Education included that the whereabouts of each residents having elopement risks will be documented as needed per shift. It was verified that Resident #1 was evaluated for discharge on 2/16, but the receiving facility was not ready to admit resident #1 at 2/16/24. Record review completed of Resident #1's Elopement Assessment done on 2/17/2024. Resident #2; Resident #3; Resident #4; Resident #5; Resident #6 and Resident #7 is in the process of being done, completion date will be 2/17/2024. Nurses' interview re- in-services had several in services and most recent in services was 2/18/2024. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, assessing resident for pain, management, gastrostomy tube, dressing. Check exit doors when alarm activated. Do head count to make sure no resident missing. Nurses verified the training received on the updated care plan which includes 1:1 supervision for Resident #1. Interviewed RN C on 2/18/2024 at 10:15 AM; RN B on 2/18/2024 at 1:00 PM; LVN D on 2/18/2024 at 1:15 PM LVN E on 2/18/2024 at 1:30 PM; LVN F on 2/18/2024.at 8:47 PM CNAs interview- Had several in services and most recent in services was on 2/18/2044. CNAs verbalized checked all exit doors when alarm activated and do head counts to make sure no resident missing, check resident every 2 hours, check if resident still breathing, listen to alarm if people are coming in or going out. CNAs verified the training received on the updated care plan which includes 1:1 supervision for Resident #1 Interviewed CNA A on 2/18/2024 at 10:30 AM; CNA B on 2/18/2024 at 10:45 AM; CNAC on 2/18/2024 at 11:00 AM; CNA D on 2/18/2024 at 11:15 AM; CNA E on 2/18/2024 at 8:50 PM; CNA F on 2/18/2024 at 9:00PM Interview with the DON on 2/19/24 at 10:00 AM revealed that training, rounding, walking, talking with confused resident, know where they are, always do rounds, documenting hourly rounds in MAR. As per IJ the facility does not have the Wander Guard System. How the resident exited, no one heard the alarm, dropped the ball. Interview with the Administrator on 2/19/23 at 10:30 AM. As per the IJ we were not aware of Resident # 1's medical diagnosis. She stated that if she had known that resident had Alzheimer's possibility of elopement looked for a secured unit for the resident to be safe. Did not know until spoke to ROP prior to visiting resident when surveyor arrived in the facility for a P1 intake. The ROP stated he was told by a medical provider that Resident # 1 has Dementia Stage 4. Resident's history was not disclosed upon admission in November 2023. She stated that she started to work here three weeks ago. While the IJ was removed on 2/19/24 the facility remained in violation at a scope of Isolated at a severity level of no actual harm with potential for more than minial harm because all staff had not been trained on the facility's newly developed implementation and effectiveness of their Plan of Removal.

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 5 residents (CR#1) reviewed for quality of care. The facility failed to ensure LVN B properly assess CR#1 when he gave medication on [DATE] at 9:00am when CR#1 vomited, aspirated and later died . The facility failed to ensure that CR#1 was checked on every two hours and was not laying in her vomit from 7:15 am until 11:15am on [DATE]. The facility failed to ensure that CNAs report to the charge nurse when they found CR#1 in her own vomit. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE] at 1:18pm, the facility remained out of compliance at a scope of Level 2 (E) Although there was IJ for one person, the potential for more than minimal harm is a pattern due to the number of staff involved, the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures could place residents who are fed via feeding tube at risk for delayed treatment that could lead to severe injury, aspiration and/or death. Findings Included: CR#1 Record review of CR #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. CR#1's diagnoses included hypertension (high blood pressure), severe protein calorie malnutrition (lack of protein and calories to meet nutritional need), atrial fibrillation (rapid heartbeat that causes poor blood flow), depression (a medical illness that effect the mood), anemia (condition where the blood does not have sufficient red blood cells( dementia (memory loss), acute cerebrovascular insufficiency (condition that affects the blood flow to the brain), gastrostomy (a surgical procedure where a tube is inserted in the stomach for feeding), chronic kidney disease (the inability of the kidney to filter waste and excess fluid from the blood), type 2 diabetes (high blood sugar, epilepsy ( is a brain disorder that causes recurring unprovoked seizures). Insomnia (difficulty falling asleep). Record review of CR#1's MDS dated [DATE] revealed the resident was coded for Cognitive Skills for Decision Making as severely impaired, indicating that CR#1 was not able to make sound decision. She was coded as total care for ADL's, incontinent of bowel and bladder and was fed via a feeding tube. Record review of CR#1's care plan revealed the resident was fed via a feeding tube due to dysphagia. CR#1 will be free from aspiration. Intervention: monitor/document and report to MD PRN: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Tube dysfunction or malfunction, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Record review of nurse's notes written on [DATE] by LVN T revealed resident returned to facility via ambulance with [family member accompanying resident. Resident in stable condition. Vital signs within normal limit. incontinent b/b. NPO. continues feeding of diabetisource 70ml/hr. 40ml/hr. flush. Antibiotic noted for UTI, resident bedbound. total assist x1. stage 3 wound @ L hip and wound @ ankle. resident lying in bed watching TV. bed in lowest position. call light in reach. will continue to monitor. Record review of Resident #1s' Physician Orders revealed the following orders dated: [DATE]: Check G-tube placement by aspirating gastric contents before feeding or before giving medications, every shift. [DATE] nurses' revealed start date [DATE]: G-tube: h2o ,d+[DATE] ml PGT before and after medication administration - monitor q shift. G-tube: h2o ,d+[DATE] ml PGT between each medication - monitor q shift. G-tube: check for residual prior to feeding / medication administration q shift. hold feeding / medication & notify MD if residual > 100 ml. Record review of the nurse's progress notes revealed no documentation regarding CR#1's activities on [DATE] in the day until 9:05pm when CR#1 became unresponsive and was sent to the hospital via 911. Record of the CR#1's assessment sheet revealed no assessment for CR#1 during the morning of [DATE]. Record review of the hospital notes dated [DATE] revealed that 911 was called at 9:22pm and CR#1 was sent to the hospital as per family request, the resident coded and was rerouted to a hospital closer to the facility. Record review of the hospital documentation dated [DATE] revealed CR#1 coded CPR initiated, and the cause of the resident death was cardiac arrest. Record review of the Autopsy Report dated [DATE] read in part . date of death [DATE]. Respiratory System: Aspirate foreign material consistent with gastric content - trachea, right and left bronchi and lungs. Pulmonary congestion and edema (combined weight 1105 grams) ,d+[DATE] grams (Right and left lobes lungs). Serous effusion (approximately 150 ml) right pleural cavity. Gastrointestinal System: Severe fecal impaction with dilated rectum. Polyp (up to 1.2 cm) descending colon. Status - Post gastrotomy placement in tack Hepatic and Binary System Atrophy (820grams: ref: ,d+[DATE]), liver. Cholelithiasis (multiple pigmented gallstones - up to 1.2cm), gallbladder. Genitourinary System: Probable benign nephrosclerosis, right and left kidney. Opinion: Based on the findings of the reasonable medical probability investigation information available at this time it is the opinion the decedent CR#1 died as a result of aspiration complicated of atherosclerotic cardiovascular diseases. In an interview on [DATE] at 1:50pm LVN B said he worked with CR#1 on [DATE] and he did not see any change in her condition. He said she did not vomit on his shift, and no one told him that she was vomiting. Further interview with LVN B, he said he gave CR#1 her medication that morning and he did not see any vomit on her. In an interview on [DATE] at 2:10 p.m. LVN A said she worked with CR#1 on [DATE] and she did not see any change in her condition, and she did not see her vomiting, nor did she see any vomit on her. She said she was new and was working with another nurse but did not remember what time she saw CR#1. In an interview with CNA G on [DATE] at 2:15pm she said she provided care to CR#1 on [DATE] and she did not see her vomiting and she did not see any vomit on her, and she did not see any change in her condition. She said if there was any change in the resident's condition, she would report it to the nurse. She was asked at what time did she see CR#1 and she said the beginning of her shift and the next time was when she was passing breakfast tray around 8.00 am, she peeped at her at from the door of the room and she was okay . She was asked when was next time after 8:00am that she saw CR#1, she said she could not give a direct time. She was asked who turned the feeding pump off when care was provided to residents with a feeding tube. She said, if the nurse was not available, she would turn the pump off and on. When asked if she had permission to turn the pump off and on, CNA G did not answer. Observation on [DATE] at 3:00pm of the motion camera footage (a camera that only records when it detects motion in the field of vision) dated [DATE] at 7:15 am revealed CR#1 was in bed with the head of the bed elevated, her left hand was resting on her stomach and was contacted to the lower extremities. Observation revealed the resident vomited up large amount of brown liquid emesis all over her neck, stomach, and running down her left hand. Further observation revealed the CR#1 was lying in her vomit and no one checked on her every two hours as per facility policy. Observation of the camera footage dated [DATE] at 11:15 am four hours later a CNA that was later identified as CNA H went in the room to check on CR#1. She pulled back the covers and muttered something and left the room. She later returned with three aides who were later identified as CNA G, CNA J and CNA K. Further observation revealed CNA H and G removed the covers and started providing care to CR#1, while CNA J stood, a little way from the resident and CNA J who brought some linen, put it on the table and stood near the doorway. Observation revealed CNA G and H did not call the nurse to turn the pump off. They provided care to the resident and left the room. Further observation revealed no evidence that the nurse entered the room during and after the care. In an interview on [DATE] with LVN B at 1:00 pm, he said when he gave medication to CR#1 she was fine. He said he was never abusive to any resident. He said he took care of CR#1 and he never saw any vomit and he was not aware the resident had vomited. He was then told that there was camera footage. At that point he said he wanted to see the camera footage. Interview with CNA H on [DATE] at 10:20am she said she was assisting CNA G providing care to CR#1 and she saw what looked like milk on her bed. She said she did not report it to the nurse because she thought CNA G reported it to the Charge nurse since CR#1 was her patient. Further interview with CNA H, she said usually if there was a change in a resident's condition, she would have reported it to the nurse. Interview with CNA I on [DATE] at 10:25am, she said she was assisting CNA G and &H she did not see CR#1 vomiting and she did not see any vomit on her. She said if she saw the vomit, she would report it to the nurse. In an interview with CNA G on [DATE] at 10:30am, she said she did not see any vomit on CR#1's body. She said if there was a change in condition, she would report it to the nurse and physician and she insisted she did not see anything on CR#1's body. She said she and CNA H gave CR#1 a bed bath and she was fine. In an interview on [DATE] at 11:00 am with CNA G after she viewed the camera footage dated [DATE] she had a look of shock on her face. When asked if she was the CNA on the camera she said yes. At that point she was asked if the nurse was called to turn the feeding pump off, she said No. Further interview on [DATE] with CNA G after viewing the video, she still insisted she did not see anything wrong with CR#1 even when she saw her vomiting on the video. She was then asked at that point if pump was turned off during care and she said No. Asked if the nurse should be called, during care she said yes. Asked why she did not call the nurse she said the nurse was not around. Interview on [DATE] at 1:00pm with LVN B after viewing the camera footage he said that was a lot of vomit from CR#1. He said he did not smell any vomit, and if he had seen the vomit on CR#1 he would have cleaned her up. He said he gave CR#1 her medication around 9:00am and he assessed her G-Tube site, he checked for residual and did not see any change in her condition. He said he was not called when the staff was providing care. Further interview with LVN B he said when he gives medications to residents who were fed via feeding tubes he usually checked for placement, residual, ensuring that the head of the bed was elevated, and resident was not at risk for aspiration. He said at the end of his shift the resident looked okay. In an interview with the DON on [DATE] at 12:03pm she said she was new to the facility and was not around when the incident took place. She said her expectation was for the CNAs to observe residents and report any changes in their condition to the nurse. She said the expectation of the nurses were to do thorough assessments of residents when they do rounds, and when the CNAs report changes to them they should notify the physician of the change. She said based on the video footage there was no way anyone should have missed the vomit on CR#1. She said they have lots of work to be done and they will have to in-service the staff. She said moving forward she will ensure orders were checked and document on the MARs. Nurses will have to document any changes in resident's condition in the resident's clinical records. She said residents were to be checked on every two hours and as needed and the stop and watch will be put in place. She said there was a form at the nurse's station and the aides were expected to fill them when providing care out and give them to the nurses for follow up. In an interview with the Administrator on [DATE] at 12:10pm she said she was new to the facility but based on the situation, the IJ came because of the lack of education and training. She said some staff were practicing out of their scope of practice and ignoring what needed to be done correctly. She said there were lots of in-servicing to be done. In an interview on [DATE] at 3:52pm the MD said he was CR#1's doctor and he was not aware that she had vomited on the morning of [DATE]. He said he was called on the night of [DATE] that CR#1 had a change in condition and was not responding and he gave orders for the resident to be sent to the hospital 911. He said the resident was sent out and later died . The Administrator and DON was notified on [DATE] at 1:43 p.m ., an Immediate Jeopardy situation (IJ) was identified due to the above failures. The Administrator was provided the IJ template on [DATE] at 1:50 P.M. and a Plan or Removal (POR) was requested. PLAN OF REMOVAL. Immediate Action Patient was discharged from facility on [DATE]. All relevant staff members were removed from the facility pending investigation. All other staff CNAs and nurses were immediately and thoroughly in serviced on G-Tube care (when performing care, a nurse is needed to disconnect patient from feeding and patient is to be pulled up in bed and HOB should be no lower than 30 degrees before having nurse to reconnect feeding. Also, report any findings they believe is vital such as patient color, vomiting or spit up to nurses, and rounding every two hours and as needed, and the degree at which a patient at risk for aspiration should be angled in bed, in-service by DON, and ADON. Signed in-service sheets reflecting education were also completed. On [DATE] and [DATE]. All nurses and nurse assistants verbalized understanding and signed in-service reflecting understanding. ,d+[DATE] and 1/ 27 Over the phone in-service completed by ADON for staff not in facility and will have in-service sign in sheets available for signing at their next scheduled work date. All involved parties, CNA, and LVN, suspended pending investigation on [DATE]. Upon further investigation, all allegations of neglect were found substantiated, and both parties were immediately terminated on ,d+[DATE]. On [DATE], MD was notified of IJ, verbalized understanding. Enteral Feeding/Care Policies reviewed, and all staff, nurses and CNAs received copies and signed confirming receipt on ,d+[DATE]. No changes were made to the policy. All enterally fed patients assessed by DON and ADON and orders implemented into PCC for Q2hour rounding and as needed and CNA rounding confirming completion of ADLs (Activities of Daily Living) and G-tube care requiring nurse documentation on ,d+[DATE]. Change of condition in-services requiring nurses to document any change of resident outside of normal status, CNAs required to complete stop and watch forms depicting any change noticed in residents conducted by DON and ADON on ,d+[DATE] and ,d+[DATE]. Orders will be integrated into the system ensuring rounding is complete every two hours, HOB are at the proper height of no lower than thirty degrees and no higher than forty-five. Orders will be implemented into system depicting times for patients to be repositioned and changed as well as any applicable physician orders, ensuring patients are attended to every two hours and as needed. Monitoring the POR on [DATE]: During the survey monitoring, the Administrator was interviewed regarding what she believed was the root cause of the IJ. The Administrator believed that a thorough assessment was not done by the nurse when medications were given to CR#1 and the aides did not report to the nurses when they saw what looked like milk on CR#1. There was a plan in place to monitor this issue, and the retraining of nursing staff and checking on residents every two hours avoid this issue occurring again. The Administrator expects the Director of Nursing to monitor all the systems daily as it relates to the IJ tags, physician notification and ensuring thorough and immediate documentation in resident medical records. During the survey monitoring, the Director of Nursing (DON) was also interviewed regarding what she believed was the root cause of the IJ. The DON believed if CR#1 was assessed properly and the CNAs reported what they saw when they were providing care the outcome might have been different. The DON plans to monitor this issue by assessing all residents that were fed via a feeding tube and document in PCC. Residents were checked every two hours and as needed. Residents that were fed via a feeding tube, bed should be set no lower than at 30 degrees angle. The DON expectations of the RN's and LVN's to follow protocols, document and report any change in condition to the doctor. The DON indicated she personally evaluated each resident, who were fed via a feeding tube. On [DATE] In-Service trainings initiated by the ADON to licensed nurses on Enteral Feeding and changes in condition. In an interview on [DATE] at 3:17pm LVN C said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 3:51 pm CNA B said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 3:57pm CNA K said she was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. She verbalized understanding of in-service provided. In an interview on [DATE] at 4:00pm CNA D said he was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. He verbalized understanding of in-service provided. In an interview on [DATE] at 10:08 pm CNA E said she was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. She verbalized understanding of in-service provided. In an interview on [DATE] at 10:23pm LVN D said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. The staff verbalized understanding of in-service provided. In an interview on [DATE] at 12:26pm LVN S said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 1:30pm with RN B she said she was in-service on change in condition, G-tube feeding, report to the doctor and assessing residents who are fed via a feeding tube. She verbalized understanding of the in-service provided. In an interview on [DATE] at 4:05pm LVN F said he was in-serviced on abuse neglect, change in condition, policies and regulations on what CNAs are allowed to do that is not to turn on and off the feeding pump and report change in condition to the nurses. He verbalized understanding of in-service provided. In an interview on [DATE] between 11:00am and 3:00pm with CNA I, CNA J, CNA L and CNA N they all said were in-serviced on change in condition, abuse and neglect, G-T (CNAs not to touch the pump because that was the nurse's job), reporting and documentation. They all verbalized understanding. Record review of the POR revealed in-service signatures of all medical personnel on change of condition, abuse neglect, G-tube care, charting documentation, and reporting. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 1:18pm. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews, observations, and record reviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (CR #105) reviewed for treatment and services to prevent and heal pressure ulcers. 1. CR #105 was not provided wound care from [DATE] through [DATE] although the wound was identified as present prior to his admission on [DATE] . 2. CR #105 was not identified with wounds upon admission; skin assessments were not completed upon admission/re-admission. CR was transferred to the hospital on [DATE] resulting in a wound evaluation that revealed severe erythema (redness of the skin), edema (swelling caused by excess fluid accumulation in the body tissues), necrosis (premature death of body tissue), induration (an increase in the fibrous elements in tissue, usually due to inflammation or swelling, making the tissue less elastic and pliable), malodor (distinctive odors that are offensively unpleasant). The resident also required debridement (the removal of damaged tissue or foreign objects from a wound) and the wound was unstageable and measured 6.9cm long by 7.2cm wide An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 11:14 AM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of immediate jeopardy to resident health or safety because the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk of further development of pressure ulcers, infections, injury, and death. Findings include: CR #105 CR #105 Record review of CR #105's admission record dated [DATE] revealed a [AGE] year-old resident admitted initially on [DATE] and readmitted on [DATE]. The record documented his diagnoses included congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), gastroparesis (condition that affects the normal muscle movements of the stomach), hypertension (high blood pressure), protein-calorie malnutrition (an imbalance of nutrients from your food and drinks that are needed to keep the body healthy and functioning properly), and acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days). Record review of CR #105's census report dated [DATE] revealed he was admitted on [DATE]. The report documented billing stopped on [DATE], resumed on [DATE], and ended on [DATE]. Record review of CR #105's Medicare/5-Day MDS dated [DATE] revealed he had a pressure ulcer upon admission. The MDS revealed the pressure ulcer was unstageable, and it was present upon entry to the facility. The MDS documented he had three total venous (a wound caused by blood flow problems in the leg veins)/arterial ulcers (wounds caused by poor delivery of nutrient-rich blood to the lower extremities). The MDS indicated he had a pressure reducing device for his chair and bed, received nutritional or hydrational therapy for the pressure ulcer, received pressure ulcer care, and received applications of non-surgical dressings and ointments and/or medications for the injury. Record review of CR #105's admission MDS dated [DATE] with an ARD of [DATE] revealed no BIMS was conducted but he had no short or long-term memory concerns, and he was able to recall the current season, the location of his room, staff names and faces, and that he was in a nursing facility. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, refusal of care, or wandering and/or elopement behaviors. Per the MDS, CR #105 required one-person assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene, and he had not walked with or without assistance. The MDS revealed he was always incontinent of bladder and bowel, but he was not on a toileting program. The MDS documented he had one unhealed, unstageable, pressure ulcer or injury upon admission. Per the MDS, CR #105 received nutrition and/or hydration interventions, pressure ulcer/injury care, application of non-surgical dressings, and application of ointments/medications as interventions to the pressure ulcer. The MDS revealed he received dialysis care. A search of the facility's EMR revealed no care plan for CR #105. The admission and 5-day MDS assessments both noted sacral ulcers upon admission. There was no documentation of location. Record review of CR #105's medical records from the discharging hospital dated [DATE] revealed an ICU checklist dated [DATE]. The checklist documented CR #105 had a pressure ulcer and/or wound. Record review of CR #105's admission note created by The facility's PA on [DATE] revealed a foot ulcer. The note did not document any other wounds. Record review of CR #105's NP/PA note dated [DATE] created by The facility's PA revealed CR #105 had a left heel wound. No other wounds were noted on the record. Record review of the facility's EMR revealed the care plan dated [DATE] revealed no care plan areas were created. Record review of CR #105's nurse's note created by ALVN M on [DATE] revealed she had observed CR #105 on [DATE] with an unstageable sacral wound. The note documented the wound was malodorous (smelling very unpleasant) with eschar (a piece of dead tissue that sheds off from the surface of the skin after an injury) and slough (layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation) and had erythema (redness) around the border. Per the note, ALVN M placed a Mepilex border (absorbent foam wound dressing) the wound bed. The note concluded CR #105 could benefit from an immediate wound care consultation. No orders related to the Mepilex were identified during the survey. Record review of CR #105's nurse's note created by ALVN M on [DATE] revealed she had observed CR #105 on [DATE] with an unstageable sacral wound. The note documented the wound was malodorous with eschar and slough and had erythema around the border. Per the note, ALVN M placed a Mepilex border on the wound bed. The note concluded CR #105 could benefit from an immediate wound care consultation. No orders related to the Mepilex were identified during the survey. Record review CR #105's dialysis communication record created by the dialysis facility and dated [DATE] revealed an admission/readmission charge nurse report dated [DATE] noting he had an unstageable sacral wound . Record review of a NP/PA note created [DATE] by The facility's PA revealed he had observed CR #105's sacral wound on [DATE] and called for continued local care. Record review of a physician's order dated [DATE] revealed The facility's MD ordered a wound consultation from The WC physician for CR #105's sacral wound. Record review of a physician's order dated [DATE] revealed The facility's MD ordered CR #105's sacral wound be cleansed with normal saline, patted dry, and have calcium alginate (non-woven, absorbent dressings made from seaweed used to treat pressure wounds)and a dry dressing applied. Record review of CR #105's Braden Scale for predicting pressure sore risk dated [DATE] revealed a score of 16. The score indicated CR #105 was at risk for development of pressure injuries. Record review of CR #105's weekly skin assessment dated [DATE] revealed his skin color was normal, was warm, and the tugor was normal. The assessment documented a wound to CR #105's sacrum. The note did not document the size of the wound, but documented it was unstageable. Record review of CR #105's physician's order dated [DATE] revealed The facility's MD ordered CR #105's unstageable sacral wound be cleansed with saline, patted dry, and have Santyl (product used to treat and aid in the healing of burns and skin ulcers) and dry dressing applied daily. Record review of CR #105's nurse's note created [DATE] by LVN D revealed CR #105 sacrum was evaluated by The WC physician. The note documented The WC physician removed dead tissue and ordered Med-i-Honey (wound and burn dressing), alginate, and an air mattress. There was no documentation of the cause of the delay in the evaluation by the wound care physician. Record review of CR #105s's progress note from the facility's contracted wound physicians dated [DATE] revealed CR #105 was not seen due to a non-wound related hospitalization . The note documented CR #105's physician was the facility's wound care physician. Record review of CR #105's after visit summary and discharge instructions from an unrelated hospitalization dated [DATE] revealed a wound care evaluation and treatment plan with a date of service of [DATE]. The wound care evaluation documented his diagnosis was impaired integumentary integrity associated with skin involvement extending into fascia (thin, fibrous connective tissue), muscle or bone, and scar formation. The evaluation noted the consultation was ordered for CR #105 for an unstageable sacral pressure injury. Per the evaluation, the wound had severe erythema (redness), edema (swelling caused due to excess fluid accumulation in the body tissues), necrosis (premature death of body tissue), induration (an increase in the fibrous elements in tissue commonly associated with inflammation and marked by loss of elasticity and pliability), and malodor. The evaluation revealed a recommendation of a surgical consultation for CR #105. The evaluation documented he had precautions for fragile skin and a high risk of obtaining future pressure injuries. Per the evaluation CR #105's pressure injury was debrided of non-viable tissue. The evaluation revealed CR #105 reported he was unable to lay on his back due to severe pain from the sacral wound. The evaluation documented he reported his pain in the sacrum was an eight out of ten. Per the evaluation the sacral pressure injury was unstageable and measured 6.9cm long by 7.2cm wide. The evaluation documented the wound tissue was 80% eschar (a collection of dry, dead tissue within a wound) and 20% slough (layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation). The evaluation revealed the wound treatment included copious irrigation with wound cleanser (washing the wound with wound cleanser) and sharp debridement (procedure to remove debris or infected/dead tissue from a wound) to the subcutaneous (under the skin) tissue. Per the evaluation, CR #105 was educated on the wound care plan, the wound's appearance, choices in wound dressings, and the need to make frequent position changes to prevent further skin break down. Record review of CR #105's weekly skin assessment dated [DATE] revealed he had a sacral pressure wound and an IV port in his left shoulder. The assessment documented his skin was normal colored, warm, and had normal tugor. The note did not document the size of the wound, but documented it was unstageable. Record review of CR #105's nurse's note dated [DATE] revealed it was created by the WN. The note documented he was assessed by the WN and was observed with an ongoing wound to the sacral area with dark slough. Per the note, the WN cleansed the wound and treated it with a dry dressing. Record review of CR #105's nurse's note created by LVN E and dated [DATE] revealed he was observed by the nurse lying in his bed with chils. The note documented vital signs were taken and his oxygen saturation levels were unable to be obtained. Per the note, CR #105 was having shortness of breath and was confused. The note revealed the facility's PA ordered CR #105 be taken to the emergency room for possible sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever). The note documented 911 was called, EMS arrived, and he was transported to a local hospital for treatment and care. Record review of CR #105's June TAR revealed his sacral wound was cleansed with normal saline, patted dry, and calcium alginate and a dry dressing were applied on ,d+[DATE], ,d+[DATE], and [DATE]. The TAR documented that order was discontinued on [DATE]. Per the TAR, CR #105's unstageable sacral wound was cleansed with normal saline, patted dry, and Santyl and a dry dressing were applied on ,d+[DATE], ,d+[DATE] and [DATE]. The TAR revealed an order for Medihoney to be applied daily beginning [DATE] and it was applied on ,d+[DATE] and [DATE]. CR #105 was not present at the facility on ,d+[DATE] and [DATE], and he returned on [DATE]. CR #105 discharged on [DATE]. Review of the TAR revealed no physician's orders for wound care prior to [DATE]. Record review of the medication report dated [DATE] revealed prescriptions active on [DATE] Ecotrin 325mg delayed release tablet one tablet once daily for congestive heart failure, Gabapentin 300mg tablet one tablet three times daily for convulsions, Metoprolol Tartrate 25mg tablet give ,d+[DATE] tablet (12.5mg) once daily for hypertension, Plavix 75mg oral tablet one tablet once daily for congestive heart failure, and Ultram 50mg tablet once every twelve hours as needed for pain. The Ultram was prescribed on [DATE]. Record review of CR #105's June MAR revealed he was administered one 325mg tablet of Ecotrin daily from [DATE] through [DATE] and on [DATE] at 9:00 AM. The MAR documented he was administered one 300mg tablet of Gabapentin daily at 9:00 AM, 1:00 PM, and 5:00 PM from [DATE] through [DATE] and on [DATE]. Per the MAR he was administered ,d+[DATE] of a 25mg tablet of Metoprolol Tartrate for a total of 12.5 mg of the medication daily at 9:00 AM from [DATE] through [DATE] and [DATE]. The MAR revealed CR #105 was administered a 75mg tablet of Plavix at 9:00 AM from [DATE] through [DATE], it was held on ,d+[DATE] through [DATE], and was administered on ,d+[DATE] and [DATE]. The MAR had no documentation of administration of Ultram during the month. Record review of CR #105's medical records from the hospital he was admitted to dated [DATE] pages one through three revealed his admission form reported information for services provided between [DATE] and [DATE]. Per the admission form, his diagnoses included ESRD (End Stage Renal Disease, occurs when chronic kidney disease, or the gradual loss of kidney function, reaches an advanced state), septic shock (widespread infection causing organ failure and dangerously low blood pressure), pressure injury of the sacral region (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar), and pressure injury of the buttock stage 4 unspecified laterality (full thickness ulcer with the involvement of the muscle or bone). The admission form documented CR #105's admission type was emergency, he was admitted [DATE] at 6:25 AM, he was transferred from an outside hospital. The admission form documented surgery was performed on CR #105 on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Record review of CR #105's medical records dated [DATE] page four included admission orders from [DATE] through [DATE]. The orders revealed his admitting diagnosis was sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever). The orders documented his level of care was critical care and his expected level of care was three to four days. Record review of CR #105's medical records dated [DATE] page thirty-three through page forty-one included H&P notes dated [DATE]. The H&P (History and Physical) notes revealed CR #105's problem list included septic shock with a likely source of a sacral decubitus ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) infection versus UTI (Urinary Tract Infection, infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra). The note documented CR #105's sacral decubitus ulcer was present at admission. Per the note, a recent previous hospitalization for sepsis/pneumonia put him at a higher risk for drug resistant organisms. The note read in part .This patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently . Record review of CR #105's medical records dated [DATE] page 42 through page 116 included a consult group 1 notes from [DATE] through [DATE]. The notes revealed on [DATE] nephrologist (medical doctor of the branch of medicine that deals with the physiology and diseases of the kidneys) documentation read in part .CR #105 is a [AGE] year old male with history of ESRD on HD [hemodialysis (treatment for ESRD in which the blood is filtered via an external machine)], CHF [congestive heart failure (condition in which the heart cannot pump enough blood to the body's other organs)], CAD [Coronary Artery Disease (condition where the major blood vessels supplying the heart are narrowed)], DM [Diabetes Mellitus] admitted with septic shock from sacral decubitus ulcer vs UTI . The note documented CR #105's diagnosis was septic shock. The notes included a wound care note from [DATE], beginning on page 50, documenting a photo of an unstageable necrotic sacral decubitus wound. The photo was documented by a hospital wound care RN as appearing to be covered with 95% black unstageable necrotic tissue. The wound care note documented recommended a general surgical consultation for debridement or pulse lavage therapy (delivery of an irrigating solution under pressure that is produced by an electrically powered device). The wound care notes included an order for application of Vashe (medication used for pressure ulcers) wet to dry dressing daily. The consult group 1 notes also included an attestation by a Doctor of Osteopathic Medicine dated [DATE], on page 51, which read in part .We would recommend emergent OR [operating room] for debridement of infection decubitus ulcer as possible cause of his septic shock . The consult group 1 notes revealed an assessment and plan dated [DATE] documenting a surgical debridement on [DATE] beginning on page 57. The assessment and plan documented significant findings including necrotic tissue (premature death of body tissue) with purulence (consisting of, containing, or discharging pus) down to sacral periosteum (the sheath outside your bones that supplies them with blood, nerves and the cells that help them grow and heal) undermining (a separation of the wound edges from the surrounding healthy tissue, often creating a pocket under the wound surface) with tracks interior down both gluteal muscles, and on right lower back. The consult group 1 notes included radiology results dated [DATE] on page 62 through page 66. The results revealed CR #105's radiological examination impression documented a sacral decubitus ulcer with gas extending to the level of the dorsal aspect of the distal scrum/coccyx without discrete collection or osseus destructive change. The impression further documented there were foci of gas extending into the gluteal musculature bilaterally. The consult group 1 notes included a palliative care consult note dated [DATE] on page 99 through page 104. The palliative care note revealed he had been intubated and was extubated on [DATE]. The note documented CR #105 had surgical debridement of his sacral wound on ,d+[DATE], ,d+[DATE], and ,d+[DATE] 2023. Interview on [DATE] at 10:24 AM with CR #105's family member, she said she had multiple concerns related to the care provided to CR #105 by the facility staff . CR #105's family member said he had been left in his feces for hours at a time on multiple occasions. CR #105's family member said because of this lack of care CR #105 developed an infection which progressed to sepsis . CR #105's family member said she was unsure if he had any open wounds and/or injuries when he admitted to the facility. CR #105's family member said CR #105 had scar tissue from cancer treatments in the past, and that skin was less stable than the surrounding skin. CR #105's family member said CR #105 developed a large open wound while in care at the facility. The family member said CR #105 was sent to the local hospital due to the sepsis. CR #105's family member said when CR #105 was admitted to the hospital, the hospital staff immediately called her and requested permission to perform surgery . CR #105's family member said she was informed by the hospital if the surgery was not completed CR #105 would likely die. CR #105's family member said CR #105 was not doing well currently, had five surgeries on the wound, and remained hospitalized . CR #105's family member said she was especially upset because when CR #105 had admitted , he was at the facility for skilled nursing and therapy to return home and he was not provided appropriate care and ended worse than when he admitted . Interview on [DATE] at 11:51 AM with DON C, she said her expectations were for an assigned wound care nurse to compete the wound care for all residents with wounds. DON C said she would also expect the wound care nurse to address resident treatment plans to ensure compliance, monitor weights, and complete assessments and audits for other areas of concern. DON C said the assigned wound care nurse would be responsible for all wound care on Monday through Friday, and that the Weekend RN supervisor would be responsible for wound care on Saturdays and Sundays . DON C said there were six wounds in the building . DON C said the admission information which should be obtained and signed on admission included consents, financial information, baseline information from the referring hospital and an admission assessment . DON C said the facility's EHR included a list of items needed at admission, and it allowed the admitting staff to attach those files and upload them to the EHR. DON C said this should be done within 24 hours. DON C said the nurse on the hall the resident is admitted to is responsible for completion of the admission information. DON C said the ADON should be responsible for skin integrity sweeps at the facility. DON C said CAN's CNA's should communicate changes of condition, including skin issues, with their charge nurse who would in turn report that to the wound care nurse, DON, and/or ADON. DON C said a wound care physician should evaluate and create wound care orders. DON C said an assigned wound care nurse would then inform the staff of the orders. DON C said she preferred a wound care company to provide wound care. DON C said a Braden assessment should be done on admission and then quarterly. DON C said the Braden assessment should be completed within the first week the resident was admitted . DON C said if a resident with a pressure wound did not receive wound care that would be neglect of the resident. DON C said if a wound did not receive care, it could get worse, and infection could set in. DON C said the infections could include MRSA and staff infection. Telephone interview was attempted with the former wound care nurse on [DATE] at 12:17 PM. The call was unsuccessful as there was no answer and no voice message was available. Telephone contact was attempted on [DATE] at 2:24 with personnel at the temporary staffing agency whom the facility contracted with, to obtain the telephone number for the temporary nurse who created the nurse's notes on ,d+[DATE] and [DATE]. The telephone contact was unsuccessful as there was no answer. A voice message was left requesting a return call. Interview on [DATE] at 9:29 AM with DON C, she said she would expect a resident returning from the hospital with an open unstageable wound to have new physician's orders, or the facility to obtain new physician's orders for wound care . Observation on [DATE] at 2:01 PM of CR #105 revealed he was sleeping on an air mattress in the ICU of a local hospital CR #105 had a catheter and IV in place. CR #105 was covered by a sheet . Interview on [DATE] at 2:30 PM with Hospital RN A, RN at the hospital CR #105 was admitted to, she said she had been assigned to provide care to CR #105 on [DATE]. Hospital RN A said a palliative care meeting was held with CR #105's family earlier on [DATE] and she was unsure of the outcome of the meeting, or the decisions the family made regarding CR #105's care. Hospital RN A said her understanding of CR #105's current condition was that the wound would not heal and was most likely terminal. Hospital RN A said CR #105 was no longer a candidate for surgery. Hospital RN A said CR #105's sacral wound would not heal without an ostomy (surgery to create an opening, or stoma, from an area inside the body to the outside). Hospital RN A said she was unsure of the decisions the family would make regarding CR #105's wound and possible end of life care. Hospital RN A said she could not say if CR #105's lack of wound care at his previous placement could have led to the current, possible, terminal sacral wound. Email received on [DATE] at 9:28 AM from CR #105's family member revealed that CR #105 died at the hospital on [DATE]. The following Plan of Removal submitted by the facility was accepted on [DATE] at 2:24 p.m. Date: [DATE], Revision Date: [DATE] The following are the Action Plan for Plan of Removal for F692: Weights 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies. 1. Immediate action: Resident #31 was seen and assessed by Registered Dietician (RD) on [DATE] and reviewed current condition and weight loss of resident. Per RD, Resident #31 has a history of dementia, AMS, Type 2 diabetes , Constipation, Dysphagia leading to PEG dependence. Resident #31 per RD has chronic disease state that made it difficult to improve PEM / inflammation state despite being on a higher basal energy expenditure (BEE ) Peg feeding schedule. Resident #31 per RD 's review includes 3 month a decline of 7.5% wt.= 126.4lbs, BMI= 21.4 and a staff report of enteral formula tolerance of Fibersource @60ml/hr added protein 30ml twice a day and water to provide 1500 calories/ 70 gm protien,1.2 L free water. Per RD, current intervention Resident #31 is to provide his BEE needs goals. The plan of care for Resident #31 was updated to reflect new goals of treatment to meet BEE goals. Attending physician and responsible party have been notified on [DATE]. 2. Immediate action: Resident #32 was seen and assessed by Registered Dietician (RD) on [DATE] and reviewed current condition and weight loss. Resident #31's current weight is 127lbs which reflects a 7.5% weight loss in 3 months. Per RD, Resident #32 has a history of losing weight due to liking high carbohydrates & eating less Protein. Per RD, Resident #32 is currently on appetite stimulant and supplement (Remeron & Med pass) to help improve nutritional status. Per RD recommendations on [DATE], Resident #32 will be provided with a fortified food plan based on food preferences and to also add Multivitamin with Iron and Fish Oil 1,000 mg. The plan of care for Resident #32 was updated to reflect new interventions for weight loss. Attending physician and responsible party have been notified on [DATE]. 3. Immediate action: Resident #18 was seen and assessed by Registered Dietician (RD) on [DATE] and reviewed current condition and weight loss of resident. Per RD, Resident #18 has a history of chronic disease, diabetes mellitus Type 2 uncontrolled, CHF , edema, constipation, anemic, down syndrome with limited mobility and uses a wheelchair with current weight of 239lbs, with an initial weight on [DATE] of 303 lbs. which is about 164% IBW , BMI 38.6. Per RD, Resident 18's recommendation is to improve mobility and decrease caloric intake. Per RD, Resident #18's intervention is working due to a decrease of 10% in the last 3 months with noted increase in energy and to continue current interventions. The care plan for Resident #18 has been updated to include weight loss planned diet. Attending physician and responsible party have been notified on [DATE]. 4. Immediate action: Resident #4 was seen and assessed by Registered Dietician (RD) on [DATE] and reviewed current condition and weight loss of resident. Per RD, Resident #4 has a history of chronic disease, Alzheimer's disease, behavior issues, HTN, CVD with a small appetite. Per RD, Resident #4 is currently on Remeron and medpass already with weight of 128 lbs., IBW 83% and BMI of 19.5. Per RD, Resident #4 will be monitored at this time and make adjustments to intervention as needed. Attending physician and responsible party have been notified on [DATE]. 5. Immediate action: Resident #89 was seen and assessed by Registered Dietician (RD) on [DATE] and reviewed current condition and weight loss of resident. Per RD, Resident #89 has a history of chronic disease and no teeth and is unwilling to eat puree diet at this time. Resident #89's meal intake is being monitored with alternatives being offered. Per RD, Resident #89 had a decline of 5% in 30 days with a current weight of 134 lbs., IBW is 83% with BMI of 19.7. Per RD recommendations on [DATE], offer Medpass of 90ml if Resident #89 eats less than 70% of meals. Attending physician and responsible party have been notified on [DATE]. 6. Immediate action: Registered Dietician has been hired with contract signed and RD began seeing patients as of [DATE]. 2. Governing Body - QAPI committee a. NHA will monitor corrective actions through on-going compliance and results of audit for weight management and assessment of nutrition and hydration management and intervention monthly. The DON and NHA will report the results of monitoring to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendations at least every 3 months during QAPI meetings until compliance is achieved. b. Monitoring of the implementation of the Plan of Removal shall be done by the DON and or Designee and Administrator weekly for one month until compliance is achieved. c. RCA: A root cause analysis will be conducted by the QAPI team to determine further interventions for the deficient practice on weight loss prevention and management completed on [DATE] during the QAPI Ad Hoc Meeting. d. Immediate Action: Review of nutritional program and policies, including the new procedures with IDT meeting and review to be completed weekly was reviewed on [DATE] through an ad hoc meeting via telephone conference with the Medical Director, DON, ADON/IP and NHA. e. The QAPI Committee will monitor the process every month for 3 months until compliance is achieved. 3. Specific staff involved in implementing the corrective actions. a. Medical Director, Administrator, Director of Nursing, Assistant Director of Nurses, Maintenance Staff, Registered Dietician, Dietary Manager, Social Services and Activity Director 4. Identification of other residents who may need to be included (who may have been affected by the deficient practice: a. All residents are affected potentially by the deficient practice. On [DATE], a total of 9 residents have been identified that have been admitted in the last 30 days. i. The attending physicians for all 9 residents have been called. All 9 residents were placed on weekly weights as ordered and has been carried out. The care plan for all 9 residents has been updated by DON/ADON or licensed nurse designee to include weekly weight interventions. Weights are being taken by dedicated C.N.A beginning [DATE]. ii. There was a total of (1) 2

Based on observation, interview, and record review the facility failed to ensure residents were able to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or the resident preferences indicated otherwise for 3 of 18 (Residents #31, #32, and #89) reviewed for nutrition and hydration status and maintenance. 1. The facility failed ensure Resident #31, Resident #32, and Resident #89 did not sustain an unplanned and/or unexpected significant weight loss. 2. There was no evidence a registered Dietitian had addressed the unplanned weight loss, assessed the residents, or implemented interventions for residents that were experiencing unplanned weight loss since April 2023. 3. The facility failed to ensure residents #31, #32, and #89 were provided with dietitian evaluations and/or interventions. These failures could have led to a failure to maintain therapeutic diets, sufficient fluid intake, proper hydration, maintain body weight and health. These failures likely caused Residents #31, #32 and #89 further significant unplanned weight loss, electrolyte imbalance and health decline. Findings include: 1. Record review of Resident #31's Admission Record revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #31 had diagnoses which included supraventricular tachycardia (a faster than normal heart rate beginning above the 2 lower chambers of the heart), type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), weakness, hypotension (low blood pressure), dysphagia (swallowing problems occurring in the mouth and or throat), and cerebral infarction (also called an ischemic stroke, occurs as a result of disrupted blood flow to the brain, due to problems with the blood vessels that supply it). Resident #31 did not have a diagnosis of gastrostomy tube listed on his admission record under the subheading Diagnosis Information. Record review Resident #31's Dietary Note by Former Dietitian, dated 12/11/2022 at 1:38pm revealed, Note Text: nutrition follow-up-tf. diet:npo tf:fibersource hn at 60 ml/hr X 22 hrs Water at 35 ml/hr q 2 hrs Skin:no pi per assessment, wt:133.3# Weight shows stability over the past quarter. Overall desired weight gain after GT placement given previous weight loss . Record review Resident #31's annual MDS, dated [DATE], revealed he was not coded for speech clarity, his ability to make himself understood or his ability to understand others. In section C Cognitive Patterns of the MDS, he was coded that a BIMS could not be conducted or attempted because Resident #31 had been coded as being rarely or never understood. His SAMS indicted he was severely impaired in his cognitive skills for daily decision making. He was coded as having no behaviors and required the extensive assistance of 2 staff for bed mobility and personal hygiene and required extensive assistance of 1 staff for dressing, eating, and toilet use. He was coded as activity did not occur, for transfers, walking in room or corridor, locomotion on and off unit and was totally dependent on 1 staff for bathing. He had both upper and lower extremity impairments to one side of his body. He was coded in section K of the MDS for Swallowing/Nutritional Status as having a feeding tube-nasogastric (passage from the nose to the stomach) or abdominal (PEG) (Percutaneous Endoscopic Gastronomy) (medical procedure in which a tube is passed into a patient's stomach through the abdominal wall) and he received a 51% or more proportion of his total calories through tube feeding, while a resident and during entire 7 day look back period of the MDS. His CAA summary and care planning identified Feeding Tube as a care area. Record review of Resident #31's Quarterly MDS, dated [DATE], revealed he was not coded for speech clarity, his ability to make himself understood or his ability to understand others. In section C Cognitive Patterns of the MDS, he was coded that a BIMS could not be conducted or attempted because Resident #31 had been coded as being rarely or never understood. His SAMS indicted he was severely impaired in his cognitive skills for daily decision making. He was coded as having no behaviors and required the extensive assistance of 2 staff for bed mobility and personal hygiene and required extensive assistance of 1 staff for dressing, eating, and toilet use. He was coded as activity did not occur, for transfers, walking in room or corridor, locomotion on and off unit and was totally dependent on 1 staff for bathing. He had both upper and lower extremity impairments to one side of his body. He was coded in section K of the MDS for Swallowing/Nutritional Status as having a feeding tube-nasogastric or abdominal (PEG) and that he received a 51% or more proportion of his total calories through tube feeding, while a resident and during entire 7 day look back period of the MDS. Record review of Resident #31's Dietary Note by Former Dietitian, dated 2/4/23 at 5:18pm revealed in part, Note Text: nutrition follow-up tf/sig wt change (sic)aler diet:npo tf:Fibersource HN at 60 ml/hr X 22 hrs water at 35 ml/hr q 2 hrs .wt:132.8# Weight shows stability over the past quarter. Overall desired sig weight gain of +11% x 4 mo. There were no other dietary notes for Resident #31 for March, April, May or June of 2023. Record review Resident #31's Weights and Vitals Summary revealed he was weighed on 5/24/23 at 1;45pm and weighed 139.7lbs. Resident #31 had no other weights documented until 7/11/23 at 6:17 am and read as follows: 07/11/2023 06:17 am 126.4 Lbs (sitting). -7.5% change (Comparison Weight 04/02/2023, 138.8 lbs, -8.9%, -12.4 lbs). Continued review revealed 07/12/2023 5:02pm 126.4 Lbs (Hoyer Mechanical Lift (H)) -7.5% change (Comparison Weight 04/02/2023, 138.8 lbs, -8.9%, -12.4 lbs). Further review revealed an additional entry of 07/12/2023 5:06pm 125.2 Lbs (Hoyer Mechanical Lift (H)) -10.0% change (Comparison Weight 04/27/2023, 139.2 lbs, -10.1%, -14.0 lbs) -7.5% change (Comparison Weight 04/14/2023, 136.2 lbs, -8.1%, -11.0 lbs). Record review Resident #31's Dietary Note by RD, dated 7/12/23 at 11:08pm revealed in part, Note Text: Patient has a history of dementia, AMS, T2DM, Constipation, Dysphagia leading to PEG dependent. This Chronic disease state has made it difficult to improve PEM/inflammation state. Despite being on a higher BEE Peg feeding schedule he had in 3 mo a decline of 7.5% wgt=126.4lbs, BMI=21.4 staff reports patient tolerates Feeding Fibersource @60ml/Hr added protein 30ml/BID and water This provides 1500 calories/ 70 gm protein, 1.2 L free water. The intervention is to provide his BEE needs. Record review Resident #31's physician order summary report dated as active as of 7/13/23 revealed he had an active order with a start date of 09/09/2022 for Nothing by mouth (NPO) diet, NPO texture. Further review revealed he had the following enteral feeding order dated as active 10/04/2022, GTUBE: Fibersource HN at 60 ML/HR X22 HRS (2 hrs to allow for ADL care/other)= 1320 ML/24 HRS-Monitor Q shift every shift related to Dysphagia, Oropharyngeal Phase. 2. Interview on 7/23/2023 at 10:05 AM with Resident #32, she said she had lost weight while at the facility. Resident #32 said she had lost approximately fifteen pounds. Resident #32 said she was unsure exactly why she lost the weight. Resident #32 said she thought part of the cause was she had been nervous when she first arrived. Resident #32 said she was concerned she may fall again causing further injury and that led to a loss of appetite. Resident #32 said the food was also not good when she first arrived but had improved substantially recently. Resident #32 said she recently had been given a shake if she wanted it. Record review of Resident #32's admission record revealed an [AGE] year-old resident admitted on [DATE]. The record documented her diagnoses included constipation (infrequent, irregular or difficult evacuation of the bowels), protein-calorie malnutrition (inadequate intake of food), depression (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder (excessive fear and worry and related behavioral disturbances). Record review of Resident #32's census record dated 9/19/2023 revealed she was admitted on [DATE] and discharged on [DATE]. Record review of Resident #32's quarterly MDS dated [DATE] with an ARD of 6/28/2023 revealed a BIMS of 15, indicating no cognitive impairment. The MDS documented she had no indicators of psychosis, behaviors affecting others, rejection of care, or wandering and/or elopement behaviors. Per the MDS, Resident #32 required one or more person assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene, and that she did not walk. The MDS revealed she had no, or an unknown, weight loss during the evaluation period. The MDS documented Resident #32 had no therapeutic or altered diet. Per the MDS, she did not receive any OT, PT, ST, or restorative nursing during the review period. Record review of Resident #32's weight record revealed her weight on 4/18/2023, at admission, was 136.5lbs, and on 7/11/2023 was 126.0lbs. This was a loss of 10.5lbs or 7.69% in three months. Record review of Resident #32's dietary note dated 5/9/2023 revealed she had a regular diet with regular liquids, had no issues with eating by mouth, and had a goal of no significant weight changes. Record review of Resident #32's dietary note dated 7/12/2023 revealed she had a history of weight loss because she liked a diet with high carbohydrates and low protein. The note documented she was on an order for med-pass supplement at that time. Per the note, Resident #32 ate 65% or more of her food. Record review of Resident #32's physician's order dated 7/12/2023 revealed an order for Med-Pass supplement daily at lunch and dinner. This was ordered by The facility's MD. Record review of Resident #32's dietary note dated 7/13/2023 revealed she had expressed her desires for food. The note documented dietary would continue to monitor her intake and preferences for any changes. Record review of Resident #32's weight loss change note dated 7/13/2023 revealed the IDT discussed her weight loss. The note documented she had orders for Remeron and Med-pass. Per the note, the DON reviewed Resident #32's care plan for appropriate interventions. Record review of Resident #32's health status note dated 7/13/2023 revealed the physician was notified of the weight loss. The note was created by the former DON. Record review of Resident #32's change in condition note dated 7/18/2023 revealed she had experienced a possible change in condition due to a weight loss. The note documented The facility's MD was notified. The note was created by the former ADON. Record review of Resident #32's plan of care note dated 7/19/2023 revealed she had an unplanned weight loss. The note documented her diet was changed to a fortified diet for all three meals. Per the note, Resident #32 would receive an order for evaluation by the local mental health provided. Record review of Resident #32's NP/PA note dated 7/19/2023 revealed it was a late entry note for 7/12/2023. Then note documented she was evaluated for her weight loss and the NP/PA ordered she continue with her supplements. The note was created by the facility's PA. Record review of Resident #32's dietary note dated 7/20/2023 revealed the Dietitian had recommended Magic Cup ice cream, and fortified foods at all meals. The note documented the dietary department would continue to monitor for further concerns. The note was created by the former wound care nurse. Record review of Resident #32's weight change note dated 7/20/2023 revealed the IDT had discussed her weight and it remained stable. The note documented no new recommendations at that time. Record review of Resident #32's physician's order dated 7/20/2023 revealed an order from The facility's MD for Magic Cup supplement at bedtime daily. Record review of Resident #32's nutritional and hydration review dated 7/20/2023 revealed Magic Cup supplement was added to her diet. The review was signed by DON C, the former ADON, and the MDS LVN. Record review of Resident #32's dietary profile dated 7/26/2023 revealed her diet was regular with a regular diet. The profile documented she had an order for fortified foods. Per the profile, Resident #32 ate 75-100% of meals, came to the dining room for lunch, and dietary would continue to monitor her intakes. Record review of Resident #32's dietary note dated 8/6/2023 revealed the IDT discussed her current weight. The note documented she had gained 1.8lbs and had a good appetite. 3. Record review of Resident #89's admission record, dated 7/14/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident 89 had diagnoses which included: chronic obstructive pulmonary disease or COPD (refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis), Type I Diabetes Mellitus, insulin-dependent diabetes, (is a chronic condition in this condition, the pancreas makes little or no insulin. Insulin is a hormone the body uses to allow sugar [glucose] to enter cells to produce energy) and Malignant Neoplasm of prostate (prostate cancer is a disease in which malignant [cancer] cells form in the tissues of the prostate). Record review of Resident #89's admissions MDS, dated [DATE], revealed a BIMS score of 15 out of 15, which indicated he was cognitively intact. The MDS assessment revealed Resident #89 required supervision to total dependence with one-person physical assistance with his ADL's . Resident #89 had an indwelling catheter and was frequently incontinent with his bowels. Section O of the MDS assessment (Special Treatments Procedures, and Programs) revealed he required oxygen therapy. Record review of Resident #89's 48-hour baseline care plan, with an effective date of 7/12/2023 and admitted [DATE], revealed he required assistance to total dependence with his ADL's, he required anticoagulants, oxygen, and pain medication Record review of Resident #89's weights report dated 9/19/2023 revealed his weight on 6/22/2023, at admission, was 144.7lbs, and on 7/11/2023 was 134.0lbs. This was a 10.7lbs loss, or 7.38%% weight loss in less than one month. The record documented his weight on 7/26/2023 was 131.0lbs, a change of 13.7lbs or 9.46% Record review of Resident #89's physician's order dated 6/27/2023 revealed an order by his PCP for a regular soft and bite-sized diet. Record review of Resident #89's dietary note dated 7/5/2023 revealed Resident #89 was admitted with a regular diet, but it was changed to a chopped diet on 6/30/2023. Record review of Resident #89's physician's order dated 7/13/2023 revealed an order by his PCP for Med-Pass supplement daily at lunch and dinner. Record review of Resident #89's weight change note dated 7/13/2023 revealed the IDT discussed his weight change due to a change of more than 5% in the previous 30 days. The note documented he was evaluated by a Dietitian and weekly weight checks would continue. Record review of Resident #89's dietary note dated 7/13/2023 revealed he had no teeth, but he was unwilling to eat a puree diet. The note documented he had a 5% change in weight in the previous 30 days. Per the note, Resident #89 would be offered med pass supplement if he ate less than 70% of his meals. Record review of Resident #89's health status note dated 7/13/2023 revealed the physician had been notified of his weight loss. Record review of Resident #89's physician's note dated 7/13/2023 revealed he had weight loss, med pass supplement ordered, and encouragement to eat by mouth. The note was created by his PCP. Record review of Resident #89's dietary note dated 7/16/2023 revealed he continued to have difficulty eating because of his teeth. Record review of Resident #89's nurse's note dated 7/17/2023 revealed a new order for a Dietitian consultation. Record review of Resident #89's physician's order dated 7/20/2023 revealed an order by his PCP for Magic Cup supplement daily at bedtime. Record review of Resident #89's Nutritional and Hydration review completed on 7/20/2023 revealed he had a 1.2lb weight loss during the review period. The review documented he had ice cream added to his dietary plan for lunch and dinner. The review was signed by the MDS LVN, DON C, and the former ADON. Per the review, a ST evaluation was recommended. Record review of Resident #89's weight change note dated 7/20/2023 revealed the IDT discussed his weight change, he was to be evaluated by a Dietitian on 7/21/2023, dietary had added ice cream to his diet for lunch and dinner. Record review of Resident #89's dietary note dated 7/20/2023 revealed Resident #89 was at the time on a regular soft and bite-sized diet. The note documented the Dietitian recommended a health shake be added to Resident #89's diet for breakfast, and ice cream be added for lunch and dinner. Per the note, dietary would continue to monitor Resident #89's intake and document any changes needed. Record review of Resident #89's dietary note dated 7/21/2023 revealed the weight team would complete weekly weight checks and then monitor. The note documented he had a current weight at that time of 136lbs and a 5% decline in the previous 30 days. Record review of Resident #89's dietary profile dated 7/26/2023 revealed he had had regular soft and bite-sized diet. The profile documented he received health shake ice cream for lunch and dinner, and as a snack. Per the profile, Resident #89 received normal portions, had a poor appetite, had chewing problems, and swallowing problems. The profile revealed he had poor meal intake, the Dietitian had ordered interventions, and dietary would continue to monitor for changes. Record review of Resident #89's dietary note dated 7/27/2023 revealed an IDT meeting was conducted regarding his weight loss concerns. The note documented Resident #89 had a 1.8lbs weight loss from the week prior. Per the note, Resident #89 refused to eat pureed meals, and was only eating approximately 25% of his meals. The note revealed recommendations for speech therapy evaluation, labs, and an MD consultation for adult failure to thrive or unavoidable weight loss. Record review of Resident #89's physician's note dated 7/27/2023 revealed he was examined, and no new issues or complaints were observed. Record review of Resident #89's physician's order dated 7/29/2023 revealed he an order by his PCP for a speech evaluation. Interview on 7/12/2023 at 10:39 AM with DON A and Admin A revealed the Admin had been employed by the facility since 06/10/23 . DON A said prior to her employment residents were weighed at least monthly . DON A said she had a list of all weight changed since her employment. DON A said the weight monitoring was the responsibility of an IDT, but she had created a summary of weight changes with interventions . Interview on 7/18/2023 at 10:05 AM with MDS LVN, revealed she had been employed by the facility since 06/19/23. The MDS LVN said she had not completed or assisted in completion of any care plans related to weight for any residents in the facility . The MDS LVN said an IDT completed the care plans and specific focus areas of the care plans. The MDS LVN said she did not complete the MDS assessment related to weights, Section K of the MDS. The MDS LVN said section K was completed by the dietary manager or Dietitian. The MDS LVN said if Section K was inaccurate related to weights a resident may have an unexpected/unplanned weight loss. The MDS LVN said the facility could also be unaware of a weight loss if the weights were inaccurate. Interview on 7/19/2023 at 3:20 PM with the CNO, she said the facility had reviewed and updated all the care plans for residents identified with unplanned or unexpected weight loss. The CNO said Resident #32's care plan was updated at that same time. The CNO said the Dietitian reviewed the plan and made changes which included a fortified diet, multivitamin, and fish oil. The CNO was informed the care plan did not include any specific information related to an actual unplanned or unexpected weight loss. The CNO said she would review the care plan. Interview on 9/15/2023 at with DON C revealed the facility had no documentation of, or knowledge, of a dietician either contracted by or on staff with the facility during the months of April 2023, May 2023, June 2023, and/or July 2023. Record review of the facility's weight charts, dated 7/24/2023, revealed all the residents' meal consumption percentages had been charted for breakfast, lunch, and dinner on 7/24/2023 . Record review of the facility's weight charts, dated 7/25/2023, provided by the wound care nurse at 9:13 AM, revealed all the residents' meal consumption percentages had been charted for breakfast on 7/25/2023. Record review of the facility's Nutritional Assessment policy, dated November 2017, read in part .it is the policy of the facility to have a nutritional assessment, including nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .the Dietitian, in conjunction with the Dietary Supervisor will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition .residents who are receiving enteral nutrition support, the nutritional assessment shall include gathering information and documenting why the enteral nutrition is medically necessary .a weight loss/gain regimen will be initiated for a cognitively capable resident with his/her approval and involvement .if a resident decline to participate in a weight loss goal, the Dietitian will document the resident's wishes, and those wishes will be respected 32422 39977

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 5 of 6 residents (Resident #1, Resident #6, CR #3, CR #4, and CR #5) reviewed for pressure ulcers, in that: -Resident #1 was readmitted with redness to the sacral area which progressed to a Stage 4 pressure ulcer in 30 days and the treatments were not consistently conducted. -Resident #6 had pressure ulcers on her left trochanter and on both ankles that were not provided treatments as per physician's orders. -CR #3 had pressure ulcers on his sacral area and both buttocks that were not provided treatments as per physician's orders. CR #3 had a DTI on his left heel that was not provided treatments as per physician's orders. -CR #4 developed a pressure ulcer in the facility. Wound care that was ordered to be provided daily was not consistently provided. -CR #5 developed a pressure ulcer in the facility. By the time the wound was documented, it was a stage 2 of significant size. The failure placed dependent residents at risk for developing pressure ulcers or existing pressure sores worsening. Findings included: Resident #1 Record review of the Admission Record for Resident #1 revealed she was [AGE] years of age and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #1's MDS assessment, dated [DATE], revealed she scored 3 out of 15 on the BIMS, indicative of severely impaired cognitive skills. She required two person assist for bed mobility and transfers. The MDS reflected she had one Stage 4 pressure ulcer at that time. Record review of Resident #1's Care Plan (target date [DATE]) revealed the pressure ulcer to the sacrum was to be assessed, recorded, and monitored every week. Record review of Resident #1's Physician's Order dated [DATE] revealed Clean right buttock skin tear with NS/WC and apply Xeroform and cover with dry dressing daily. Record review of the [DATE] TAR for resident #1 revealed weekly skin assessments were to be conducted every Thursday. The TAR reflected the skin assessments were not conducted on [DATE] and [DATE]. Review of Resident #1 [DATE] TAR for Resident #1 revealed the treatment was not provided on [DATE]. Record review of resident #1's Physician's Order dated [DATE] revealed TX: Wound Pressure Stage 4 to the sacrum, cleanse with NS/WC, pat dry, apply Calcium Alginate and cover with absorptive dressing daily. Record review of the [DATE] TAR for Resident #1 revealed the sacrum treatment was not conducted on 16 of the 30 days of the month. The missed treatments occurred on both weekdays and weekends. Record review of the [DATE] and [DATE]TARs for Resident #1 revealed the sacral pressure ulcer treatments were missed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Observation and interview on [DATE] at 9:04 a.m. revealed Resident #1 to be lying in bed. She was on a pneumatic (air) mattress, and she had heel protectors on. LVN A, the facility treatment nurse, and CNA B were in the room. Resident #1 was turned onto her right side, and her brief was loosened by CNA B. Observation at that time revealed Resident #1 had recently had a wet bowel movement. She had a pressure ulcer on her sacral area that was covered with feces. Observation revealed there was no dressing on the wound, and there was no dressing loose in the disposable brief. Both staff confirmed. CNA B said she began her shift at 6:00 a.m., and had not provided incontinent care for the resident on that day prior to this observation. LVN A said no one had informed her that there was no dressing on the resident's wound. In an interview on [DATE] at 9:14 a.m., LVN C, the Charge Nurse for Resident #1, said no one had informed her that the wound dressing had been removed. She said she should have been informed. Observation and interview on [DATE] at 11:00 a.m. revealed LVN A conducted wound care for Resident #1. CNA B assisted. LVN A said Resident #1 had two areas that required treatment. She said she would provide treatment to the sacral area, followed by the right hip. Observation of the resident's sacral area revealed a pressure ulcer of approximately 1 x 2 cm, with significant depth. The tissue appeared to be granulated, with no visible slough. The wound was cleaned and packed with calcium alginate, which was then secured with a dressing. Continued observation revealed CNA B assisted the resident onto her left side. Resident #1 had an intact dressing on her right hip. The dressing was relatively clean, and had a date of [DATE]. The date was confirmed by both staff. Observation revealed that when the dressing was removed, a small area of open skin was exposed. It appeared to be a skin tear or a ruptured blister. It was approximately 1 cm diameter, and the depth was superficial. There was no drainage. The wound was cleaned and covered with Xeroform, then secured with a dressing. Record review of the Skilled Wound Care Communication for Daily Rounds dated [DATE] for Resident #1 revealed no assessment was conducted by PA D. Record review of the Weekly Skin Assessment Tool dated [DATE] revealed the sacral wound measured 7 x 6 x 2.8 cm. Record review of the Progress Notes revealed Resident #1 had returned from the hospital on [DATE]. No wound measurements were noted at that time. There were no additional wound measurements available to compare progression of the pressure ulcer. The Admission/Readmission Screener dated [DATE] reflected 'redness' was marked on the form for the sacrum area. Record review of the Weekly Skin Assessment Tool dated [DATE] for Resident #1 revealed the right buttock wound was determined to be a Stage 2 pressure ulcer, with measurements of 1 x 1.8 x 0.1 cm. This Weekly Skin Assessment was conducted during the 'sweep' and was the first documentation regarding this pressure ulcer. Resident #6 Record review of the Admission Record for Resident #6, dated [DATE], revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. record review of Resident #6's Admission/Readmission Screener dated [DATE] reflected the resident exhibited a pressure ulcer to the left hip, but reflected no measurements or staging. Record review of Resident #6's MDS dated [DATE] revealed the resident had one stage 3 pressure ulcer at that time. Record review of Resident #6's Care Plan (no date) revealed the staff was to provide treatment and weekly documentation to include measurement, type of tissue and exudate for the pressure ulcer to the left hip. Record review of Resident #6's Physician's Order dated [DATE] revealed Right lateral Malleolus-unstageable. Cleanse with wound cleanser. Pat dry. Apply Honey Gel. Apply calcium alginate. Apply dry dressing daily. Record review of the Weekly Skin Assessment Tool for Resident #6, dated [DATE], revealed the right ankle pressure ulcer was unstageable, and was measured at 2.5 x 2.0 cm with undetermined depth. Record review revealed there were no prior measurement for comparison. Record review of Resident #6's [DATE] TAR revealed the daily-ordered treatment was not provided on [DATE]. Record review of Resident #6's Physician's Order dated [DATE] revealed left lateral malleolus-unstageable. Cleanse with wound cleanser. Pat dry. Apply Honey Gel. Apply calcium alginate. Apply dry dressing daily. Every day shift for wound healing. Record review of Resident #6's Weekly Skin Assessment Tool dated [DATE] revealed the left ankle pressure ulcer was unstageable, and was measured at 2.0 x 2.0 cm with undeterminable depth. Record review revealed there were no prior measurement for comparison. Record review of the [DATE] TAR for Resident #6 revealed the left trochanter treatment were missed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review of Resident #6's [DATE] TAR revealed the daily-ordered treatment was not provided on [DATE]. Record review of Resident #6's Physician's Order dated [DATE] revealed Left lateral Malleolus-unstageable. Cleanse with wound cleanser. Pat dry. Apply calcium alginate. Apply dry dressing daily. Record review of Resident #6's Weekly Skin Assessment Tool dated [DATE] revealed the Left Trochanter ulcer was measured to be 1.7 x 1.7 cm with undeterminable depth. It was documented as a stage 4 pressure ulcer. Record review revealed there were no prior measurement for comparison. Record review of the [DATE] TAR for Resident #6 revealed the left trochanter pressure ulcer was a stage 3. The TAR reflected the daily-ordered treatment was not provided on 12 of 30 days of the month. Record review of the [DATE] TAR for Resident #6 revealed the treatment for [REDACTED]. Observation on [DATE] at 8:56 a.m. revealed Resident #6 was lying in bed. The head of the bed was elevated to approximately 30 degrees. She was tilted to the right. LVN E was in the room. The resident had on socks. When the left sock was removed, a dressing was visible on the left lateral Malleolus (ankle). The dressing was dated [DATE]. LVN E confirmed the date. When the right sock was removed, the dressing was visible on the lateral area of the right ankle/heel. Due to the resident's position, the date on the dressing could not be determined at that time. Observation on [DATE] at 9:44 a.m. revealed LVN A provided wound care for Resident #6. The dressing on the right ankle/heel was removed, and it had the date [DATE] scribed on it. LVN A confirmed the date. The wound was not visible to the surveyor due to positioning of the resident. Continued observation revealed LVN A provided wound care for the left Malleolus. The dressing was dated [DATE], which was confirmed by LVN A. The resident exhibited an unstageable pressure ulcer, of approximately 2 cm diameter and the dressing had scant serous drainage. Continued observation revealed Resident #6 was repositioned onto her right side. There was a wound dressing visible on her left trochanter (hip) area. The dressing was dated [DATE]. LVN A verified. CR#3 Record review of the Admission Record for CR #3, dated [DATE], revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. He was discharged to home on [DATE]. [DIAGNOSES REDACTED]. Record review CR #3's MDS assessment dated [DATE] revealed he required two-person assist for transfers and bed mobility. The Care Plan reflected no plans regarding ADLs or pressure ulcers. Record review of the Weekly Skin Assessment Tool dated [DATE] revealed CR #3 had a sacral pressure ulcer that measured 9.0 x 8.0 x 0.1 cm. He also had a pressure ulcer on his left heel that measured 0.5 x 0.4 x 0 (superficial). Record review revealed no other measurements to evaluate progression of the pressure ulcers. Record review of CR #3's Physician's Order dated [DATE] revealed TX: Sacrum Cleanse with NS. Pat dry. Apply Calcium Alginate and dry dressing QD. Record review of the [DATE] TAR revealed the treatment for [REDACTED]. Record review of CR #3's Physician's Order dated [DATE] revealed Left heel cleanse with NS, pat dry, apply [MEDICATION NAME], ABD, and small dry dressing. Record review of the [DATE] TAR revealed the treatment for [REDACTED]. CR #4 Record review of the Admission Record for CR #4, dated [DATE], revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. CR #4 was discharged to the hospital on [DATE]. She has since expired. Record review of CR #4's Admission MDS, dated [DATE], revealed a BIMS score of 1 out of 15, indicative of severely impaired cognition. The MDS reflected she required two persons assist for bed mobility and transfers. The MDS did not reflect any pressure ulcers. Record review of CR #4's Care Plan (no date) reflected the resident had pressure ulcers on her left foot and heel, right foot, ankle and heel, and sacral area. The Care Plan reflected the staff were to assess, record, and monitor healing weekly for all pressure ulcers. Record review of the [DATE] TAR revealed CR #4's pressure ulcers on the left foot and heel, right foot and outer ankle required only skin prep as treatment. Record review of CR #4's Physician order dated [DATE] revealed the sacral pressure ulcer was a stage 3, and was to be cleansed with soap and water, pat dry, then Dakin's solution applied. The wound was then to be covered with a dry dressing. The order reflected the treatment was to be conducted daily. The order was changed on [DATE]. Record review of the [DATE] TAR revealed the treatment for [REDACTED]. Record review of CR #4's Physician's Order dated [DATE] revealed the sacral wound care was changed to applying [MEDICATION NAME] and an absorptive dressing daily. Record review of CR #4's [DATE] TAR revealed the treatment for [REDACTED]. Record review of Interact 4 Nursing Transfer Form revealed CR #4 was transferred to the hospital on [DATE]. There was no reason for the transfer reflected on the form. It listed that the resident had a stage 3 to sacrum and to right lateral ankle. CR #5 Record review of the Admission Record for CR #5, dated [DATE], revealed he was [AGE] years of age, and was admitted on [DATE]. [DIAGNOSES REDACTED]. Record review of the Admission MDS dated [DATE] revealed CR #5 required one person transfer for bed mobility, and two person transfer for bed mobility. The MDS reflected the resident had no pressure ulcers at that time. Record review of CR #5's Admission/Readmission form dated [DATE] revealed the residen's sacrum exhibited blanchable redness. Record review of the Physician's Order dated [DATE] revealed CR #5 had a sacral pressure ulcer. The wound required a daily dressing change. The treatment was ordered as sacral pressure wound, cleanse with NS-WC, pat dry, apply [MEDICATION NAME], cover with dry dressing daily. Record review of the Weekly Skin assessment dated [DATE] revealed CR #5 had a stage 2 pressure ulcer on the sacral area that measured 7.0 x 5.5 cm (no depth noted). Record review revealed no prior identification of the pressure ulcer. In an interview on [DATE] at 4:52 p.m. with the Corporate LVN, she said she was the corporate care planner. She said when a pressure ulcer was found by a CNA, they were to inform the charge nurse, who would then assess and also inform the wound care nurse. The wound care nurse would also assess the resident. The charge nurse or wound care nurse would call the physician for a treatment order. Whoever called the physician was responsible to enter the order into the computer. She said there was a separate TAR for wound care. She said on the weekend, the Weekend Supervisor was responsible to check if the treatment was conducted or not. She said the facility had been looking for a wound-care nurse. She said corporate level nurses would 'spot-check' for the treatments when they came to the building. She said since the prior visit by the surveyors, the facility had conducted a 'sweep' of the residents for pressure ulcers. She said the facility had been without a DON for one month. She said PA D had been the wound care 'doc' for three weeks. Record review of the facility policy Pressure Ulcers/Skin Breakdown (revised February 2014) revealed the physician would authorize orders related to wound treatment. The policy reflected the nurse would provide wound treatments per physician's orders.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #1) of 7 residents reviewed for change of condition, in that: Resident #1's physician was not consulted of a change of condition from 1/14/2018 to 1/17/2018. Resident #1 was transferred to a local hospital on [DATE] due to complaints of shortness of breath, low oxygen levels and history of [MEDICAL CONDITION]. Resident was dialyzed at the hospital. This failure affected one former resident and had the potential to affect the 26 residents on the 200 hallway by placing them at risk for not recognizing and reporting change of condition which could result in worsening of condition and hospitalization . Findings include: Intake # 0 Resident # 1 Record review of Resident #1's clinical record revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record Review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 15 which indicated no impairment, no behavioral symptoms, required limited to extensive assistance on all ADLs, and had no pain or shortness of breath. Record review of Resident #1's Care Plan with an admission date of [DATE] revealed the following care plans in part: *Focus- The resident has an ADL self-care performance deficit related to recent deconditioning and hospital stay. *Goal- The resident will improve current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, overall ADL score through the review date *Interventions- Monitor/document/report to MD as needed for any changes, any potential for improvement, and reasons for self-care deficit, expected course, and declines in function. *Focus- The resident has [MEDICAL CONDITION] *Goal- The resident will have clear lungs sounds, heart rate and rhythm within normal limits through the review date. *Interventions- Give cardiac medications as ordered *Monitor/document/report to MD as needed any signs/symptoms of [MEDICAL CONDITION]; dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea, weakness and/or fatigue, increased heart rate, lethargy and disorientation Record review of Resident #1's skilled nursing notes dated 1/14/18 written by LVN C revealed the following in part: Left Foot swollen and red. Continue to monitor. Daily weight. Patient denies pain at this time. Request patch for restless leg syndrome. Administered to right thigh. Record review of Resident #1's Daily Weights revealed the following: On 1/3/18 he weighed 202.8 lbs; On 1/9/18 he weighed 203 lbs; On 1/10/18 he weighed 207.4 lbs; On 1/11/18 he weighed 208.2 lbs; On 1/12/18 he weighed 210 lbs; On 1/13/18 he weighed 210 lbs; On 1/14/18 he weighed 209 lbs; On 1/15/18 he weighed 209 lbs; On 1/16/18 he weighed 209 lbs. Record review of a Stop and Watch form for Resident #1 dated 1/15/18 written by Therapist D revealed the following for Resident #1: -Overall needs more help -Diarrhea, patient stated he have been having diarrhea since Friday (3days) -Confused, patient have increased confusion and word problems today Reported to: LVN Y Nurse Response: Nurse stated she will look into it and check on patient Interview on 2/8/18 at 12:41pm with Therapist D revealed Resident # 1 had a change of condition with increased fatigue and confusion on 1/15/18 in therapy. She revealed that she completed a Stop and Watch form per protocol and notified LVN Y. Interview on 2/8/18 at 4:38pm LVN Y revealed that she did not recall receiving a stop and watch from or notification of change of condition for Resident #1. She revealed that usually she notifies the physician if she receives a stop and watch form or notice of change of condition. Interview on 2/8/18 at 4:55pm LVN C revealed that Resident #1 did have swelling on 1/14/17 and she did not notify the physician because she elevated his leg and the swelling went down. She revealed she did not think it was necessary to notify the physician. Record review of a Daily Skilled Nurse's Note dated 1/11/18 revealed he oxygen saturations 96% on room air. There were no other oxygen saturations documented between 1/11/18 and 1/17/18. Record review of Resident #1's nursing progress notes dated 1/17/18 revealed the following: Resident #1 noted to be experiencing a potential change in condition, the following areas of concern noted: Functional decline (worsening function and/or mobility). Other change of condition, MD notified: Dr. H at 4:00pm. Record review of Resident # 1's nursing progress notes dated 1/19/18 (late entry for 1/17/18) revealed the following: Resident complains of shortness of breath. O2 applied at 4 liters nasal cannula. O2 saturation at 88%. Resident has history of [MEDICAL CONDITION]. MD notified and ordered to send resident to hospital. Record review of an SBAR Communication Form completed by ADON M dated 1/17/18 revealed Resident #1 had decreased level of consciousness and shortness of breath, described as recently progressive or persistent minor (shortness of breath) without other symptoms OR with progressive leg [MEDICAL CONDITION]. Record review of Resident #1's Nursing Home to Hospital transfer form dated 1/17/18 revealed Resident #1 was sent to the hospital on [DATE]. Record review of Resident #1's hospital records, Emergency Department (ED) Provider Note dated 1/17/18 revealed the following in part: -History of present illness: Resident #1 is a [AGE] year old with a history of [MEDICAL CONDITION] Fibrillation, Diabetes Mellitus, and [MEDICAL CONDITION] who presents to the emergency department with shortness of breath. Patient was brought by EMS from nursing home. Reports a couple weeks ago patient was able to do daily activities on his own. According to family patient's strength has deteriorated. Patient with bilateral swelling lower extremities. Physical Exam: Coarse breathing sounds; 2+ [MEDICAL CONDITION] bilaterally lower extremities; Alert and oriented x1 (person only) ED Course: Patient with [MEDICAL CONDITION] (7.7) and shift potassium. Dr. A consulted and will come in to evaluate patient at bedside. Placed inline emergently and dialyzed him. -Final Diagnoses: [REDACTED]. Interview on 2/6/18 at 9:55am ADON A revealed that when a resident has a change of condition the physician should be notified and a SBAR form should be completed. Interview on 2/8/18 at 12:52pm the Corporate Nurse stated that when there is a change of condition in a resident, the physician should be notified. The facility policy for Change in Condition was requested upon entry from the Administrator on 2/6/18 but was not received prior to exit. Please refer to F755 for more information. According to the Daily Census report there were 26 residents on the 200 hall.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 7 residents (Resident #1, #4) reviewed for medication administration. The facility failed to ensure Resident #1's admission medication orders were accurate. The facility failed to ensure all hospital discharge medications were acquired timely for Resident #1. The facility failed to ensure Resident #1 was administered ordered medications. Resident #1 was transferred to a local hospital on [DATE] due to complaint of shortness of breath, low oxygen levels and history of [MEDICAL CONDITION]. Resident was dialyzed at the hospital. -The facility failed to correctly prepare and administer Total Parental Nutrition (TPN) intravenously (IV) to Resident #4. These failures affected 1 former resident and 1 resident and could affect 32 other residents on the 200 and 400 halls by putting them at risk for not receiving medications as ordered by the physician and had the potential to cause adverse reactions, medication overdosing, and worsening of medical condition. Findings include: Intake # 0 Resident # 1 Record review of Resident #1's clinical record revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record Review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 15 which indicated no impairment, no behavioral symptoms, required limited to extensive assistance on all ADLs, and had no pain or shortness of breath. Record review of Resident #1's Care Plan with an admission date of [DATE] revealed the following care plan in part: *Focus- The resident has [MEDICAL CONDITION] *Goal- The resident will have clear lungs sounds, heart rate and rhythm within normal limits through the review date. *Interventions- Give cardiac medications as ordered -Monitor/document/report to MD as needed any signs/symptoms of [MEDICAL CONDITION]; dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea, weakness and/or fatigue, increased heart rate, lethargy and disorientation Record review of discharge medication list from the hospital generated on 1/3/18 revealed the following medications were ordered in part: Carvedilol 6.25mg tablet (a medication to treat [MEDICAL CONDITION]). Take one tablet by mouth two times a day for 30 days. [MEDICATION NAME] 25mg tablet (a diuretic medication to treat [MEDICAL CONDITION]). Take 0.5 tablet (12.5mg) by mouth two times a day for 30 days. Change how you take this Medication: [MEDICATION NAME] 40 mg tablet (a diuretic medication to treat [MEDICAL CONDITION]). Take one tablet by mouth two times daily for 30 days. What changed: medication strength, how much to take, when to take Continue taking: Potassium chloride 20mEq (a medication to treat or prevent [DIAGNOSES REDACTED]). Take 20mEq by mouth two times a day Rotigotine 4mg/24hour; commonly known as Neupro (a medication to treat [MEDICAL CONDITION]). Place one patch on the skin daily. Record review of the admission orders [REDACTED]. Record review of physician orders [REDACTED]. Carvedilol 6.25mg tablet. Take one tablet by mouth one time a day. [MEDICATION NAME] 25mg tablet. Take 0.5 tablet (12.5mg) by mouth two times a day [MEDICATION NAME] 40 mg tablet. Take one tablet by mouth one time daily Neupro Patch24 hour 4mg/24hour (Rotigotine) Place one patch on the skin daily Record review of physician orders [REDACTED]. Potassium Chloride Liquid 20mEq. Take 20mEq by mouth two times a day Rotigotine 4mg/24hour; commonly known as Neupro. Apply 1 patch [MEDICATION NAME] one time a day for [MEDICAL CONDITION]. Record review of Resident #1's Medication Administration Record for January 2018 revealed the following: - Carvedilol 6.25mg, 1 tablet by mouth once daily had a start date of 1/9/18 and was administered through 1/17/18. -[MEDICATION NAME] 40mg, 1 tablet by mouth once daily had a start date of 1/9/18 and was administered through 1/17/18. -Neupro Patch24 hour 4mg/24hour (Rotigotine), place one patch on the skin daily, had a start date of 1/11/18. Resident #1 refused the medication on 1/12/18, 1/15/18, 1/16/18 snf 1/17/18. -[MEDICATION NAME] 25mg, 1/2 tablet by mouth twice daily had a start date of 1/9/18 and was administered through 1/17/18. -Potassium Chloride Liquid 20mEq, take 20mEq by mouth twice daily had a start date of 1/10/18 and the first dose was administered on 1/11/18. The medication was administered through 1/17/18. Interview on 2/6/18 at 3:51pm with the Corporate Nurse revealed that the discharge medication list from the hospital should be reviewed by the admitting nurse. This list should be verified with the physician and family and orders should then be entered for medications at the facility. Interview on 2/8/18 at 8:37am with ADON M revealed that the discharge medication list from the hospital and family medication list is reviewed upon admission. The physician is called to verify medications and medications are entered into the system for the resident. The final medication list should be reviewed with the resident and family. Interview on 2/8/18 at 5:05pm ADON M revealed that she did not have a completed medication list on admission for Resident #1. She revealed that Resident #1's family member came days later with another list that included medications that were left off. Record review of Resident # 1's nursing progress notes dated 1/19/18 (late entry for 1/17/18) revealed the following: Resident complains of shortness of breath. O2 applied at 4 liters nasal cannula. O2 saturation at 88%. Resident has history of [MEDICAL CONDITION]. MD notified and ordered to send resident to hospital. Record review of an SBAR Communication Form completed by ADON M dated 1/17/18 revealed Resident #1 had decreased level of consciousness and shortness of breath, described as recently progressive or persistent minor (shortness of breath) without other symptoms OR with progressive leg [MEDICAL CONDITION]. Record review of Resident #1's Nursing Home to Hospital transfer form dated 1/17/18 revealed Resident #1 was sent to the hospital on [DATE]. Record review of Resident #1's hospital records, Emergency Department (ED) Provider Note dated 1/17/18 revealed the following in part: -History of present illness: Resident #1 is a [AGE] year old with a history of [MEDICAL CONDITION] Fibrillation, Diabetes Mellitus, and [MEDICAL CONDITION] who presents to the emergency department with shortness of breath. Patient was brought by EMS from nursing home. Reports a couple weeks ago patient was able to do daily activities on his own. According to family patient's strength has deteriorated. Patient with bilateral swelling lower extremities. Physical Exam: Coarse breathing sounds; 2+ [MEDICAL CONDITION] bilaterally lower extremities; Alert and oriented x1 (person only) ED Course: Patient with [MEDICAL CONDITION] (7.7) and shift potassium. Dr. A consulted and will come in to evaluate patient at bedside. Placed inline emergently and dialyzed him. -Final Diagnoses: [REDACTED]. Resident #4 Record review of Resident #4's clinical record revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's MDS revealed it was still in process since the resident was at the facility for six days at the time of the investigation. Record review of Resident #4's clinical record revealed he had a 48 hour care plan addressing care areas. Record review of Resident #4's physician orders [REDACTED]. [MEDICATION NAME]/[MEDICATION NAME] (5/15) Solution 5% (Amino Acid Infusion in D15W). Use 83ml/hr intravenously every shift for TPN (a intravenous solution that provides nutrition). Record review of Resident #4's Medication Administration Record dated February 2018 revealed on 2/6/18, the [MEDICATION NAME]/[MEDICATION NAME] (5/15) Solution 5% (Amino Acid Infusion in D15W) was administered on the 6am-2pm shift. Observation on 2/6/18 at 12:51pm revealed a bag of IV fluid that had two sides, one side was labeled with amino acids and the other side was labeled as [MEDICATION NAME]. The sides were not mixed together and the side that was labeled with amino acids was empty and the side with [MEDICATION NAME] was full. Interview on 2/6/18 at 12:53pm, after surveyor intervention, LVN F stated that both sides of IV fluid should be mixed before administering. She revealed that she did not hang the medication. LVN F stated that she did not realize both sides were not mixed until now. Interview on 2/6/18 at 1:01pm ADON A revealed that both sides of the IV fluid should have been mixed and she will be counseling the nurse who hung the IV fluids. Resident #4's family was at the bedside and on the telephone and LVN F notified them. ADON A then call the pharmacist to find out contraindications. He advised the facility the blood sugar could be affected. Blood sugar checked and it was 91mg/dl. Interview on 2/6/18 at 1:58pm the Pharmacist revealed that both sides of the IV fluid should have been mixed together. He stated that there should be no harm to Resident #4. He revealed there is a chance for [DIAGNOSES REDACTED] due to [MEDICATION NAME] not being administered. He recommended glucose checks and treat with [MEDICATION NAME] if needed. Record review of a Nurse Note written by ADON A dated 2/6/18 at 1:55pm revealed she notified Resident #4's family, the pharmacist and the nurse practioner. .per pharm he received amino acid given, that there should not reaction (sic), monitor blood sugar .per (nurse practioner), ok to place lipid on hold until IV pump and tubing are delivered, pending labs for today. Record review of the facility's Reconciliation of Medication on Admission policy revised December 2012 revealed the following in part: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission. Gather the information that is needed to reconcile the medication list: -Approved medication reconciliation fore -Discharge summary from referring facility -Admission order sheet -all prescription and supplement information obtained from resident/family during the medication history and If a medication history has not been obtained from the resident or family, complete this information first. Using an approved medication reconciliation form or other record, list all medication from the medication history, the discharge summary, the previous MAR and the admitting orders. Review the list carefully to determine if there are discrepancies/conflicts. Record review of the facility's Medications/Pharmacy policy, no revision dated revealed the following in part: All pharmacy recommendations must be noted, reviewed and implemented within 72 hours. All medication errors should be addressed accordingly by completing the medication errors report. According to the facility's census, there were 28 residents residing on the 200 hall and 5 residents residing on the 400 hall.