Every finding on record at Tomball Rehab & Nursing

Based on record review and staff interview, the facility failed to ensure laboratory services were obtained and reported in a timely manner for 1 of 5 residents (Resident #4) reviewed for laboratory services. The facility failed to ensure prompt communication of Resident #4's stat laboratory order which delayed further medical assessment and treatment. This failure placed residents at risk of experiencing delays in clinical decision-making and treatment. Findings include: Record review of Resident #4's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included urinary tract infection, acute kidney failure, cognitive communication deficit and delusional disorder. Record review of Resident #4's Quarterly MDS dated [DATE] revealed the following:*Section C revealed a BIMS score of 1 (severe cognitive impairment).*Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and one persons assisting with bed mobility, transferring and toilet use. It also revealed resident required one-person assistance with dressing, and personal hygiene. Record review of Resident #4's care plan dated 04/07/26 revealed Resident#4 was care planned for falls. ADL Self Care Performance Deficit:Goal-Resident will remain free from falls. Approach- Residents bed will be placed in its lowest position and a fall mat will be placed next to the resident's bed. Record review for Resident #1 physician's orders for March 2026 and April 2026 revealed a STAT laboratory test was entered into the electronic medical record on 04/02/26 at 10:21 AM. Further review showed the order was not confirmed until 1:30 PM by LVN-A. Interview conducted on 04/09/26 at 10:15 AM, the NP reported that a STAT laboratory/imaging order for a KUB for Resident #4 was issued at 10:29 AM on 03/24/26. The NP stated that the order was not confirmed until 10:09 PM on 03/24/26, indicating a significant delay in processing a STAT order. In an interview conducted on 04/09/26 at 10:00 a.m. with the facility Administrator, she stated that physician orders that are ordered stat should be confirmed right away. She stated that the KUB lab for Resident#4 that was ordered on 03/24/26 at 10:29am should have been confirmed right away and not at 10:09pm. Interview conducted on 04/09/26 at 10:44 AM, LVN-A stated that she did not recall the Nurse Practitioner issuing a STAT order for Resident #4 on 03/24/26 at 10:29 AM. LVN-A further stated that she received a high volume of orders and was not always notified when orders are entered into the electronic medical record. During an interview on 04/09/26 at 2:15 PM, the facility administrator stated the delay in confirming the STAT KUB order for Resident #4 was not acceptable. Record review of the facility's policy titled STAT Laboratory Services, dated 02/13/2020, revealed the following:If the laboratory technician has not arrived within one (1) hour, the nurse is to notify the laboratory again.If the laboratory technician has not arrived within two (2) hours, the nurse is to notify the Director of Nursing (DON).If the laboratory technician has not arrived within three (3) hours, the nurse is to notify both the DON and the physician for further direction.

Based on record review and interview, 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 1 of 5 residents (Resident #1) reviewed for pharmaceutical services. The facility did not administer Resident #1's medication as prescribed. This failure placed residents at risk of experiencing worsening conditions, infection, and further decline. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included acute kidney failure, major depressive disorder, chronic pain syndrome, paraplegia, insomnia, muscle weakness, and Type 2 diabetes mellitus without complications. Review of Resident #1's Quarterly MDS dated [DATE] revealed the following:*Section C revealed a BIMS score of 15 (cognitively intact).*Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and one persons assisting with bed mobility, transferring and toilet use. It also revealed resident required one-person assistance with dressing, and personal hygiene.Record review of Resident #1's physician order dated 04/02/26 reflected a prescription for Levaquin 500 mg PO at bedtime. The order was entered into the EMR by the Nurse Practitioner at 11:34 AM on 04/02/26 but was not confirmed until 12:39 AM on 04/03/26. Record review of Resident #1's Medication Administration Record (MAR) dated 04/02/26 revealed an order for Levaquin 500 mg PO, one tablet at bedtime. Documentation indicates the medication was not administered until bedtime on 04/03/26. Interview on 04/07/26 at 10:00 AM, the Nurse Practitioner (NP) reported that an order for Levaquin 500 mg PO was entered into the EMR at 11:34 AM on 04/02/26 for Resident #1. The medication was scheduled to start at 9:00 PM on 04/02/26; however, order confirmation did not occur until 12:39 AM on 04/03/26. Consequently, the initial dose was administered at 9:00 PM on 04/03/26. Interview conducted on 04/07/26 at 10:35 AM with LVN-A (the nurse responsible for receiving the physician order for Resident #1's Levaquin 500 mg PO at bedtime on 04/02/26). LVN-A stated she did not recall receiving the order from the Nurse Practitioner and was not aware that the medication required confirmation on 04/02/26. Interview conducted with the facility Director of Nursing (DON) on 04/07/26 at 11:32 AM. The DON stated that the physician order for Resident #1 should have been confirmed within two hours of being entered into the EMR. She further stated there was no justification for the delay in confirmation, which did not occur until 12:39 AM on 04/03/26. Interview conducted with the facility Administrator on 04/07/26 at 11:49 AM. The Administrator stated that when a physician's order was entered into the EMR, it was expected to be confirmed within two hours and carried out as prescribed. Record review of the facility's medication treatment administration and documentation policy dated 04/06/23 revealed it read in part, . 2.Administer the medication according to the physician order .

Based on interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for all 89 residents.The facility failed to demonstrate its measures to minimize the risk of legionella (bacteria naturally found in water that can cause a type of lung infection called legionellosis (legionnaires' disease and Pontiac fever; a milder flu-like illness) when people inhale tiny water droplets containing the bacteria) in the building's water system, when the facility's Water Management Program team failed to develop and implement an adequate water management policy and procedure to reduce the risk of growth and spread of legionella and other opportunistic pathogens in the building water system 02/19/2026.This failure could place residents at risk of outbreaks of legionellosis.Findings included: Record reviews of the facility's Infection Prevention and Control Program dated 11/06/2024, revealed the following: .Water Management:a. A water management program has been established as part of the overall infection prevention and control program.b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems.c. The Maintenance Director serves as the leader of the water management program .Record reviews of the facility's Legionnaires Monitoring Protocol dated 10/19/2015, revealed the following:The facility did not develop and implement a water management program that considers the ASHRAE industry standard and the CDC toolkit.The facility did not have a risk assessment to identify where legionella could grow and spread in the facility water system.The policy did not have a procedure on how to use the control measures to control the introduction and/or spread of legionella in the building water system. The policy did not include control limits (the maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for legionella growth and spread) and parameters. The policy did not have monitoring procedures to include: a. Specified and documented environmental testing protocols for legionella. b. Established control limits acceptable for the control measures the facility monitored to reduce the risk for legionella growth and spread. The policy did not have established ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis in the facility.During an interview on 02/19/2026 at 2:33 p.m., the facility's Regional Director of Operations, the IDON and the Maintenance Director stated they were not aware the LWMP was inadequate to prevent the growth and spread of legionella in the building water system. They stated they were not aware the plan did not have:- A risk assessment to identify where legionella could grow and spread in the facility water system,- procedures to explain how to use the control measures,- what were the acceptable control limits and parameters,- what were the monitoring procedures,- what were the testing protocols,- and what were the established ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis in the facility.The facility's Administrator, who has been working at the facility for a week, stated the Water Management Program team should have established and maintained an adequate program to prevent the growth and spread of legionella in the building.

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 in 1 of1 kitchen reviewed for food procurement.The facility failed to ensure leftover food to be used later with temperature in the danger zone foods were discarded.The facility failed to ensure that food past the use by date were discarded which included 1 bag lunch dialysis used by date 2-12-26, 1 bag lunch dialysis used by date 2-13-26 .A pan of corn niblets no used by date, a package of sausage use by date 2-14-26, a package of sliced swiss cheese no label no used date.The facility failed to ensure foods were stored 6 inches off the floor.Dirty can opener blade.Observation of the facility on 2-17-26 at 7:45 am revealed the following. 1. A dialysis lunch bag used by date 2-11-26 and 2-13-26. 2.A pan of corn nib lets no used by date . 3. A package of breakfast sausage use by date 2-14-26. 4. A package of shredded cheese no used by date. 5.A package of sliced swiss cheese no used by date. 6. A case of frozen ground beef in the freezer floor. 7. A pan of soft mechanical sausage with a temperature of 130.1 degrees Fahrenheit in the steam table. 8. Scoop for salt bin should not be in the food bin. Interview with the dietary food service manager on 2-17-26 @ 8:00 AM , revealed that the following foods were stored in the refrigerator to be used for later date should be discarded prior to use by date. She stated the leftover food with danger food temperature 40 degrees Fahrenheit to 140 degrees Fahrenheit should have been discarded. She further stated that she will in -service dietary staff on proper handling,storing,dating laftover food for compliance.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5% for 3 of 7 residents (Residents #41, #46, #96) reviewed during medication administration. Staff administered 26 medications with 3 errors, which resulted in a medication error rate of 11.54%.The facility failed to ensure physician orders were followed for preparing MiraLAX with a specific amount of water for Resident #41 and Resident #46 on 02/18/2026 and 02/19/2026.The facility failed to ensure staff followed physician orders for IV medication administration by not obtaining flushing orders before and after IV medication administration for Resident #96 on 02/19/2026.The failure could place residents at risk of receiving less than optimal results from their medication regimen, stomach irritation and fluid overload (when body retains too much water). The failure could result in inadequate medication delivery and harm related to improper IV therapy.Findings included: Record review of Resident #96's undated admission record revealed a [AGE] year-old female with an initial admission on [DATE] and most recent admission on [DATE]. Resident #96 had diagnoses of sepsis, respiratory failure, pneumonia, aphasia, and enlarged lymph nodes. Record review of Resident #96's Care Plan initiated on 09/04/2023 and revised on 09/13/2023 read, resident was at risk for infection/signs and symptoms of viral respiratory infection. The interventions read, encourage/educate resident/resident family on vaccinations for respiratory viruses such as, COVID-19, Influenza, pneumonia, etc. Observe for and promptly report signs and symptoms: fever, coughing, shortness of breath, or other respiratory issues. Record review of Resident #96's Quarterly MDS dated [DATE] revealed a BIMS score of 8 with moderate cognitive impairment, meaning the resident has severe impairment but still able to participate meaningfully in an interview with support. Record review of Resident #96's MAR dated 02/18/2026 revealed to begin Vancomycin HCI Intravenous Solution 500 MG/100ML. Use 1 dose intravenously every 12 hours for IV ABT related to Pneumonia until 03/07/2026. There were no flushing orders Sodium Chloride Solution 0.9% to be completed before or after treatment. In observation on 02/19/2026 at 7:40am RN O administered Vancomycin HCI Intravenous Solution 500 MG/100ML to Resident #96. RN O flushed the resident's IV line with 10mL of 0.9% sodium chloride solution. After completing the infusion, RN O again flushed the IV line with 10mL of 0.9% sodium chloride solution. In an interview and observation on 02/19/2026 at 7:48am with RN O reviewed the MAR and the physician order with this surveyor, in which there was no order for flushing the IV line with 10mL. RN O stated it was nurse practice when administering IV therapy to flush the IV line and because there was no flushing order, she would just obtain an order from the doctor. In an interview on 02/19/2026 at 8:57am with the IDON stated the expectation for administering medication should be followed according to the doctor order. It was standard practice to flush, but the order should be verified before administering. The risk of flushing IV lines without an order was an adverse effect and bad practice. Resident #46 Record review of Resident #46's Physician Orders, dated 09/11/2023, revealed an active order of polyethylene glycol 3350 oral (by mouth) powder 17 gm/scoop. Give 1 scoop by mouth two times a day for constipation. The order did not specify how much water to mix the powder with. During an observation on 02/18/2026 at 8:45 a.m., MA A poured and mixed polyethylene glycol powder with water and attempted to give it to Residents #46. Resident #41 Record review of Resident #41's Physician Orders, dated 11/14/2025, revealed an active order of polyethylene glycol 3350 oral powder 17 gm/scoop. Give 1 scoop by mouth in the morning for constipation. The order did not specify how much water to mix the powder with. During an observation on 02/19/2026 at 9:51 a.m., MA A poured and mixed polyethylene glycol powder with water and attempted to give it to Residents #41. During an interview on 02/19/2026 at 10:57 a.m., MA A stated she should have contacted the provider to seek clarification about the water amount to mix the polyethylene glycol powder with before she gave it. She stated administering the powder with the wrong amount of water could cause health issues to residents. During an interview on 02/19/2026 at 11:24 a.m., the NP stated both polyethylene glycol orders should have included between 4 and 8 oz. of water to mix the powder with. The NP stated she expected the prescribing provider, who did not work with the facility any longer, to include the amount of water in those orders. The NP stated she expected nurses and MAs to contact the provider for clarification about medication orders when those orders missed instructions on how to use them. She stated administering the powder with the wrong amount of water could cause stomach irritation. She also stated it could also cause fluid overload and coughing for residents who had fluid restrictions on their daily fluid intake. During an interview on 02/19/2026 at 4:25 p.m., the IDON stated he expected Nurses and MAs to call the provider to seek clarifications about medication orders when those orders missed instructions on how to use them. He stated nurses and MAs should have sought clarification about the amount of water required to mix the powder with before each administration. The IDON stated using the wrong amount of water to mix the powder could prevent the medication from working as prescribed and could cause fluid overload for residents with fluid restrictions.

Based on observations, interviews 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 #33, Resident #85) reviewed for medication storage and labeling.The facility failed to ensure nurses dated Residents #33 and 85's opened insulin glargine (a medication prescribed to help the body manage blood sugar levels) pens and discarded them within 28 days of opening, on [DATE].This failure could place residents at risk of receiving medications that were less effective or expired and the risk of contamination or chemical degradation (change of a substance into something else, often making it weaker, useless, or harmful).Findings included:Record review of Resident #33's Provider Orders dated [DATE], revealed an active order to receive insulin glargine 100 units/ml multiple-dose pen. Inject 15 units SQ (under the skin) at bedtime for diabetes (a disease in which the body cannot make or properly use insulin).Record review of Resident #85's Provider Orders dated [DATE], revealed an active order to receive insulin glargine 100 units/ml multiple-dose pen. Inject 10 units SQ every 12 hours for diabetes.During an observation of Hall A's medication cart and interview on [DATE] at 2:03 p.m., revealed, staff opened and dated 2 insulin glargine, 100 units/ml multiple-dose pens and kept them in the medication cart beyond 28 days of the opening date.Staff opened and dated an insulin pen that belonged to Resident #33 on [DATE] and opened and dated a second insulin pen that belonged to Resident #85 on [DATE].LVN A stated all nurses should have checked the pens dates before each administration and discarded them after 28 days of opening. LVN A added if nurses kept using the insulin pens after 28 days of opening, residents might have received insulin that was less effective in controlling their blood sugar levels.During an interview on [DATE] at 4:23 p.m., the IDON stated he expected all nurses to check insulin pens for opening dates before each administration and discard them after 28 days of opening. The IDON added if nurses kept using the insulin pens after 28 days of opening, residents might have received insulin that did not work as prescribed.Record review of the facility's Storage of Medications Policy dated [DATE], revealed .Drugs dispended in the manufacturer's original container will carry the manufacturer's original expiration date. Once opened, these products will be acceptable to use until the manufacturer's expiration date is reached and unless the medication is:.iii. An item or which the manufacturer has specified a usable duration after use.Record review of the most current manufacturer's guide for insulin glargine pens dated [DATE], revealed staff must throw away all opened pens after 28 days of first use, even if there is insulin left in the pen.

Based on observation, record review, and interviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 23 residentsResident #43) reviewed.The facility failed to ensure adequate supervision was provided for Resident #43 while smoking. Resident #43 was outside smoking without staff supervision on 2/17/26.This failure could place the residents at risk for burns, injury, and fire hazards.Findings included:Record review of Resident #43's undated face sheet revealed he was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE]. Resident #43 has diagnoses of intermittent explosive disorder, epilepsy, lack of coordination, weakness, muscle spasm, transient ischemic attack (short period of symptoms like a stroke), and atrial fibrillation (very rapid heartbeat).Record review of Resident #43's Smoking Evaluation dated 05/20/2025 revealed resident has a BIMS score less than 12 and can make decisions regarding tasks of daily life. Resident #43 was dependent and requires assist/supervision to smoke by IDT.Record review of Resident #43's Smoking Evaluation dated 07/27/2025 revealed resident has a BIMS score equal to or greater than 12 and can make decisions regarding tasks of daily life. Resident #43 was independent and requires no supervision to smoke by IDT.Record review of Resident #43's Smoking Evaluation dated 09/25/2025 revealed resident has a BIMS score equal to or greater than 12 and can make decisions regarding tasks of daily life. Resident #43 was dependent and requires assist/supervision to smoke by IDT.Record review of Resident #43's Care Plan dated 06/27/2025 and revised on 08/21/2025 stated resident was a smoker and was at risk of injury. The interventions read, remind resident and family that all cigarettes, lighters, matches, and smoking paraphernalia must be kept at the nurse's station. The resident will be supervised while smoking on facility property to reduce the risk for smoking related injuries.In an observation on 02/17/2026 at 6:21 am, Resident #43 was observed in his wheelchair exiting the facility back door with 1 cigarette in hand and going towards the end of the building, passing the no smoking sign. Resident #43 was observed lighting his own cigarette with a lighter, which he then placed in his pocket while the cigarette remained lit.In an interview on 02/17/2026 at 6:21am, Resident #43 stated he was always smoking outside by himself and then asked who she was. The resident no longer wished to answer any questions after surveyor identified self.In an interview on 02/17/2026 at 6:23am with LVN K stated residents were not allowed to go out and smoke by themselves, they must be supervised. LVN K was not aware the resident went out the unlocked back door of the facility to smoke, until it was made aware by the surveyor. LVN K stated the door is to be always locked, but unsure who unlocked the door. The risk could be the resident falling out of the wheelchair.In an interview on 02/17/2026 at 9:40am with the ADMN stated smoking was to be supervised anytime in the designated area. Residents should not have any smoking paraphernalia, and it was to always be locked away with only staff who have access. The risk of a resident smoking unsupervised was safety.In an interview on 02/17/2026 at 12:20pm with the ADON stated residents were not allowed to smoke unsupervised. Residents were to have no smoking paraphernalia. The risk of a resident smoking unsupervised was they could possibly set themselves on fire, pass out, or have some type of injury. In an interview on 02/17/2026 at 12:21pm with the IDON stated residents were not to smoke unsupervised, if they do, they sign themselves out and were r no longer on facility grounds. Residents should not have their own smoking paraphernalia, and it was kept in a locked area where only monitoring staff have access. The risk of a resident smoking unsupervised was injury and/or the resident could burn themselves.In an interview on 02/19/2026 at 3:24pm with CNA B stated the policy for resident smoking was to ensure safety. Smoking paraphernalia was kept locked in the medication's storage room, only nurses and appointed staff for allotted smoke times have access. The risk of a resident smoking unsupervised was burning themselves.In an interview on 02/19/2026 at 3:50pm with the AD stated residents shouldn't have any smoking paraphernalia and it was locked in the medication storage room. The procedure while supervising residents who smoke was to check if they were required to wear an apron, provide resident with their cigarette, light it for them, make sure they're not dropping any ashes, empty the ash tray, and clean up before leaving the smoking site. The risk of a resident smoking unsupervised was burning themselves or their clothes.Record review of the facility's Smoking Policy dated 02/26/2014 with a revision dated 07/14/2023 read.PolicyIt is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking. To evaluate a patient's ability to participate and exercise the privilege to smoke/Use smokeless Tobacco products while residing within the facility.3. Facilities will have a designated Smoking/Tobacco use area. Signs will be prominently posted. Smoking is prohibited in all other areas. Safety measures for the designated smoking area will include, but not limited to:a. Protection from weather conditions (i.e., covered)b. Ashtrays made of noncombustible material and safe designc. Accessible metal container(s) with self-closing covers into which ashtrays can be emptied.d. Accessible fire extinguishere. Sign Prohibiting use of oxygen in the smoke areaf. Type A Fire extinguisher or fire blanket8. Staff members distribute smoking accessories to patients at center designated smoking times or when signing out of the centers. Smoking accessories are returned to the staff when the patient signs in to the facility.16. Upon completion of the evaluation, the interdisciplinary team lead by the social worker or designee, will assess the patient's ability to understand smoking/smokeless Tobacco guidelines and handle smoking and smokeless paraphernalia.a. If the patient is determined to be an Independent Smoker, the patient may smoke without assistance at center designated times and with designated staff present.b. If the patient is determined to be a Dependent Smoker, or Dependent Smokeless Tobacco user, the patient is supervised during smoking. The resident/family is educated on the use of protective smoking equipment which may include but not limited to a protective smoking vest or apron, smoking, clips etc.

Based on observation, interview and record review the facility failed to ensure a comprehensive plan is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments reviewed for 1 of 23 (Resident #94) residents.The facility failed to revise Resident #94's care plan after completing the comprehensive assessment to reflect Resident #94 pocketing food in the mouth, being lethargic, and having a decreased appetite. The failure could result in the resident not receiving proper care.Findings included:Record review of Resident #94's undated face sheet revealed he was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] and then 01/01/2026. Resident #94 has diagnoses of protein-calorie malnutrition, dysphagia (difficulty swallowing), dementia, gastro-esophageal reflux disease without esophagitis (heartburn), muscle weakness, epidural hemorrhage without loss of consciousness (dangerous lucid head injury that causes arterial bleeding between the skull and dura mater) and Alzheimer's.Record review of Resident #94's Care Plan initiated date 07/15/2025 with no updates after this date read resident was on mechanical soft and thin liquids and at nutritional and hydration risk related to diet restrictions. Intervention read, serve diet as ordered. Monitor intake and record every meal, provide and serve supplements as ordered, dietary manager to discuss food preferences with resident or family upon admission and then as needed to meet dietary needs, registered dietitian to evaluate and make diet/supplements change recommendations as needed.Record review of Resident #94's Quarterly MDS assessment dated [DATE] revealed resident has a BIMS score of 01, reflects severe cognitive impairment, indicating the resident is not able to provide correct responses. Functional abilities for eating are scored 02, which means the resident does require substantial/maximal assistance, more than half the effort to eat. The helper lifts or holds trunk of limbs and provides half the effort. Section K0100 revealed Resident #94 did not have a swallowing disorder and showed no signs or symptoms. Section K0300 revealed Resident #94 loss of 5% or more in the last month or loss of 10% or more in the last 6 months scoring was 0, no or unknown.Record review of Resident #94's Nutrition assessment dated [DATE] revealed nutrition orders were no added salt, mechanical soft texture, and thin liquids diet. Eating ability was extensive assistance, should be in the dining room, and should oral intake 26-50% of food. Monitoring/Evaluation read 1. Nsg/IDTverify wt. Weigh wkly x 4 wks; continue if patter wt loss. 2. Monitor meal records/intake for meal intake less than 51-100% of most meals; verify alternates provided then intake less than 51-100%. Signed by RD S on 12/20/2025, which was not updated into the care plan.Record Review of Resident #94's MAR dated 12/27/2025 revealed Med plus 2.0 three times a day for supplement 90ml with medication pass may use med pass 2.0 or house shake. Protonix Tablet Delayed Release 40MG (Pantoprazole Sodium), give 1 tablet by mouth in the morning for GI bleed. Ascorbic Calcium Oral Tablet 500 MG (Ascorbic Acid), give 1 tablet by mouth in the morning for supplement.Record review of Resident #94's Follow Up on 01/15/2026 with NP P read advance care planning with patient/family/member/surrogate the following treatment preferences were discussed as follows: Discuss power of attorney and living will. Discussed IV fluids and enteral feeding.Record review of Resident #94's SBAR Communication dated 01/18/2026 by LVN A read resident has had the following change in condition: decreased appetite, pocketing food, and lethargic. Since the change/symptoms started, it has gotten worse. This condition, symptom, or sign has occurred before. NP S was notified, assessed and recommended to continue monitoring and will update current NP tomorrow about possible hospice. RP was contacted.Record review of Resident #94's Progress Note dated 01/19/2026 by MA A read Med plus 2.0 three times a day for supplement 90 ml with medication pass may use med pass 2.0 or house shake PRN as alternate - unable to swallow nurse notified. Ascorbic Acid Oral Tablet 500MG give 1 tablet by mouth in the morning for supplement - unable to swallow nurse notified, which was not updated into the care plan.Record review of Resident 94's Progress Note dated 01/21/2026 by LVN A read poor appetite and weakness noted. NP & RP aware.Record review of Resident #94's Progress Note dated 01/21/2026 by LVN A read this nurse observed resident looking lethargic. Two CNA and this nurse helped transport resident to bed and obtain vitals. Low o2 and pulse noted. Notified DON and lowered resident to the floor. NP was present. This nurse started CPR for 3 rounds of 30 compression and took over giving 2 breaths after 30 compressions. 911 was called by ADON. AED pad were placed while DON was giving compressions. EMS arrived and took over. EMS called time of death at 12:31pm. Called RP and spoke with him regarding resident passing away. RP called this nurse with funeral arrangements and will be out to the facility collect belonging.Record review of Resident # 94's Follow Up Question Report dated 02/18/2026 for multiple meal intake dates.01/15/2026 at 12:03pm, 0-25% of meal was eaten.01/18/2026 at 8am, 0-25% of meal was eaten.01/18/2026 at 11am, 26-50% of meal was eaten.01/19/2026 at 8am, 0-25% of meal was eaten.01/19/2026 at 11am, 0-25% of meal was eaten.01/21/2026 at 11:51am, 02-25% of meal was eaten.In interview on 02/18/2026 at 10:38am with RD S stated she does not recall a recent change in condition for Resident #94 for decreased appetite, pocketing food, and being lethargic. For evaluations, she was notified via email or telephone call and after she will relay her concerns to the DON or ADON along with the Dietary Manger for updated changes. RD S provided communication forms with diet changes for all residents in the facility from December 2025- January 2026 and it did not reveal any changes for Resident #94's diet or any updated recommendations.In attempts on 02/18/2026 at 10:56am to contact NP S by telephone and e-mail, no response was received.In an interview on 02/18/2026 at 11:26am with NP P stated the last time she saw Resident #91 was on 01/15/2026 for his quarterly visit and blood pressure medications, but there was a weekend NP that may have seen the resident on 01/18/2026. She was not made aware of any recent change in conditions for Resident #94 pocketing food, decreased appetite, and being lethargic. NP P stated the resident had orders for dietary consultation and speech was working with him, but she was unsure how recent. The RP declined for the resident to have tube feeding when it was last discussed on 01/15/2026. On 01/21/2026 she was called into the room of Resident #94, as LVN A was providing CPR to the resident. For the change in condition, the follow up should have been an order for speech therapy and then a recommendation for swallow evaluation. Once the recommendations were complete, the speech therapist or MDS would follow the recommendations and the orders will be updated in the chart, interventions into the care plan.In an interview on 02/18/2026 at 11:42am with LVN A stated on 01/18/2026 she completed a change in condition for Resident #94 due to decreased appetite, pocketing food, and being lethargic. She could not recall if there were any recent changes made from the RD, but the CNAs monitor the resident's feedings and input the percentage into Kardex. She was informed the RP declined for the resident to have a g-tube and hospice care. After she completed the change in condition, someone would have informed the speech therapist regarding a consult/evaluation. Normally the DON update pull the reports or 24 hour report to alert a change has occurred before the morning meeting and that was how the team was made aware of new conditions and had previously happened the day before. The risk of the care plan not being revised after an assessment could result in a missed opportunity to properly address the residents needs of care and they could possibly decline.In an interview on 02/18/2026 at 12:34pm with P ADMN stated she was not made aware of Resident #94's change in condition but was present when the resident expired. The expectation for a change in condition was to notify the DON and the ADMN once the SBAR has been completed, recommendations can be made by the NP or MD, notify the RP, and the care plan will be revised. Once the care plan was revised, all nursing staff would have access to the change before providing care to the residents. Communication was made throughout the day, which can be verbal, e-mail, or electronically. The P DON would have been responsible for ensuring the recommendations from the SBAR were completed and followed up on and any new interventions that would have been completed by the DON to reflect the change in condition with the resident. The risk of the care plan not being revised after an assessment could result in missed adjustments needed, preventable side effects, or even neglect.In an interview on 02/18/2026 at 12:46pm with ST B stated that she does not recall conducting an assessment for Resident #94. For resident evaluations, there was an order in the electronic medical record, which she is informed by the DOR. A speech therapy evaluation requires a physicians order. Speech therapy does not assess a resident without that order. In practice, evaluations are typically initiated when a resident is unable to swallow safely or when an upgrade in diet texture does not require a speech therapy evaluation; however, an upgrade would require assessment by a speech- language pathologist to ensure the resident can safely tolerate the higher texture. The last evaluation that was completed for Resident #94 was on 07/01/2025 and the recommendations at that time were solids mechanical soft and thin liquids.In an interview on 02/18/2026 at 2:06pm with P DON stated she was not aware of a recent change in condition for Resident #94, but he did have swallowing problems. The NP and MD were notified of the change and there was a speech therapy evaluation completed, but she does not recall any new interventions. P DON stated she was responsible for updating care plans, once the SBAR was complete and all proper recommendations had been made. Once the care plan has been revised, all nursing staff can verify the updated change before caring for the residents through Kardex. The expectation was for staff to inform her of the residents having a change in condition to start notifying all needed parties to ensure the residents were evaluated. The risk of the care plan not being revised after an assessment could result in harm to the residents.In an interview on 02/18/2026 at 2:20pm with the DOR stated speech therapy services for Resident #94 were from 07/01/2025-09/18/2025. There were no referrals, recommendations, or follow ups completed after the discharge of services on 09/18/2025.Record review of facility policy for Care Plans ad Care Area Assessments dated 01/21/2015, revised on 05/06/2016 reads.The purpose of this guide is to ensure that an interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CATs) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident.All admission and Significant Change care plans that are generated by the MDS-CAAs will be initiated by a Registered Nurse (RN).All comprehensive care plans will be completed utilizing the Point Click Care electronic system.All care plans will be kept in an area that is accessible by all staff.The facility IDT members are responsible for addressing their assigned CAT/CAA triggered by the MDS at the time of MDS assessment.Acute Care PlansAs acute problems or changes to intervention or goals are identified, an appropriate care plan will be developed or modified by a Nursing staff member.

Based on observation, interview, and record review the facility failed to ensure housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 9 residents (Resident #91) on the 200 hall.The facility failed to create a sanitary environment by leaving two soiled briefs on the floor, in Resident #91's room on 02/17/2026.This failure could result in high risk of cross-contamination.Findings included:Record review of Resident #91's undated face sheet revealed she was a [AGE] year-old female with and initial admission date of 11/22/2026 and most recent admission on [DATE]. Resident #91 has diagnoses of lack of coordination, polyneuropathy (many nerves in different parts of the body become damaged), abnormal posture, absence of left leg above the knee, congestive heart failure, anxiety, and major depressive disorder.Record review of Resident #91's Initial MDS assessment dated [DATE] revealed a BIMS score of 9. Resident #91's BIMS demonstrated moderate cognitive impairment, which could reflect problems with thinking and memory.Record review of Resident #91's Care Plan revised on 12/01/2025 revealed resident was incontinent of bowel/bladder. The interventions read, check frequently for wetness and soiling, and change as needed.In an observation on 02/17/2026 at 8:17am in Resident #91's room on the 200 hall revealed two soiled briefs on the floor, trash on the floor, and multiple bed pads in the trash bin.In an interview on 02/17/2026 at 10:56 am with Resident #91 stated she had just come back from the hospital. She normally throws used briefs on the floor, and the staff will come pick them up. Resident #91 stated that she has a problem with her hands and couldn't fold it. Resident #91 didn't state the risk of the soiled briefs being left on the floor, but stated when she presses the call light button, staff will not come, which was why she would leave the brief on the floor and clean herself up.In an interview on 02/17/2026 at 11:21 am with the IDON stated the expectation for cleanliness in the resident rooms and throughout the facility was to conduct rounds within a two-hour period and for staff to come behind residents and clean up. The risk of soiled briefs being left on the floor could cause a break in infection control.In an interview on 02/17/2026 at 11:53am with the ADON stated the expectation for cleanliness in the resident rooms was the aides should be going behind residents and making sure nothing was on the floor or in the trash. Rounds should be made every two hours to ensure residents were not soiled and briefs were not being left around. The resident doesn't usually have this behavior, as this was the first time she had left soiled briefs on the floor. ADON assured cleanliness, infection control, and call lights will be re-educated to Resident #91. The risk of soiled briefs being left on the floor was contamination.In an interview on 02/19/2026 at 2:04pm LVN A stated for soiled briefs with incontinence care, they should be put into a bag and into a barrel to be taken out by staff. The expectation for cleanliness would be conducting rounds and making sure barrels were being taken out along with picking up trash. The risk of soiled briefs being left on the floor was unsanitary and could possibly cause issues in areas of infection control.In an interview on 02/19/2026 at 2:16pm with EVS F stated resident trash was emptied once a day, but nurse oversees taking out their own trash in resident rooms. The expectation was daily cleaning of resident rooms, to include mopping and disinfecting. The risk of soiled briefs being left on the floor was possible infection such as Clostridioides difficile (bacteria that can cause diarrhea) that could be carried through bodily fluid.In an interview on 02/19/2026 at 2:34pm CNA B stated for soiled briefs, they should be placed into a plastic bag and then taken to the barrel. The expectation for cleanliness was to keep things tidy and housekeeping ensure the rooms were disinfected. The risk of soiled briefs being left on the floor was becoming sick, a resident could become depressed or have a fall.Record review of Resident Rights policy dated 02/23/2016 reflects.Policy: The facility will inform the resident both orally and in writing in a language that the resident understands his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. 1. The facility failed to ensure foods were not stored past their use by date. 2. The facility failed to ensure all food and drinks in storage were labeled. 3. The facility failed to ensure the dishwasher was maintained and effectively sanitizing dishware. These failures could place residents at risk of foodborne illness. Findings included: Observation of the kitchen on 11/05/2024 at 9:10AM revealed the following: - Fridge #1 contained a bin of mandarin oranges, dated 10/23/2024 and butterscotch pudding, date 10/18/2024, and a tray of individually poured drinks without a label. In an interview with the Dietary Manager on 11/05/2024 at 9:15AM, she stated she did not know for how long the leftover pudding and mandarin oranges were to stay in storage before throwing them away. She also said the drinks were supposed to be labeled and it may have been stored without a label by the dietary staff that was in training. Observations of the low-temp dish machine on 11/05/2024 at 9:30AM, and interview with the Dietary Manager and Dietary Aide A revealed dishes were being washed by Dietary aide A while the wash cycle was running at 98 F and the rinse cycle was running at 104 F. The Dietary Manager was then observed to ask Dietary aide A to document temperatures on the dishwasher temperature log. Dietary Aide A then wrote 100 for the wash cycle and 120 F for the rinse cycle. When asked how she knew what the temperatures were for the dishwasher, she stated she dipped the test strips in the dish machine water to check the temperature. She then grabbed the water sanitation test strips to show the surveyor the ppm was ranging from 50-100 ppm. When asked where the temperature gauge was on the dish machine, she stated she did not understand. The Dietary Manager then came forward to show Dietary Aide A where the temperature gauge was and stated it looked like the temp was at about 118-120 F. The Surveyor at this time checked the temperature gauge and rebutted that the temperature gauge was actually reading 110 F, to which the Dietary Manager agreed. The Dietary Manager said water temperatures ranging from 110 F to 120 F was appropriate for operating the dish machine. In an interview with the Dietary Manager on 11/07/2024 at 2:30PM, she stated Dietary Aide A had been working in the facility kitchen for about six years but had never in-serviced her on how to use the dish machine. She said she assumed Dietary Aide A knew how to use the dish machine and she had never done a competency check or audit on her kitchen staff while they operated the dishwasher. She stated the dish machine had since been fixed and the temperature of the water was now reaching 128 F. She stated if the temperature of the dishwasher was not reaching at least 120 F, then it should not be used because the dishes would not be sanitized properly and would put the residents at risk of foodborne illness from cross contamination. Record review of the facility's policy on food storage, dated November 2017, reflected, . Ready-to-eat food will be clearly labeled using calendar date to indicate the date the product was prepared and the date the product must be used or discarded. Use the following to determine the use by date: Held at 41 F or below = 7 days . Record review of the facility's policy on ware washing, dated 12/11/2017, reflected, . Low Temperature Dish Machines a. 120 F = minimum water temperature for both wash and rinse cycles b. chemical: chlorine sanitizer = 50ppm . Record review of FDA Food Code, dated 2022, reflected, .(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

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 1 of 1 resident (Resident #51) reviewed for gastrostomy tube management. - The facility failed to ensure LVN D mixed crush medications with water as ordered by MD to Resident #51 by pouring dry powder medication into the resident's G-tube. This failure could place residents at risk for adverse effects, pain, discomfort and not receiving the therapeutic effects of the medication. Findings included: Record review of Resident #51's Face Sheet dated 07/24/2024 revealed [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included: difficulty swallowing, dementia, gastrostomy status (a gastrostomy feeding tube (G-tube) insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach.). Record review of Resident #51's MDS dated [DATE] revealed the resident had severely impaired cognition as indicated by a BIMS score of 00 out of 15, and used of a feeding tube while a resident. Record review of Resident #51's undated Care Plan revealed, focus- requires tube feeding related to difficulty swallowing; intervention: administer tube feeding and water flushes as ordered, check for placement and gastric contents/residual per facility protocol. Record review of Resident #51's MD Order revealed the following active orders: Every shift flush enteral tube with 30 milliliters of water dash post medication administration and 5 to 10 milliliters water between each medication. Every shift for peg tube crushed medication contents of open capsule as well as liquid medications are diluted with at least five meals of water when fluid is not restricted. May crush crushable meds, open caps and mix with palatable substance. Observed on 11/6/24 at 7:52 am LVN D preparing medication for administration to Resident #51. She retrieved Norvasc 10 mg, Tylenol 650 mg, Lorazepam 0.5 mg, Carvedilol 6.25mg, Losartan 25 mg, Metformin 500mg, Lexapro 5 mg, Prilosec 20 mg and Xarelto 20 mg. Medications that were in dry, powder form were returned to the medication cup and LVN D entered into the resident's room. After repositioning the resident, LVN D retrieved 2 cups of room temperature water (each cup containing about 6-8 ounces) from Resident #51's bathroom and then checked the resident for placement and residual feeding. At 08:24 AM, LVN D flushed Resident #51's G-tube with a syringe containing 30 ml of water. She then poured undissolved powder medication down Resident # 51's G-tube followed by 5-30 ml of water. The method was continued for 6 more medications until the syringe became clogged on the seventh medication. LVN D unclogged the syringe and continued to place undissolved powder medication into the syringe followed by water for the remaining 2 medications. She the flushed the G-tube with 30 ml of water and reconnected the enteral feeding. Interviewed LVN D on 11/6/24 at 8:36 am regarding the process of giving undissolved powder medication into the G-tube and she stated she had learned to place undissolved powder medication into the syringe followed by water here and there. Interviewed LVN E on 11/6/24 at 10:05 am regarding administration of medications with residents with a G-tube. LVN E verbalized the policy regarding placing water with undissolved powder medication, mixing together and after administration, following with 10-15 milliliters water to flush between medications. LVN E stated undissolved powder medication placed directly into syringe was not done because it may cause blockage in the syringe during medication administration. LVN E reported he had a recent in-service by the facility regarding G-tube medication administration within the last 60 days. Interviewed LVN D on 11/6/24 at 10:06 am, LVN D reported going forward she would mix undissolved powder medication with water prior to administration. LVN D stated she was in-serviced by the facility within the last 60 days regarding G-tube medication administration. Interviewed the DON on 11/6/24 at 1:55 pm, the DON verbalized the facility procedure for administering medications into a G-tube. The DON said prior to administering medication via G-tube, nurses must dissolve the medications in 5-10 mL and LVN D should not have poured powdered/crushed medications directly into the Resident #51's tube because it could clog the tube. The DON stated medications were to be crushed, mixed with water and followed with 5-10 ml water between medications. When asked should undissolved powder medication be placed into the syringe and followed with 5-30 milliliters of water, the DON stated she had never heard of that. The DON reported risks to the resident if not mixing undissolved powder medication in water and followed with 10-15 milliliters water could clog the G-tube or syringe. Interviewed the Administrator on 11/7/24 at 2:40 pm regarding expectation for nursing staff and nursing tasks. The Administrator stated he expected his nurses to follow doctors' orders and facility policy and procedures for all tasks. The DON was responsible for nursing staff competencies and all nursing managers were expected to assure proper nursing care. When there was a failure with nursing care, such as not following doctors' orders or facility policy and procedures the Administrator expected the DON and nursing managers to educate and monitor nursing staff until proficient. Record review of the facility policy titled Medication Administration Enteral Tube Feeding issued 02/02/2015 and reviewed 02/10/2020 revealed 8. Crushed medication, contents of opened capsules, as well as liquid medications are diluted with at least 5 ml of water when fluid is not restricted. 11. Enteral tube must be flushed with at least 10 to 15 ml of water between each medication, unless otherwise ordered by prescriber.

Based on interviews and record reviews, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 Residents (R #1), reviewed for medical records accuracy, in that: 1.The facility failed to document Resident #1's 8:00am blood sugar levels were checked by AccuCheck two times day for diabetes mellitus by LVN A. 2.The facility failed to document Resident #1 received his Vital signs and record in PCC during LVN A 6:00am-2:00pm shift. 3.The facility failed to document Resident #1 was monitored for an Adverse Drug Effects during LVN A 6:00am-2:00pm shift. 4.The facility failed to document Resident #1 was monitored for an Adverse Drug Effects Anticoagulant Monitoring during LVN A 6:00am-2:00pm shift. 5.The facility failed to document Resident #1's was monitored for Adverse Antidepressant Medication during LVN A 6:00am-2:00pm shift. 6.The facility failed to document Resident #1's was monitored for Adverse Antidiabetic Medication during LVN A 6:00am-2:00pm shift. 7.The facility failed to document Resident #1's was monitored for Adverse Cardiac Medications (blood pressure medications, beta blockers) during LVN A 6:00am-2:00pm shift. 8.The facility failed to document Resident #1's Catheter stabilizer was in place and secure during LVN A 6:00am-2:00pm shift. 9.The facility failed to document Resident #1's suprapubic site was cleaned and pat dry then place a split gauze on site during LVN A 6:00am-2:00pm shift. 10.The facility failed to document Resident #1's head of bed elevated to 30 degrees during LVN A 6:00am-2:00pm shift. 11.The facility failed to document Resident #1 was evaluated for pain during LVN A 6:00am-2:00pm shift. 12.The facility failed to document Resident #1's was monitored for Adverse Insulin Therapy effects during LVN A 6:00am-2:00pm shift. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. Findings included: Review of R#1's face sheet revealed he was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident was diagnosed with type 2 Diabetes Melltus without complication (prevents the body from producing insulin), Hypertension (high blood pressure), chronic kidney disease (kidneys are damage and can't filter blood), peripheral vascular disease (slow progressive disorder or the blood vessels). Review of R#1 orders revealed, (insulin Glargine)-Inject 15 units subcutaneously in the morning; (orders start 6/8/23 at 6:30am); Accu Checks blood levels two times a day for DM (diabetes Mellitus (orders Start 1/28/23 at 8:00am); Vital signs twice daily and record in PCC (electronic health record) every day and evening shift (order Start 11/14/2022); Adverse drug event monitoring by licensed nurse, every shift, to observed resident for side effects from taking an Anticoagulant, antidiabetic and cardiac medication, which could cause excessive bleeding, blood pressure issues; Check catheter (a tube inserted into bladder, allowing urine to drain freely) for infection and trauma (order Start 8/16/2019); Elevate head of bed to >30 degrees at all times every shift (order Start 1/26/2016). Review of R#1's annual MDS assessment, dated 5/19/2024 revealed BIMS of 03, which indicates severe cognitive impairment. Review of R #1's care plan dated 10/31/2018 was at risk for pain r/t stage 4 pressure ulcer and administered meds as ordered by MD (medical doctor) (initiated 3/2/2018 and revision on 4/11/2023), Catheter care every shift cleanse site daily and apply dry dressing daily (date initiated 7/24/2015), resident is currently taking antihypertensive medication which should be administered as ordered. Monitor for side effects such as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart rate (Bradycardia); give medications for improved blood flow or anticoagulants as ordered Plavix 75mg QD (initiated 7/24/2015 and revision 6/3/2021); resident is at risk for unstable blood sugars related to type II diabetes (Insulin-date initiated 7/24/2015 revision 6/19/2023)-Administer diabetes medications as ordered by the physician and monitor for adverse reactions and report as detected. Review of R#1's electronic nursing notes revealed no nursing documentation at all in R#1's notes between 6/6/2024 at 2:06pm and 6/13/2024 5:05pm. MAR revealed no vital signs or monitoring resident for adverse medication effects on 6/8/2024 during the 6:00am-2:00pm. In an interview with LVN A on 6/20/24 at 1:09pm, she was working the 6am-2pm shift on 6/8/2024. Also during the interview with LVN A, she stated she was assigned and worked the 500 hall. LVN A stated she administered medication and documented in the EMAR/ETAR during her shift. LVN A stated she has no idea and does not know why there was no documentation in the resident's orders or in PCC during her shift. LVN A stated there must have been an issue in getting service on the 500 hall area. LVN A stated it was important to document along with following the physician orders regarding residents' conditions. She further stated it was equally as important to monitor resident's adverse reaction to medication as they could go into an anaphylactic shock (blood pressure drops suddenly and the airways narrow, blocking breathing), get extremely sick and or die. In an interview with RN on 6/20/24 at 2:40am stated that all the orders must be followed, and documentation must be completed in PCC, EMAR, ETAR and initialed when medications are administered. RN stated, the missing documentation on 6/8/2024 should never occurred and there is no excuse for not documenting and following physician orders. In an interview with LVN B on 6/21/24 at 9:30am stated she worked 6/7/2024 6am - 2pm shift, but she worked on a different resident hall. She stated the PCC, EMAR/ETAR systems were working, and she did not experience any interferences in the computer system. She stated she had no complaints. LVN B stated documentation is a required practice for nurses as it shows what you've done, talks about the resident, change of conditions and reports problems to others. LVN B stated if it's not documented it didn't happen. LVN B stated she documents as she goes to eliminate being sidetracked. She further statedshe reports to the weekend nurse manager if there are any issues with residents and if there was an issue with the PCC system, she would immediately report it. In an interview with LVN C on 6/21/24 at 10:10am she stated she worked 6/7/2024 on 6am - 2pm shift on 6/7/2024. She was assigned to hallway 500. She stated she did not have any issues with documentation in the PCC, EMAR/ETAR or system failure that prevented the required electronic documentation in the PCC system. LVN C stated sometimes there was limited reception in the 500 hallway, where documenting may not post in the resident's file, but nurses are aware of the limited reception in the entrance of the hallway, so they just walk a few steps away and then document. She stated it is important to document to show residents are receiving care and any type of change of conditions. Record Review of the facility's Medication -Treatment Administration and Documentation Guidelines policy dated 1/9/2014 and revised 4/6/2023 Revealed the follow: #5-Document e-signature for medications and treatments administered on the EMAR or ETAR immediately following administration. #7- Medications or treatments that were not administered should be documented as not administered on the EMAR/ETAR with the reason for the not administration.

Based on observation, interviews and record reviews, 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 1 of 5 residents (R #1) reviewed for medication administration The facility failed to ensure Resident #1 was administered the 6:30am Lantus Solution-Insulin injection for a metabolic disorder that affects glucose metabolism (a medication used to treat pain) by LVN A. This failure could place residents at risk for a delay in medication administration and medication error and could result in a decline in health. Findings included: Review of R#1's face sheet revealed he was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident was diagnosed with type 2 Diabetes Melltus without complication (prevents the body from producing insulin), Hypertension (high blood pressure), chronic kidney disease (kidneys are damage and can't filter blood), peripheral vascular disease (slow progressive disorder or the blood vessels). Review of R#1 orders revealed, (insulin Glargine)-Inject 15 units subcutaneously in the morning; (orders start 6/8/23 at 6:30am); Accu Checks blood levels two times a day for DM (diabetes Mellitus (orders Start 1/28/23 at 8:00am); Vital signs twice daily and record in PCC (electronic health record) every day and evening shift (order Start 11/14/2022); Adverse drug event monitoring by licensed nurse, every shift, to observed resident for side effects from taking an Anticoagulant, antidiabetic and cardiac medication, which could cause excessive bleeding, blood pressure issues; Check catheter (a tube inserted into bladder, allowing urine to drain freely) for infection and trauma (order Start 8/16/2019); Elevate head of bed to >30 degrees at all times every shift (order Start 1/26/2016). Review of R#1's annual MDS assessment, dated 5/19/2024 revealed BIMS of 03, which indicates severe cognitive impairment. Review of R #1's care plan dated 10/31/2018 was at risk for pain r/t stage 4 pressure ulcer and administered meds as ordered by MD (medical doctor) (initiated 3/2/2018 and revision on 4/11/2023), Catheter care every shift cleanse site daily and apply dry dressing daily (date initiated 7/24/2015), resident is currently taking antihypertensive medication which should be administered as ordered. Monitor for side effects such as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart rate (Bradycardia); give medications for improved blood flow or anticoagulants as ordered Plavix 75mg QD (initiated 7/24/2015 and revision 6/3/2021); resident is at risk for unstable blood sugars related to type II diabetes (Insulin-date initiated 7/24/2015 revision 6/19/2023)-Administer diabetes medications as ordered by the physician and monitor for adverse reactions and report as detected. Review of R#1's electronic nursing notes revealed no nursing documentation at all in R#1's notes between 6/6/2024 at 2:06pm and 6/13/2024 5:05pm. MAR revealed no vital signs or monitoring resident for adverse medication effects on 6/8/2024 during the 6:00am-2:00pm. In an interview with LVN A on 6/20/24 at 1:09pm, she was working the 6am-2pm shift on 6/8/2024. Also during the interview with LVN A, she stated she was assigned and worked the 500 hall. LVN A stated she administered medication and documented in the EMAR/ETAR during her shift. LVN A stated she has no idea and does not know why there was no documentation in the resident's orders or in PCC during her shift. LVN A stated there must have been an issue in getting service on the 500 hall area. LVN A stated it was important to document along with following the physician orders regarding residents' conditions. She further stated it was equally as important to monitor resident's adverse reaction to medication as they could go into an anaphylactic shock (blood pressure drops suddenly and the airways narrow, blocking breathing), get extremely sick and or die. In an interview with RN on 6/20/24 at 2:40am stated that all the orders must be followed, and documentation must be completed in PCC, EMAR, ETAR and initialed when medications are administered. RN stated, the missing documentation on 6/8/2024 should never occurred and there is no excuse for not documenting and following physician orders. In an interview with LVN B on 6/21/24 at 9:30am stated she worked 6/7/2024 6am - 2pm shift, but she worked on a different resident hall. She stated the PCC, EMAR/ETAR systems were working, and she did not experience any interferences in the computer system. She stated she had no complaints. LVN B stated documentation is a required practice for nurses as it shows what you've done, talks about the resident, change of conditions and reports problems to others. LVN B stated if it's not documented it didn't happen. LVN B stated she documents as she goes to eliminate being sidetracked. She further statedshe reports to the weekend nurse manager if there are any issues with residents and if there was an issue with the PCC system, she would immediately report it. In an interview with LVN C on 6/21/24 at 10:10am she stated she worked 6/7/2024 on 6am - 2pm shift on 6/7/2024. She was assigned to hallway 500. She stated she did not have any issues with documentation in the PCC, EMAR/ETAR or system failure that prevented the required electronic documentation in the PCC system. LVN C stated sometimes there was limited reception in the 500 hallway, where documenting may not post in the resident's file, but nurses are aware of the limited reception in the entrance of the hallway, so they just walk a few steps away and then document. She stated it is important to document to show residents are receiving care and any type of change of conditions. Record Review of the facility's Medication -Treatment Administration and Documentation Guidelines policy dated 1/9/2014 and revised 4/6/2023 Revealed the follow: #4- administer the medication according to the physician order. #5-Document e-signature for medications and treatments administered on the EMAR or ETAR immediately following administration. #7- Medications or treatments that were not administered should be documented as not administered on the EMAR/ETAR with the reason for the not administration.

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 of 2 residents (CR #1) reviewed for basic life support, including CPR. The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. The facility failed to immediately initiate CPR at about 3:28 AM on [DATE] when CR#1 was found unresponsive, by waiting an additional 7 minutes. The facility failed to ensure CPR was performed appropriately and accurately for approximately 10 minutes once initiated by staff. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:20pm. While the IJ was removed on [DATE] at 4:00 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern. as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings Included: Record Review of CR#1's face sheet revealed, a [AGE] year-old female, admitted to the facility on [DATE] with primary diagnoses of Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Dysphagia (Difficulty swallowing), Oropharynegeal phase (voluntary and depends on motor and sensory pathways that move food posteriorly through the oral cavity to the oropharynx, triggering as series of reflexive mov), Cognitive communication deficit (may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage, which result in difficulty with thinking and how someone uses language), cardiac arrest (sudden unexplained loss of heart function, breathing and consciousness), epilepsy (Brain disorder that causes reoccurring, unprovoked seizures), not intractable, without status epilepticus (can't be controlled through anti-seizure medications), type 1 Diabetes Mellitus without complications (Insulin dependent), Hypothyroidism (deficiency of thyroid hormones), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), Hypertension (condition in which the force of the blood against artery walls is too high), Acidosis, (Too much acid in body fluids), Elevated white blood cell count (the immune system is working to destroy an infection, a sign of physical or emotional stress, or particular types of cancer), , anoxic brain damage (the brain is starved of oxygen), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), Morbid (severe) Obesity (More than a 100 pounds over you ideal body weight) Record Review of the MDS dated [DATE], revealed CR#1 was unable to respond and had no BIMS (Brief Interview for Mental Status) score, which suggest severe impairment. Record Review of Care Plan dated [DATE] revealed CR #1 was full code. Staff to anticipate needs. Record Review of Orders revealed: Assess for pain every shift and document using: Numerical Scale of ,d+[DATE] if verbal or PAINAD if non-verbal [DATE] 2200 D/C Date [DATE] 0856; Enteral feed order-every shift check G/T placement prior to administration of meds and hanging enteral feedings [DATE] 2200 D/C Date [DATE] 0856; Enteral feed order-every shift check gastric residual volume. Hold feeding for 1 hr and notify physician for residual greater than 70cc; Eternal Feed Order-every shift Flush enteral tube with 30ml water pre/post medication administration and ,d+[DATE] ml water between each medication [DATE] 2200 D/C Date [DATE] 0856; Enteral Feed Order every shift keep HOB elevated ,d+[DATE] degrees at all times-aspiration precautions [DATE] 2200 D/C Date [DATE] 0856; HOB elevated at 30 degrees due to SOB while lying flat. [DATE] 2200 D/C Date [DATE] 0856; Monitor 02 sat, respirations, and lung sounds q shift. Every shift for Tracheostomy Lung Sounds: C=Clear, W=Wheezes, D=Diminished, R=Rales/Rhonchl; Respiratory Quality: U=Even and Unlabored, S=Shallow, L=Labored, D=Distress [DATE] 2200 D/C Date [DATE] 0856; Oral care Q shift-every shift Suction with a yankuer daily [DATE] 2200 D/C Date [DATE] 0856; Provide oral care Qshift & PRN every shift [DATE] 0600 D/C Date [DATE] 0856; Suction Qshift & PRN. Report abnormal secretions to MD [DATE] 2200 D/C Date [DATE] 0856; Trach care Qshift and PRN. Notify MD with changes every shift [DATE] 2200 D/C Date [DATE] 0856; Verify the following emergency supplies are at the bedside (above the HOB): Ambu bag, Obturator, Water-soluble lubricant, Trach in the size ordered, Trach in a size below and size above (preferably), E-cyclinder at the bedside for emergency 02 use. [DATE] 2200 D/C Date [DATE] 0856; Enteral Feed Order four times a day (Bolus) Enteral Feeding: Glucerna 1.5 Amount:240 ml 4x/day, volume to be delivered 948 ml.***(May use Diabetlsource A/A or Glucerma 1.2 if 1.5 is not available)*** [DATE] 0600 D/C Date [DATE] 0856; Enteral Feed Order four times a day (Bolus) Enteral Feeding: Glucema 1.5 Amount 240 ml 4x/day, volume to be delivered 948 ml.**(May use Dlalbetlsource A/A or Glucema 1.2 if 1.5 is not available) [DATE] 2200 D/C Date [DATE] 1050; Enteral Feed Order four times a day (Bolus) Enteral Feeding: Glucema 1.5 Amount 240 ml 4x/day, volume to be delivered 948 ml.**(May use Dlalbetlsource A/A or Glucema 1.2 if 1.5 is not available.)***[DATE] 1200-Hold Date- from [DATE] 1724 to [DATE] 0856 D/C Date [DATE] 0856; Enteral Feed Order four times a day Flush peg tube with 90 ml water before and after each bolus feeding. Start date [DATE] 1200 -D/C Date-[DATE] 0856; Enteral Feed Order four times a day for 5 days Jevity 1.5 four times a day 8 fluid ounces-start date-[DATE] 2000-D/C date- [DATE] 0856; Insulin Lispro [NAME] KwikPen Subcutanious Solution Pen-Injector 100 UNIT/ML (Insulin Lispro)-Inject as per sliding sale: if ,d+[DATE]=2 units, ,d+[DATE]=4units, ,d+[DATE]=6units, ,d+[DATE]=8units, ,d+[DATE]=10 units 401 and above give 12 units and notify the NP/MD, subcutaneously before meals and at bedtime for DM-start date [DATE] 0630-D/C [DATE] 0856. Record review of last documented Vitals revealed the following for Blood Sugar: [DATE] at 9:10pm:10 121.0 mg/dL-Blood Sugar [DATE] at 5:16pm 81.0 mg/dL-Blood Sugar [DATE] at 11:38am 101.0 mg/dL-Blood Sugar [DATE] at 8:24am 98.0 mg/dL-Blood Sugar Record review of last documented Vitals revealed the following for breaths/min [DATE] at 5:51pm 18-breaths/min [DATE] at 9:58am 18-breaths/min [DATE] at 12:01am 18-breaths/min Record review of last documented Vitals revealed the following for Trach [DATE] at 5:51pm 96.0% Trach [DATE] at 9:58am 96.0% Trach [DATE] at 12:01am 96.0% Trach Record review of last documented Vitals revealed the following for Pain Level [DATE] at 10:38pm 0 bpm Pain ad-Pain Level [DATE] at 2:53pm 0 bpm Numerical-Pain Level [DATE] at 9:58am 0 mg/dL-Painad-Pain Level [DATE] at 12:00am 0 mg/dL-Numerical-Pain Level Record review of progress note revealed the only note documented on [DATE] at 05:11AM by LVN A reflected, [CR#1] was found nonresponsive around 3:30AM CPR was started and 911 was called. EMS arrived at 3:40AM to take over. EMS attempted to revive CR#1 until 4:04AM when they informed staff that they could not get any vitals and asked if we had anyone to pronounce time of death on duty. Staff RN pronounced CR#1 dead. Body was put back in bed via lift by staff and was cleaned up. [LVN A] informed FM that CR#1 had passed. FM called Mortuary to come pick up CR#1, they said they would call back with ETA. Family removed all belonging from room. MD and DON informed. In a telephone interview on [DATE] at 2:30pm with LVN A said CNA B came to her and told her that something was wrong with CR#1. LVN A stated she came back to the nursing station and immediately telephoned 911. LVN A stated she checked on CR#1 by sticking her head around the curtain about 11:30pm to ensure she was breathing. At that time, she stated she did not provide any services to CR#1 even though her initials indicated she did. LVN A stated when she cam on to shift, she put her initial on the computer, then made note of who she needed to see during the night. She was asked if she thought that indicating in the treatment notes was professionally appropriate when she had not provided any treatment services to residents. She stated she didn't see anything wrong with it since she was going to see her patients anyway. Observation of surveillance camera revealed on [DATE] at 3:28AM CR#1 was found unresponsive by CNA's A & B then they exited the room. LVN B began compressions 7 minutes after CR#1 was initially found unresponsive. LVN B was told by RN to stop the compressions while she placed the board under CR#1's back. Four minutes later, RN attached the ambu bag to the oxygen tank. Three minutes later EMS arrived to CR#1's room and took control. In an interview on [DATE] at 5:38pm with CNA B revealed the facility was short staff. Both CNA's Had 30 residents a piece. CNA A asked for assistant round 12:30am to assist with changing resident. Around 3:30 family called went back into the room to assist. She went in the resident room, tongue yellowish color. Noticed she wasn't breathing. She went and got nurse. Completed full code. Stated she believes the nurse on break. Stated she went to the car and got the nurse. Stated she went out and got nurse LVN who was on break. Stated she was in the room when Fire and Rescue police, then EMS arrived. EMS took over. Stated LVN B was performing CPR alone. He started compressions. Nurse supervisor was supposed to be assisting LVN B. Did not go into the room. In an interview on [DATE] at 5:50pm with CNA A, revealed she initially observed CR#1 around 12:00am when she went in the room to change resident. The resident was still alive. Around after 2:00am or 3:00am FM called and stated the nurse has not been in CR#1's room. Five (5) minutes after speaking with FM, we (CNA A and CNA B) went to check on CR#1 and change her. CNA A stated that the two of them began removing the pillows supporting CR#1's hand because she needed to be changed. When we looked at her face, she did not look the same as she did when we went in her room at 12:00am. We immediately left and called the nurse and told her what we observed. Someone called emergency. In an interview on [DATE] at 9:29pm with LVN B who stated CNA A and CNA B came to him around 3:30am and said CR#1 was not breathing. He stated he immediately checked the face sheet and scrolled through the miscellaneous paperwork to ensure there was no DNR. LVN B went to CR#1's room, was assisted by other staff in getting CR#1 on the floor where he began compressions. He continued compressions until EMS arrived and took over. LVN B said RN got the (ambu) bag (known as a manual resuscitator). He stated the primary nurse, LVN A called EMS. EMS took over and started the compressions and placed tube in the resident throat and continued ,d+[DATE] minutes. EMS stated they did everything then they called code and asked the facility to sign documents and RN stated CR#1 was dead. LVN B also stated he could not remember when dates of his CPR certification, but stated the facility could pull it up on their computer. In an interview on [DATE] at 1:30pm with DON revealed, when a code is called protocol is urgency and immediate! The compressions and oxygen bag are simultaneously. RN should not have asked LVN B to stop doing compressions to allow her to place a board under CR#1's back. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:20PM. The Administrator, the DON and the Regional Nurse were notified. The Administrator was provided with the IJ template and a POR was requested at this time. The following Plan of Removal submitted by the facility and was accepted on [DATE] at 4:00PM Tag Cited: F-678 Issue Cited: Failure to ensure that a resident received CPR in accordance with professional standards of practice. Immediate Action Taken A. Resident # 1 expired in the facility on [DATE]. B. On [DATE] the DON/Designee began In Service education to all licensed nurses on Cardiopulmonary Resuscitation Policy that is a guideline for processing the patient's right and choice regarding Cardiopulmonary Resuscitation, to provide basic life support, including CPR to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advanced directive or a Do Not Resuscitate order. This In-Service education was completed on [DATE] at 7:30 pm, and no licensed nurse was allowed to work until they had completed this In-Service. C. On [DATE] Social Worker/Designee began 100% audit of all resident's code status to correctly identify if they are a full code or DNR. This will be completed on [DATE] at 7:30 pm and corrective action will be addressed if identified. D. On [DATE] DON/Designee reviewed the crash cart check list and validated that all items were present on crash cart. E. On [DATE], an audit was completed by Human Resources to validate that 14 of 17 licensed nurses were CPR certified. The 3 licensed nurses what were not CPR certified, will not be allowed to work until they attend the CPR training course on [DATE]. F. On [DATE] the primary night nurse for resident # 1was suspended and will be terminated. Two other nurses involved in the incident will not be allowed to work until they receive 1:1 education from the DON or Regional Nurse Consultant regarding Cardiopulmonary Resuscitation, to provide basic life support, including CPR to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advanced directive or a Do Not Resuscitate order. G. On [DATE] the DON/Designee conducted a mock CPR drill with the 2 pm to 10 pm shift, after the IJ was called. H. The DON/Designee will conduct a mock CPR drill on each shift daily x 3 days, beginning on [DATE]. 1. Identification of Residents Affected or Likely to be Affected: 2. The DON/Designee validated that there are no other like residents in the facility at this time. 3. Actions to Prevent Occurrence/Recurrence: A. On [DATE] all license nurses will receive in-person CPR training by a Certified CPR Instructor. No license nurse will be allowed to work until they have received CPR certification. B. On [DATE] all certified Nurse Aides on the evening and night shifts will receive in-person CPR training by a Certified CPR Instructor. No certified Nurse Aide on the evening or night shift will be allowed to work until they have received CPR certification. C. DON/Designee will do mock drills weekly x 4 weeks, 2 x month x 2 months, then monthly ongoing. D. Starting [DATE] any newly hired licensed nurse, or certified nurse aide will be required to have CPR certification within 2 weeks of hire. E. For all new or readmissions, the social worker or designee will review resident's code status daily in the morning meeting to validate that resident's code status is correct. F. DON will review crash cart check list 5 x weekly to validate that all needed items to conduct a code is available, this will be on going. E. On [DATE] an ad hoc meeting regarding the immediate Jeopardy was conducted to review the plan of removal and interventions. On [DATE] the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to start CPR in accordance with professional standards of practice, and reviewed plan to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ______[DATE]___________ Monitoring completed from [DATE] through [DATE]. Interview were conducted with the following employees from varying shifts: Administrator, DON, RN A, RN B, LVN A, LVN B LVN C, CNA A, CNA B, CNA C, CNA D, CNA E, CNA F and CMA A, all of whom indicated they received training on [DATE] in the areas of CPR and protocol. During an interview, each employee listed, indicated they are aware of performing CPR and the protocols (which entailed the resident is Full-Code and Not DNR prior to performing CPR). Each employee was able to give an example of a Code Blue and the procedures they were to follow (ex.calling Help Room # and Bring Crashcart the individual responsible for calling 911 and ensuring that all actions taken are urgent). Record Review for the In-service training in the following areas: AHS Emergency Codes (specifically code blue) on [DATE]; Cardiopulmonary Resuscitation -Advanced Directives Policy [DATE]; Clinical Document Guideline [DATE]; Mock CPR-Drill conducted on [DATE] at 1:07am and ending 1:38am; Code Blue documentation timeline & steps during a code blue [DATE]; and auditing of the residents who are DNR, Full-Code and those needing a Code Status in PCC; BLS (RN from the American Heart Association) which includes applying the Ambu bag to a trach for CPR. The Facility's Policy Review on Cardiopulmonary Resuscitation-Advance Directives revised date [DATE] reads, Licensed nurses must maintain current CPR certification for Healthcare Providers through a CPR provider who training includes hands-on-practice and in-person skills assessment. The IJ was lowered on [DATE] at 4:00 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern. as the facility continued to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 7 residents (Resident #1, Resident #2, Resident #3) reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1, Resident #2 and Resident #3 were supervised while smoking during unscheduled smoking hours. This failure could place residents at risk of burns and other serious injuries. Findings include: 1. Record review of Resident #1's face sheet, dated 01/03/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Hemiplegia (paralysis of partial or total body function on one side of the body) and Hemiparesis (one-sided weakness, but without complete paralysis); Cerebral Infarction (necrotic tissue in the brain due to disrupted blood supply and restricted oxygen supply); Right Elbow Contracture and, Muscle wasting and atrophy (significant shortening of the muscle fibers and a loss of overall muscle mass). Record review of Progress Notes in Resident #1's electronic health record reflected on 03/21/23, Social Worker B noted, MSW contacted resident smokers during 930a break to discuss reported noncompliance (ie . vaping in room, lighters/cigarettes being kept in personal belongs), MSW reminded residents of smoking agreement that was previously signed and also guidelines that must be maintained on behalf of resident safety, MSW went on to further discuss residents ' rights as well as extend social services to address any questions that may arise surrounding smoking policy. Record review of Resident #1 ' s progress notes dated 09/15/23 reflected, LVN D noted, CNA notified this nurse that while resident was outside smoking, resident had her head down and cigarette was burning through her shorts . No burns on skin noted. CNA pushed resident inside. This nurse pushed resident to her room to assess. I had to pick up resident left leg because it was dragging d/t past stroke . Record review of Resident #1's Annual MDS, dated [DATE], reflected the resident's BIMS score was 15, which indicated cognitive intactness. Resident #1 required two-person physical assist for transferring, one-person physical assist with bed mobility and toilet use, and required setup help with eating. Further review of the MDS did not reveal whether Resident #1 did or did not use tobacco. Record review of Resident #1's Smoking Evaluation, dated 10/04/23, indicated the resident was independent and does not require supervision to smoke. The resident had no evidence of burn holes noted in clothing or equipment. A care plan was used to ensure Resident #4 was safe while smoking. Further review of the evaluation reflected, If all of the answers on the evaluation are yes, the resident is determined to be an independent smoker. If any of the answers on the evaluation are no, the resident is determined to be a dependent smoker. The resident's care plan must include individualized interventions that may be utilized. Record review of Resident #1's care plan, last revised on 10/04/23, reflected she was a smoker and was at risk for injury, but was a safe smoker and did not require an apron. Interventions included performing smoking assessments according to facility policy; educating the resident on the smoking policy; explaining and showing the resident and family designated smoking areas and repeat as necessary; assisting the resident to and from smoking area as needed; and reminding the resident and family all smoking paraphernalia must be kept at the nurses station. The care plan also indicated a revision was made on 03/22/23 to include the Resident #1's history of having a lighter and refusing to give to staff, causing risk for injury however, the care plan reflected no intervention updates on 03/22/23. Further review of the care plan revealed no revisions to include Resident #1 ' s smoking incident which resulted in burnt clothing on 09/15/23 . 2. Record review of Resident #2's face sheet, dated 01/16/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cellulitis (an acute infection of the skin caused by bacteria that enter the skin through a cut, scratch, sting, animal bite, splinter, puncture wound, piercings and tattoos) of the Buttocks; Unspecified open wound (open wound or gunshot wound) of lower back and pelvis without penetration into retroperitoneum (space behind the abdomen); Type 2 Diabetes (long-term medical condition in which the body improperly uses insulin, resulting in unusual blood sugar levels) and, Difficulty in walking. Record review of Resident #2's Quarterly MDS, dated [DATE], reflected the resident's BIMS score was 14, which indicated cognitive intactness. Resident #2 used a wheelchair and required substantial assistance with taking on/off footwear; moderate assistance with toileting, bathing, and lower body dressing; and supervision or touching assistance with upper body dressing. The resident performed all other ADLs independently. Further review of the MDS did not reflect whether Resident #2 did or did not use tobacco. Record review of Resident #2's care plan, last revised on 01/03/24, reflected he was not a safe smoker, was at risk for injury and did not require an apron. Interventions included educating the resident on the smoking policy; and, explaining and showing the resident and family designated smoking areas and repeat as necessary. Further review indicated the care plan was updated on 01/03/24 to include an incident of noncompliance. The care plan did not reflect specific details of the noncompliance, however, was revised to include the resident required direct supervision while smoking but was noncompliant as an intervention. Record review of Resident #2's electronic health record did not reflect Progress Notes, or any other documentation which indicated the resident had an incident of noncompliance with the smoking policy on 01/03/24. Record review of Resident #2's Smoking Evaluation, dated 08/22/23, did not reflect whether the resident was an independent smoker or safe to smoke. The resident required supervision and the facility to store his cigarettes and lighter. The evaluation also indicated a plan of care was used to ensure Resident #2's safety while smoking. 3. Record review of Resident #3's face sheet, dated 01/16/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Hemiplegia (paralysis of partial or total body function on one side of the body) and Hemiparesis (one-sided weakness, but without complete paralysis); Right Elbow Contracture (stiff right elbow with limited range of motion); Cerebral Infarction (necrotic tissue in the brain due to disrupted blood supply and restricted oxygen supply); and, Muscle wasting and atrophy (significant shortening of the muscle fibers and a loss of overall muscle mass). Record review of Resident #3's Quarterly MDS, dated [DATE], reflected the resident's BIMS score was 9, which indicated moderate cognitive impairment. Resident #3 had impairments on both sides of her upper and lower extremities, used a motorized wheelchair, required substantial assistance for toileting and bathing, supervision or touching assistance for all other ADLs, but she ate independently. Further review of the MDS did not reflect whether Resident #3 did or did not use tobacco. Record review of Resident #3's care plan, last revised on 01/03/24, reflected she was a smoker and was at risk for injury but was a safe smoker and did not require an apron. Interventions included performing smoking assessments according to facility policy; educating the resident on the smoking policy; explaining and showing the resident and family designated smoking areas and repeat as necessary; assisting the resident to and from smoking area as needed; and reminding the resident and family all smoking paraphernalia must be kept at the nurse ' s station; and, did not require direct staff supervision during smoking breaks. The care plan also indicated a revision was made on 11/16/23 to include Resident #3's noncompliance with the smoking contract on 11/15/23. Further review of the care plan did not reflect specific details of the noncompliance incident, nor revisions to include interventions after the resident ' s noncompliance on 11/15/23. Resident #3 ' s care plan also indicated the resident had an ADL self-care performance deficit related to cognitive impairment, functional limitations in range of motion or decreased mobility and a contracture of the right elbow. Record review of Resident #3's electronic health record did not reflect progress notes, or any other documentation which indicated the resident had an incident of noncompliance with the smoking policy on 11/15/23. Record review of Resident #3's Smoking Assessment, dated 03/23/23, did not reflect whether the resident was an independent smoker or safe to smoke. Resident #3 had cognitive loss, a visual deficit, required supervision and required the facility to store her lighter and cigarettes. Resident #3 did not have dexterity problems. The Smoking Assessment also reflected a care plan was used to ensure Resident #3 was safe while smoking. Record review of Resident #3's Smoking Evaluation, dated 10/04/23, indicated resident was independent and does not require supervision to smoke. Resident #3 had cognitive loss, vision sufficient for safe smoking; required supervision and required the facility to store her lighter and cigarettes. The Smoking Evaluation also indicated a care plan was used to ensure Resident #3 was safe while smoking. Further review of the evaluation reflected, If all of the answers on the evaluation are yes, the resident is determined to be an independent smoker. If any of the answers on the evaluation are no, the resident is determined to be a dependent smoker. The resident's care plan must include individualized interventions that may be utilized. Observation of facility smoking area on 01/03/24 at 10:20 AM revealed, no scheduled smoke times posted on the door, or anywhere else near the area inside or outside in the smoking area. Resident #1 was sitting in her wheelchair at a table in the outside area. Resident #1's profile of the right side of her body was facing the door which led from inside the facility out to the smoking area. Resident #1 was rummaging through cigarette butts inside a tabletop cigarette receptacle. Resident #2 and Resident #3 sat in their wheelchairs diagonally across from Resident #1, near the wall of the facility. Residents #2 and #3 were smoking a cigarette and having a conversation. Resident #2 often looked over in the direction of Resident #1, and either asked if she was okay or attempted to include Resident #1 in the conversation Resident #2 was having with Resident #3. Resident #2 finished his cigarette, wheeled over to and tossed the butt into the Smoker's Pole which sat on the ground, and wheeled back over to the same spot near Resident #3. Resident #1 began wheeling herself backwards. Resident #2 wheeled over to the rear of Resident #1's wheelchair and pushed Resident #1's wheelchair toward the door leading inside the facility. Resident #2 stopped near Resident #1's wheelchair near the door, but with enough space between the door and Resident #1's wheelchair to allow Resident #2 to wheel himself over and hold the door open while still attempting to assist Resident #1 through the doorway and into the facility. Resident #2 let the door close behind Resident #1 and then wheeled back over near Resident #3. Resident #3 finished her cigarette, then Residents #2 and #3 wheeled themselves inside the facility. No staff joined the residents in the smoker's area while they smoked. No staff observed the smoking residents by approaching or standing near the windows looking out into the smoker's area. The smoker's area was at the end of the 400 hall, which was also a hall with occupied resident rooms. The distance between the nurse's station, which was where 400 hall began, was at least 60 feet away from the windows looking out into the smoker's area. In an interview with Resident #1 on 01/03/24 at 10:38 AM, she said she did not know how long she had been at the facility. She said she was a smoker. She said she did not know what time it was and did not know what the facility ' s scheduled smoke times were. She said she knew the facility ' s smoking policies. Resident #1 stopped responding to questions. In an interview with Resident #2 on 01/03/24 at 10:40 AM, he said he had been living at the facility since the summertime. He said Resident #1 needed a lot of help and was the reason he went over to help her get back inside the building. He said he tried to look out for Resident #1 and so did other residents at the facility. He said one of the aides usually helped Resident #1 go inside and out of the building to smoke. He said the staff who went outside with the smoking materials would light Resident #1 ' s cigarette for her. He said Resident #1 smoked but did not think she had smoked a cigarette while she was outside a few minutes ago. He said the nurse ' s kept everyone ' s cigarettes and passed them out when they went outside during smoke breaks. He said Resident #1 went outside on her own this morning. He said staff did not have to be outside for him to smoke cigarettes. He said the staff knew he could handle smoking on his own. He said if he wanted to smoke, he was going to smoke no matter what anyone said. He said if a staff said anything to him about smoking, he would probably cuss them out. He said he did not have any cigarettes nor a lighter with him or in his room. He said he did not recall ever seeing Resident #1 or Resident #3 with their own cigarettes or lighters. Resident #2 refused to answer questions regarding how he and Resident #2 accessed the cigarettes they had just smoked or how he and Resident #2 were able to light the cigarettes. Resident #2 said he was not for sure of the scheduled smoke breaks, but he thought there were four smoke breaks each day. He said he knew what the facility ' s smoking policies were but was told he was safe to smoke. In an interview with Resident #3 on 01/03/24 at 10:40 AM, she said she could not remember how long she had been living at the facility. Resident #3 said she was a smoker. She said Resident #1 was a smoker too. She said she did not know if Resident #1 smoked a cigarette while she was outside earlier. Resident #3 said she did not know where the cigarette she smoked came from and did not remember who lit the cigarette for her. She said staff were not outside with the residents, but the staff went outside when residents were smoking. She said she did not know what time the smoke breaks were. She said she was not sure if she knew all of the facility ' s smoking policies. In an interview with the DON on 01/03/24 at 10:58 AM, she said she was not aware residents were outside smoking cigarettes unsupervised. She said she would have to find out which staff were assigned to oversee the smoke breaks for the day. She said the residents were aware of the smoking policies, but the residents also knew today was the new administrator ' s first day and a lot of different things were happening at the facility. She said residents who violated the smoking policy had recently become a problem . She said management was aware and was working to address the issue. She said staff knew to remind residents who were noncompliant of the smoking policies and to immediately report the noncompliance to a nurse or the ADON. She said she did not know who would have to review the electronic health records for Residents #1, #2 and #3 because she could not recall off the top of her head when they were last assessed for safe smoking, if they were care planned for smoking or what their interventions related to smoking were . She said she was not aware of any past smoking incidents which involved Residents #1, #2 or #3, but would have to review their electronic health records to be sure. The DON said management would immediately work to address the incident and review other necessary information . In an interview with LVN B on 01/10/24 at 10:00 AM, she said she had worked at the facility as a float nurse during the 6AM-2PM shift for almost two years. She said the facility had four scheduled smoking times and assigned staff members who took residents outside to smoke. She said she did not know what the scheduled smoking times were because she was not one of the staff assigned to any smoking duties . She said even though she did not know the smoking schedule, she still knew what the smoking policies were. She said it was not okay for residents to smoke outside during unapproved times or without an assigned staff present. She said residents were not allowed to have smoking materials. She said the resident's cigarettes were kept in a storage area and passed out during smoke breaks. She said the assigned staff were responsible for lighting cigarettes. She said if she discovered a resident violating the smoking policy, she would immediately notify the ADON to prevent the situation from becoming a safety issue. She said she never found a resident violating the policy herself, but had a CNA notify her a resident was violating the smoking policy. She said the CNA came and told LVN B the CNA found a resident smoking unsupervised. She said she could not remember the exact date this occurred, or who the CAN was, but it had been a few months since the incident. She said the resident involved in the incident was Resident #1. She said the CNA told her Resident #1 was outside smoking and had burned a hole in her pants. She said after the CNA notified her, she returned to the smoking area with the CNA to talk to the resident. She said the CNA made sure the resident's cigarette was put out and thrown away before notifying LVN B about what was going on. LVN B said she knew Resident #1 had violated the smoking policy in the past but did not know anything about the incidents. She said she knew other staff had spoken with the resident in the past about being noncompliant. She said when she observed Resident #1 that day, she seemed more tired than normal, and saw the hole in the resident ' s pants left from the cigarette. She said she asked the resident if she was hurt or burnt anywhere, and Resident #1 said no. She said she reminded the resident about the smoking policy and told her she could have consequences if she kept violating the policy. She said she had the CNA assist LVN B with getting the resident back to her room. She said they assisted the resident into bed then LVN B performed a head-to-toe assessment to check for injuries, vitals and blood pressure. She said the resident did not have any injuries from the incident with the cigarette, but Resident #1 had difficulty breathing and was very lethargic. She said she completed a change in condition assessment in the resident's electronic health record and contacted the resident's doctor. She said the doctor gave orders to send the resident out to the hospital. She said she notified the DON and the resident's responsible party and documented the smoking incident in the resident's progress notes. She said she did not know if the resident's care plan was updated after the resident burnt her clothing. She said that was something the charge nurse, ADON or DON probably took care of. She said all of the staff knew residents were not supposed to smoke unattended by staff. She said staff also knew incidents with residents smoking were supposed to be immediately reported to the ADON. In an interview with LVN C on 01/10/24 at 10:28 AM, she said she began working as the former MDS Coordinator's assistant in October 2023. LVN C said charge nurses assessed smoking residents upon admission and if the residents were safe to smoke, they could do so. She said smoking was something that needed to care planned for smoking residents. She said if a resident had an incident while smoking the resident needed to be re-assessed for safe smoking and have their care plan updated based on the incident and the new assessment. She said a charge nurse or the ADON was responsible for doing smoking assessments. LVN C said she did not know why Resident #1's care plan was not updated after the resident had an incident with burning her clothes. She said the incident took place before she began working for the facility. She said she was not aware of Resident #1's incident or history of noncompliance with the facility's smoking policies. LVN C said residents breaking the smoking policy was not uncommon and sometimes a little difficult for staff to manage. She said a lot of the residents were completely independent before living at the facility and wanted to feel like they were being treated like adults. She said both the residents and staff were aware residents were not supposed to smoke unsupervised and only during smoke breaks. She said she could not remember the scheduled smoking break times. She said the staff knew they were supposed to ask the resident to put their cigarette out and then report the incident to the ADON. LVN C said staff tried to abide by asking residents to put their cigarettes out when they were caught being noncompliant, but some residents would become upset, aggressive, and even violent with staff sometimes over being reminded about the smoking policies. She said in those instances or if the staff anticipated behavior like that from a resident being noncompliant, staff knew to immediately report the noncompliance to the ADON. She said even though residents who were noncompliant with the smoking policy knew what the consequences were, but likely chose to continue noncompliant behavior because consequences were not enforced. In an interview with LVN A on 01/10/24 at 11:43 AM, she said the smoking area was located on the back of the 400 hall and residents had scheduled 4 smoke breaks. She said residents were not allowed to smoke outside of those four times. She said it was okay for residents to smoke during unauthorized times if they were accompanied by one of their family members in the smoking area. LVN A said the residents' smoking supplies were kept at Station B in a tackle box and any overflow of supplies were kept in cubbies in the medication room. She said if staff were to catch a resident being noncompliant with the facility's smoking policy, the staff were supposed to have a conversation with the resident and document the incident in a progress note in the resident's electronic health record. In an interview with CNA A on 01/10/24 at 11:56 AM, he said he had worked at the facility for [AGE] years. He said there were four designated smoke breaks for residents. He said the residents did not always adhere to the smoking times. He said if residents were caught smoking unsupervised or smoking outside of the designated times, staff were supposed to report the information to the nurse. He said if he saw a resident smoking unsupervised, he might say something to the resident, but some of the residents could get verbally aggressive and sometimes violent. He said he did not know why but a lot of the residents got really angry about cigarette smoking. He said whether he said something to the resident or not, he would always call the nurse for everything . In an interview with Med Aide A on 01/10/24 at 12:10 PM, she said she had worked at the facility one year. She said she knew what the facility's smoking policies were for the residents and staff. She said she also was in-serviced on the smoking policies but could not recall when. Med Aide A said all residents had to be supervised if they were smoking. She said if she saw a resident smoking unsupervised, she would immediately notify a nurse. In an interview with LVN D on 01/10/24 at 12:24 PM, she said there was supposed to be a staff member outside with residents whenever they smoked. She said if she saw a resident smoking a cigarette unsupervised, she would ask the resident to put the cigarette out immediately. LVN D said she would re-educate the residents on the policies and put a progress note in the resident ' s chart and notify the ADON and DON. In an interview with ADON B on 01/10/24 at 12:35 PM, she said smoking evaluations should be completed for residents on admission, on a quarterly basis and if a resident showed signs of a decline. She said she was not aware Residents #1 and #2 were smoking unsupervised on 01/03/24. She said she did not know exact dates of the last smoking evaluations for Residents #1, #2 and #3. ADON B said she did not know whether the residents were considered safe smokers and would have to look at the residents' charts. ADON B said she was sure Residents #1, #2 and #3 were care planned for smoking but was not aware of each of their interventions. She said again, she would have to review their charts. She said the residents were aware of the facility's smoking policies and should not have been smoking unsupervised. She said the staff were also aware of the smoking policies. ADON B said if residents were outside smoking unattended or during off hours it was her expectation that staff asked the noncompliant resident to put the cigarette out. She said she knew asking residents to do that could be difficult for staff anticipating certain residents' reactions. ADON B said some residents would use profane language or get aggressive with staff. She said at the very least, the staff were expected to notify management so they could immediately ensure safety for the smoking residents. She said the residents signed smoking agreements when they were admitted to the facility. ADON B said the residents really did not respect the smoking policies because they got reminded of the policies each time, they were noncompliant. She said there were no real consequences beyond reeducation for the residents. She said the residents knew one of the potential risks of violating the smoking policies was being asked to leave the facility. ADON B said she could not recall any incidents of noncompliance with the smoking policies that resulted in a documented disciplinary action or reprimand for any residents since she started working for the facility. She said she thought the residents might not have taken the policies seriously since there had been changes in the administrator's position several times and expectations of each administrator had been different. ADON B said now they had a permanent Administrator who started last week, she was hopeful about improvements with the smoking residents. She said the new Administrator had been made aware that smoking noncompliance was an issue. ADON B said she did not recall any incidents of Resident #1 being noncompliant with smoking policies. She said she did not recall an incident that resulted in Resident #1 burning her clothes. ADON B said Resident #1 should have been reassessed for safe smoking by a nurse after burning her clothes but did not know whether this was done. ADON B said if the incident occurred before then, she would not have known whether Resident #1's care plan was updated afterwards. She said smoking residents were at risk of not receiving appropriate care from facility staff without accurate and up to date smoking evaluations and care plans. ADON B said smoking residents were also at risk of being put in unsafe situations and sustaining injuries when their care plans were not appropriately followed or smoking unsupervised. In an interview with the Administrator and DON on 1/10/24 at 1:15 PM, the Administrator said her first day on the job was 01/03/24. She said she was aware of issues with residents being noncompliant with the facility's smoking policies. She said she was already working with the rest of the management team to address the issue. Both the Administrator and the DON said they were not aware Resident #1 had an incident that resulted in Resident #1 burning her clothing. The Administrator said a re-assessment for safe smoking, care plan updates and disciplinary action according to the facility's policy all should have taken place after Resident #1 burnt her clothes while smoking. The DON said she began working at the facility in October 2023 and was never made aware the resident had an incident where she burnt her clothing. The DON agreed Resident #1 should have been re-assessed and had her care plan updated. The DON said the chair of the smoking policy was the Social Worker. She said the facility had not had a permanent social worker in a while. The DON said the social worker helped to oversee and manage the effectiveness of the smoking policy. She said a permanent social worker had just been hired along with having an administrator in place. The DON said she was confident issues with residents violating the smoking policy would decrease. The DON said the staff had been re-educated on the facility smoking policies since she had started her position as the DON but could not remember the exact date. The Administrator and the DON agreed it was their expectation residents either put their cigarette out or staff remain with the resident until they finished their cigarette when staff found residents smoking unsupervised. The Administrator said she would prefer for the resident to put their cigarette out immediately; however, she understood it might take some time working with the residents to get them to comply with policies. The Administrator and the DON agreed Resident #1's smoking incident and incidents of residents smoking unsupervised put the residents at risk of unmet care needs and at risk of burns or other serious injuries. Record review of the facility ' s, undated, Smoking Agreement for residents reflected the following: .At no time is a resident allowed to have smoking materials of any kind (this includes lighters, cigarette, electronic cigarettes, smokeless tobacco, etc.) in their possession, all smoking materials will be kept by the facility in a central location . Smoking is always supervised by a staff member, at no time shall a resident smoke on the premises without a staff member present .Smoking is only allowed at the designated smoke times .Smoking outside the designated scheduled times may occur if a staff member is present .Periodic evaluation of the resident ' s physical and cognitive status will be completed .Failure to follow this agreement will result in re-education regarding the smoking policy and procedures and could lead to discharge depending upon the severity of incident . By signing the acknowledgment agreement below, you attest that during your stay at the facility: I will not keep any type of smoking materials in my possession .I will not smoke on premises except at designated times at designated location, and with staff present .I understand that I will periodically have an evaluation completed to determine the type of smoking supervision, I may, or may not need .I have received a copy of the facility ' s smoking policy and Smoking Agreement .I understand failure to follow the facility smoking policies may lead to reeducation and or discharge from the facility. Record review of the facility ' s, undated, Smoking Policy Statement reflected the following: 2. Residents and Visitors .This facility will supervise all resident smoking for the safety of all residents and employees .All resident smoking paraphernalia must be checked in with the nurse .Resident smoking paraphernalia will be secured at the nurse ' s station and provided to the resident at specified smoking times .Supervision of smoking residents will be a shared responsibility of all departments . 3. Reporting Violations a. It is the responsibility of all personnel to report smoking violations. Violations should be reported to the employee ' s supervisor as soon as practical. The various supervisors are responsible for enforcing these rules .c. Residents that fail to abide by facility smoking rules will be given a notice of intent to discharge .Scheduled smoking times for residents. Facility will determine smoking times . For your safety, residents are not permitted to have tobacco products or lighting devices in their rooms

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 7 residents (Resident #1, #2 and #3) reviewed for care plans . 1. The facility failed to develop a care plan for Resident #1 after the resident had several incidents of observed unsafe smoking practices. 2. The facility failed to appropriately implement Resident #2' s care planned safe smoking goals and interventions when the resident was smoking outside of scheduled hours unsupervised. 3. The facility failed to appropriately implement Resident #3 ' s care planned safe smoking goals and interventions when the resident was smoking outside of scheduled hours unsupervised. These failures could place residents at risk for unmet care needs and decreased quality of care. Findings Include: 1. Record review of Resident #1's face sheet, dated 01/03/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Hemiplegia (paralysis of partial or total body function on one side of the body) and Hemiparesis (one-sided weakness, but without complete paralysis); Cerebral Infarction (necrotic tissue in the brain due to disrupted blood supply and restricted oxygen supply); Right Elbow Contracture and, Muscle wasting and atrophy (significant shortening of the muscle fibers and a loss of overall muscle mass). Record review of progress notes in Resident #1's electronic health record reflected the following: On 03/21/23, Social Worker B noted, MSW contacted resident smokers during 930a break to discuss reported noncompliance (ie . vaping in room, lighters/cigarettes being kept in personal belongs), MSW reminded residents of smoking agreement that was previously signed and also guidelines that must be maintained on behalf of resident safety, MSW went on to further discuss residents ' rights as well as extend social services to address any questions that may arise surrounding smoking policy. Record review of Resident #1 ' s progress notes dated 03/24/23, Social Worker B noted, MSW conducting room rounds this date, res observed having vape pen in her lap, MSW asked res to return vape to smoke box, resident handed vape to MSW and propelled away, res has been CP for hiding smoking paraphernalia on her person, MSW will continue to closely monitor. Record review of Resident #1 ' s progress notes dated 04/27/23, LVN B noted, CNA retrieved a vape pen from this resident at this time. RP was made aware and reminded of the care plan that was recently had. Record review of Resident #1 ' s progress notes dated 04/28/23, LVN B noted, Another vape pen was removed from this resident possession at this time. Phoned RP and notified her. [RP] stated she has not been to the facility since last weekend, and she also say that after our last care plan she will not bring anymore. She believes are vape pens that she has hidden. So this nurse informed her that is she says they were stolen they are in my office. Record review of Resident #1 ' s progress notes dated 09/15/23, LVN D noted, CNA notified this nurse that while resident was outside smoking, resident had her head down and cigarette was burning through her shorts. no burns on skin noted. CNA pushed resident inside. This nurse pushed resident to her room to assess. I had to pick up resident left leg because it was dragging d/t past stroke. Record review of Resident #1's Annual MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated cognitive intactness. Resident #1 required two-person physical assist for transferring, one-person physical assist with bed mobility and toilet use, and required setup help with eating. Further review of the MDS did not reflect whether Resident #1 did or did not use tobacco. Record review of Resident #1's Smoking Evaluation, dated 10/04/23, indicated the resident was independent and does not require supervision to smoke. Further review of the smoking evaluation indicated the resident had no evidence of burn holes noted in clothing or equipment. The Safety Screen also indicated a care plan was used to ensure Resident #1 was safe while smoking. Further review of the evaluation reflected, If all of the answers on the evaluation are yes, the resident is determined to be an independent smoker. If any of the answers on the evaluation are no, the resident is determined to be a dependent smoker. The resident's care plan must include individualized interventions that may be utilized. Record review of Resident #1's care plan, last revised on 10/04/23, reflected she was a smoker and was at risk for injury, but was a safe smoker and did not require an apron. Interventions included performing smoking assessments according to facility policy; educating the resident on the smoking policy; explaining and showing the resident and family designated smoking areas and repeat as necessary; assisting the resident to and from smoking area as needed; and reminding the resident and family all smoking paraphernalia must be kept at the nurse ' s station. The care plan also indicated a revision was made on 03/22/23 to include the Resident #1's history of having a lighter and refusing to give to staff, causing risk for injury however, the care plan reflected no intervention updates on 03/22/23. Further review of the care plan reflected no revisions to include Resident #1 ' s smoking incident which resulted in burnt clothing on 09/15/23. 2. Record review of Resident #2's face sheet, dated 01/16/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cellulitis (an acute infection of the skin caused by bacteria that enter the skin through a cut, scratch, sting, animal bite, splinter, puncture wound, piercings and tattoos) of the Buttocks; Unspecified open wound (open wound or gunshot wound) of lower back and pelvis without penetration into retroperitoneum (space behind the abdomen); Type 2 Diabetes (long-term medical condition in which the body improperly uses insulin, resulting in unusual blood sugar levels) and, Difficulty in walking. Record review of Resident #2's Quarterly MDS dated [DATE], reflected the resident's BIMS score was 14, which indicated cognitive intactness. Resident #2 used a wheelchair and required substantial assistance with taking on/off footwear; moderate assistance with toileting, bathing, and lower body dressing; and supervision or touching assistance with upper body dressing. The resident performed all other ADLs independently. Further review of the MDS did not reveal whether Resident #2 did or did not use tobacco. Record review of Resident #2's care plan, last revised on 01/03/24, reflected he was not a safe smoker, was at risk for injury and did not require an apron. Interventions included educating the resident on the smoking policy; and, explaining and showing the resident and family designated smoking areas and repeat as necessary. Further review indicated the care plan was updated on 01/03/24 to include an incident of noncompliance. The care plan did not reflect specific details of the noncompliance, however, was revised to include the resident required direct supervision while smoking but was noncompliant as an intervention. Record review of Resident #2's electronic health record did not reflect Progress Notes, or any other documentation which indicated the resident had an incident of noncompliance with the smoking policy on 01/03/24. Record review of Resident #2's Smoking Evaluation, dated 08/22/23, did not reflect whether the resident was an independent smoker or safe to smoke. Further review of the smoking evaluation reflected the resident required supervision and for the facility to store his cigarettes and lighter. The evaluation also indicated that a plan of care was used to ensure Resident #2's safety while smoking. 3. Record review of Resident #3's face sheet, dated 01/16/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Hemiplegia (paralysis of partial or total body function on one side of the body) and Hemiparesis (one-sided weakness, but without complete paralysis); Right Elbow Contracture (stiff right elbow with limited range of motion); Cerebral Infarction (necrotic tissue in the brain due to disrupted blood supply and restricted oxygen supply); and, Muscle wasting and atrophy (significant shortening of the muscle fibers and a loss of overall muscle mass). Record review of Resident #3's Quarterly MDS, dated [DATE], reflected the resident's BIMS score was 9, which indicated moderate cognitive impairment. Resident #3 had impairments on both sides of her upper and lower extremities, used a motorized wheelchair, required substantial assistance for toileting and bathing, supervision or touching assistance for all other ADLs , but she ate independently. Further review of the MDS did not reflect whether Resident #3 did or did not use tobacco. Record review of Resident #3's care plan, last revised on 01/03/24, reflected she was a smoker and was at risk for injury, but was a safe smoker and did not require an apron. Interventions included performing smoking assessments according to facility policy; educating the resident on the smoking policy; explaining and showing the resident and family designated smoking areas and repeat as necessary; assisting the resident to and from the smoking area as needed; and reminding the resident and family all smoking paraphernalia must be kept at the nurses ' station; and, did not require direct staff supervision during smoking breaks. The care plan also indicated a revision was made on 11/16/23 which included Resident #3's noncompliance with the smoking contract on 11/15/23. The care plan did not reflect specific details of the noncompliance incident, nor revisions to include interventions after the resident ' s noncompliance on 11/15/23. Resident #3 ' s care plan indicated the resident had an ADL self-care performance deficit related to cognitive impairment, functional limitations in range of motion or decreased mobility and a contracture of the right elbow. Record review of Resident #3's electronic health record did not reflect progress notes, or any other documentation which indicated the resident had an incident of noncompliance with the smoking policy on 11/15/23. Record review of Resident #3's Smoking Assessment, dated 03/23/23, did not reflect whether the resident had an independent smoker or was safe to smoke. The assessment indicated Resident #3 had cognitive loss, a visual deficit, required supervision and required the facility to store her lighter and cigarettes. The assessment indicated Resident #3 did not have dexterity problems. The Smoking Assessment reflected a care plan was used to ensure Resident #3 was safe while smoking. Record review of Resident #3's Smoking Evaluation, dated 10/04/23, indicated resident was independent and does not require supervision to smoke. The evaluation reflected Resident #3 had cognitive loss, vision sufficient for safe smoking; required supervision and required the facility to store her lighter and cigarettes. The Smoking Evaluation indicated a care plan was used to ensure Resident #3 was safe while smoking. Further review of the evaluation reflected, If all of the answers on the evaluation are yes, the resident is determined to be an independent smoker. If ANY of the answers on the evaluation are no, the resident is determined to be a dependent smoker. The resident's care plan must include individualized interventions that may be utilized. Observation of residents smoking on 01/03/24 at 10:20 AM revealed, no scheduled smoke times posted on the door, or anywhere else near the area inside or outside in the smoking area. Resident #1 was sitting in her wheelchair at a table in the outside area. Resident #1's profile of the right side of her body was facing the door that leads from inside the facility out to the smoking area. Resident #1 was rummaging through cigarette butts inside a tabletop cigarette receptacle. Resident #2 and Resident #3 sat in their wheelchairs diagonally across from Resident #1, near the wall of the facility. Residents #2 and #3 were smoking a cigarette and having a conversation. Resident #2 often looked over in the direction of Resident #1, and either asked if she was okay or attempted to include Resident #1 in the conversation Resident #2 was having with Resident #3. Resident #2 finished his cigarette, wheeled over to and tossed the butt into the Smoker's Pole that sat on the ground, and wheeled back over to the same spot near Resident #3. Resident #1 began wheeling herself backwards. Resident #2 wheeled over to the rear of Resident #1's wheelchair and pushed Resident #1's wheelchair toward the door leading inside the facility. Resident #2 stopped near Resident #1's wheelchair near the door, but with enough space between the door and Resident #1's wheelchair to allow Resident #2 to wheel himself over and hold the door open while still attempting to assist Resident #1 through the doorway and into the facility. Resident #2 let the door close behind Resident #1 and then wheeled back over near Resident #3. Resident #3 finishes her cigarette, then Resident #2 and #3 wheel themselves inside the facility. No staff joined the residents in the smoker's area while they smoked. No staff observed the smoking residents by approaching or standing near the windows looking out into the smoker's area. The smoker's area is at the end of the 400 hall, which is also a hall with occupied resident rooms. The distance between the nurse's station, which is where 400 hall begins, is at least 60 feet away from the windows looking out into the smoker's area. In an interview with Resident #1 on 01/03/24 at 10:38 AM, she said she did not know long she had been at the facility. She said she was a smoker. She said she did not know what time it was and did not know what the facility ' s scheduled smoke times were. She said she knew the facility ' s smoking policies. Resident #1 stopped responding to questions. In an interview with Resident #2 on 01/03/24 at 10:40 AM, he said he had been living at the facility since the summertime. He said Resident #1 needed a lot of help and that was the reason he came over to help her get back inside the building. He said he tried to look out for Resident #1 and so did other residents at the facility. He said one of the aides usually helped Resident #1 go inside and out of the building to smoke. He said the staff that came outside with the smoking materials would light Resident #1 ' s cigarette for her too. He said Resident #1 smoked but did not think she had smoked a cigarette while she was outside a few minutes ago. He said the nurse ' s kept everyone ' s cigarettes and passed them out when they come outside during smoke breaks. He said Resident #1 came outside on her own this morning. He said that staff did not have to be outside for him to smoke cigarettes. He said the staff knew he could handle smoking on his own. He said if he wanted to smoke, he was going to smoke no matter what anyone said. He said if a staff said anything to him about smoking, he would probably cuss them out. He said he did not have any cigarettes nor a lighter with him or in his room. He said he did not recall ever seeing Resident #1 or Resident #3 with their own cigarettes or lighters. Resident #2 refused to answer questions regarding how he and Resident #2 accessed the cigarettes they had just smoked or how he and Resident #2 were able to light the cigarettes. Resident #2 said he was not for sure of the scheduled smoke breaks, but he thought there were four smoke breaks each day. He said he knew what the facility ' s smoking policies were but was told he was safe to smoke. In an interview with Resident #3 on 01/03/24 at 10:40 AM, she said she could not remember how long she had been living at the facility. Resident #3 said she was a smoker. She said Resident #1 was a smoker too. She said she did not know if Resident #1 smoked a cigarette while she was outside earlier. Resident #3 said she did not know where the cigarette she smoked came from and did not remember who lit the cigarette for her. She said staff was not outside with the residents right now, but that the staff did come outside when residents were smoking. She said she did not know what time the smoke breaks were supposed to be. She said she was not sure if she knew all the facility ' s smoking policies. In an interview with the DON on 01/03/24 at 10:58 AM, she said she was not aware residents had been outside smoking cigarettes unsupervised. She said she would have to find out which staff was assigned to overseeing the smoke breaks for the day. She said the residents were aware of the smoking policies, but the residents also knew today was the new administrator ' s first day and a lot of different things were happening at the facility on that day. She said resident ' s violating the smoking policy had recently become a problem. She said management was aware and had been working to address the issue. She said staff knew to remind residents who were noncompliant of the smoking policies and to immediately report the noncompliance to a nurse or the ADON. She said she did not know would have to review electronic health records for Residents #1, #2 and #3 because she could not recall off the top of her head when they were last assessed for safe smoking, if they were care planned for smoking or what their interventions related to smoking were. She said she was not aware of any past smoking incidents involving Resident #1, #2 or #3, but would have to review their electronic health records to be sure. The DON said management would immediately work to address the incident and review other necessary information. In an interview with LVN B on 01/10/24 at 10:00 AM, she said she had worked at the facility as a float nurse during the 6a-2p shift for almost two years. She said the facility had four scheduled smoking times and assigned staff members that take residents outside to smoke. She said she did not know what the scheduled smoking times because she was not one of the staff assigned to any smoking duties. She said even though she did not know the smoking schedule, she still knew what the smoking policies were. She said it is not okay for residents to smoke outside during unapproved times or without an assigned staff present. She said residents are not allowed to have smoking materials. She said the resident's cigarettes were kept in a storage area and passed out during smoke breaks. She said the assigned staff was responsible for lighting cigarettes. She said if she discovered a resident violating the smoking policy, she would immediately notify the ADON to prevent the situation from becoming a safety issue. She said she had never found a resident violating the policy herself, but had a CNA notify her that a resident was violating the smoking policy. She said the CNA came and told LVN B that the CNA had found a resident smoking unsupervised. She said she could not remember the exact date this occurred, but it had been a few months since the incident. She said the resident involved in the incident was Resident #1. She said the CNA told her Resident #1 was outside smoking and had burned a hole in her pants. She said after the CNA notified her, she returned to the smoking area with the CNA to talk to the resident. She said the CNA made sure the resident's cigarette was put out and thrown away before notifying LVN B about what was going on. LVN B said she knew Resident #1 had violated the smoking policy in the past but did not know anything about the incidents. She said she knew other staff had spoken with the resident in the past about being noncompliant. She said was when she observed Resident #1 that day, she seemed more tired than normal, and saw the hole in the resident ' s pant left from the cigarette. She said she asked the resident if she was hurt or burnt anywhere, and Resident #1 said no. She said she reminded the resident about the smoking policy and told her she could have consequences if she kept violating the policy. She said she had the CNA assist LVN B with getting the resident back to her room. She said they assisted the resident into bed then LVN B performed a head-to-toe assessment to check for injuries, vitals and blood pressure. She said the resident did not have any injuries from the incident with the cigarette, but Resident #1 was having difficulty breathing and was very lethargic. She said she completed a change in condition assessment in the resident's electronic health record and contacted the resident's doctor. She said the doctor gave orders to send the resident out to the hospital. She said she notified the DON and the resident's responsible party and documented the smoking incident in the resident's progress notes. She said she did not know if the resident's care plan was updated after the resident burnt her clothing. She said that was something the charge nurse, ADON or DON probably took care of. In an interview LVN C on 01/10/24 at 10:28 AM, she said she began working as the former MDS Coordinator's assistant in October 2023. She said the former MDS nurse left her position with the facility last week and she had been promoted to the MDS Coordinator position. She said she was responsible for assessing residents and reviewing notes from the nurses to put together care plans for residents. She said she performed assessments for care plans and quarterlies, and assisted with new admissions, discharges and PASSR. LVN C said a resident having a change in condition, being put on or taken off of hospice services, falls and other incidents were all reasons to update a resident's care plan. She said the MDS Coordinator would know when it was necessary to update a resident's care plan during the morning staff meetings. She said during morning meetings the staff discuss the things going on with residents like changes in condition, falls and incidents. She said the MDS Coordinator was typically responsible for making updates to care plans, but other staff had the ability to make changes to care plans. She said updating care plans was a joint effort because the social worker, dietary services, the ADON's and the DON all worked on updating care plans. LVN C said charge nurses assessed smoking residents upon admission and if the residents were safe to smoke, they could do so. She said smoking was something that needed to care planned for smoking residents. She said if a resident had an incident while smoking the resident needed to be re-assessed for safe smoking and have their care plan updated based on the incident and the new assessment. She said a charge nurse or the ADON was responsible for doing smoking assessments. LVN C said she did not know why Resident #1's care plan was not updated after the resident had an incident with burning her clothes. She said the incident took place before she began working for the facility. She said she was not aware of Resident #1's incident or history of noncompliance with the facility's smoking policies. She said the former MDS nurse left her position with the facility last week and she had been was promoted to the MDS Coordinator position. She said she was responsible for assessing residents and reviewing notes from the nurses to put together care plans for residents. She said she performed assessments for care plans and quarterlies, and assisted with new admissions, discharges and PASSR. LVN C said a resident having a change in condition, being put on or taken off of hospice services, falls and other incidents were all reasons to update a resident's care plan. She said the MDS Coordinator would know when it was necessary to update a resident's care plan during the morning staff meetings. She said during morning meetings the staff discussed the things going on with residents like changes in condition, falls and incidents. She said the MDS Coordinator was typically responsible for making updates to care plans, but other staff had the ability to make changes to care plans. She said updating care plans was a joint effort because the social worker, dietary services, the ADON's and the DON all worked on updating care plans. In an interview with ADON B on 01/10/24 at 12:35 PM, she said the MDS Coordinator, ADONs and the DON were all responsible for working on resident care plans. She said even though ADONs and the DON completed care plans, the MDS Coordinator was responsible for verifying the accuracy of all resident care plans, so it was a team effort. ADON B said smoking evaluations should be completed for residents on admission, on a quarterly basis and if a resident showed signs of a decline. She said she was not aware Residents #1 and #2 were smoking unsupervised on 01/03/24. She said she did not know exact dates of the last smoking evaluations for Residents #1, #2 and #3. ADON B said she did not know whether the residents were considered safe smokers and would have to look at the residents' charts. ADON B said she was sure Residents #1, #2 and #3 were care planned for smoking but was not aware of each of their interventions. She said again, she would have to review their charts. ADON B said she did not recall any incidents of Resident #1 being noncompliant with smoking policies. She said she did not recall an incident that resulted in Resident #1 burning her clothes. ADON B said Resident #1 should have been reassessed for safe smoking by a nurse after burning her clothes but did not know whether this was done. She said Resident #1's care plan should have also been updated after the incident by the MDS Coordinator. She said prior to 12/6/23, the MDS Coordinator was solely responsible for updating resident care plans, so she stayed out of dealing with them. ADON B said if the incident occurred before then, she would not have known whether Resident #1's care plan was updated afterwards. She said smoking residents were at risk of not receiving appropriate care from facility staff without accurate and up to date smoking evaluations and care plans. In an interview with the Administrator and DON on 1/10/24 at 1:15 PM, the Administrator said her first day on the job was 01/03/24. She said she was aware of issues with residents being noncompliant with the facility's smoking policies. She said she was already working with the rest of the management team to address the issue. Both the administrator and the DON said they were not aware Resident #1 had an incident that resulted in Resident #1 burning her clothing. The Administrator said a re-assessment for safe smoking, care plan updates and disciplinary action according to the facility's policy all should have taken place after Resident #1 burnt her clothes while smoking. The DON said she began working at the facility in October 2023 and was never made aware the resident had an incident where she burnt her clothing. The DON agreed that Resident #1 should have been re-assessed and had her care plan updated. The Administrator and the DON agreed Resident #1's smoking incident and incidents of residents smoking unsupervised not being care planned put the residents at risk of unmet care needs and at risk of burns or other serious injuries. Record review of the facility policy, revised 02/10/2021, titled, Comprehensive Care Plans reflected the following: 3. 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 practicable physical, mental, and psychosocial well-being . 6.The objectives will be utilized to monitor the resident ' s progress. Alternative interventions will be documented, as needed

Based on interview and record review, the facility failed to complete an assessment that accurately reflected the resident's status for 1 of 6 residents (Resident #6) whose records were reviewed for MDS accuracy, in that: The facility failed to ensure Resident #6's Admission MDS accurately reflected his hearing loss and use of hearing aids. This failure by the facility placed the resident at risk of not receiving the care and services to meet his needs. Findings included: Review of Resident #6's face sheet dated 1/4/2024 revealed Resident #6 was an [AGE] year-old male who was admitted to the facility on [DATE] with a primary diagnosis of fracture of left femur. Other diagnoses include diabetes type 2, anemia, and anxiety. Record review of Resident #6's admission progress note dated 11/16/23 at 7:04 PM written by LVN A reflected that Resident#6 had hearing aids in both ears. Record review of Resident #6's Admission MDS assessment dated [DATE], Section B0200 revealed the resident was determined to have normal, adequate hearing. On section B0300, the resident was marked as not using hearing aids. Record review revealed a progress note dated 12/4/23 at 5:59 PM written by LVN B that notated Resident #6's ability to hear is adequate and resident does not use a hearing aid. Record review of Resident #6's care plan dated 12/24/23 noted the resident had a communication problem. The communication problem was not defined or detailed in the care plan. The intervention for the communication problem was to monitor effectiveness of communication strategies and assistive devices. Hearing aids were not included in the care plan. During an interview on 1/4/24 at 11:50 AM, Resident #6 was unable to hear surveyor speaking to him unless a loud voice was used while leaning near his ear. Resident reported his ability to hear was poor without his hearing aids. He reported that he lost one of his hearing aids and the other had a dead battery. During an interview on 1/4/24 at 2:43 PM, DON said the nurse responsible for MDS accuracy was on bereavement leave. DON was not able to explain why Resident #6's hearing loss and use of hearing aids were not documented accurately on his MDS. Record review of CMS's RAI Version 3.0 Manual, revised 10/2023, stated the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals. (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.

Based on observations, interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for two facility hallways reviewed for environment, in that. The facility failed to ensure they repaired the bulging and chipped floor which exposed the rough and uneven concrete on the 400 hallway. The facility failed to ensure the 100 hallway was free of strong urine odor. This deficiency could expose residents living in the facility to an uncomfortable living environment and to safety hazards such as falls, fractures, and hospitalization . Findings include: On 11/10/2023 at 5:04am, an observation on the 100 hallway revealed a very strong urine odor on 100 hall. On 11/10/2023 at 5:22am in an interview with Nurse A stated he was not sure where the odor was coming from, he said it could be probably from one of the resident's bowel movement. On 11/10/2023 at 6:12am observation revealed residents were observed in their wheelchair moving up and down the 400 hallway - some were wheeling themselves while some were being assisted by the staffs. Observation also revealed the floor on the 400 hall between rooms 400 - 402 and rooms 403 - 404 was chipped and exposing uneven concrete underneath. On 11/10/2023 at 10:10am in an interview with the DON, she stated the floor had been like that before she got to the facility in September 2023, and that was how the floor had been. She stated they (their corporate office) know about it. She stated the maintenance personnel was the one in charge of the floor. She stated she already talked to upper people about that, she stated she talked to the Administrator and corporate personnels about it, she stated the Administrator said the floor need to be re-done. as the exposed concrete on the floor was a safety hazard to the residents. On 11/10/2023 at 10:14am in an interview with the Maintenance Director, he stated they are aware of it, he stated the Administrator was aware of it, and he (Maintenance Director) had replaced the floor laminate a couple of times, he stated he replaced it two times but it kept coming off. He said it had not always been like this all along, he said it came off gradually and the concrete under the laminate eventually got exposed. Maintenance Director stated someone could trip on the floor. On 11/20/2023 at 5:35pm in an interview with the DON, she stated they would get together and figure out going from room-to-room and see if it was the mattress, linen, resident, or if any of the residents was hiding anything that was causing the odor. Review of facility policy titled 'Fall Management System' dated 'Review Date 2/19/2021' revealed in part Extrinsic risk factors for falls are part of the resident's environment and are most likely to be seen in areas such as the bedroom, bathroom, dining room and hallways.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #1 and #2) out of 2 residents reviewed for infection control, in that The facility failed to ensure CNA B changed glove and performed hand hygiene during incontinent care for Resident #1 and Resident #2. The facility failed to ensure CNA B cleaned Resident #1's anus during incontinent care. These failures could place residents living in the facility at risk of exposure to infections. Findings include: Review of Resident #1's face sheet revealed a [AGE] years old female initially admitted to the facility on [DATE]. Her current admission was on 06/15/2023. Her diagnoses included Lymphedema (Swelling in the body, arm or leg caused by a blockage in the lymph.), cellulitis of limb (a condition characterized by bacterial infection of the skin that causes redness, swelling, and pain in the infected area of the skin.), hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone.), Type 2 diabetes mellitus (characterized by high levels of sugar in the blood), hyperlipidemia (A condition in which there are high levels of fat particles in the blood). Review of Resident #1's MDS dated [DATE], section G revealed Resident #1 required one-person extensive assistance with toilet use and personal hygiene. Review of Resident #1's Care plan dated 06/19/2023 revealed resident had an ADL self-care performance deficit related to activity intolerance, impaired balance/ impaired coordination and she was a 1 to 2 person dependent for ADLs and 1 person assistance with personal hygiene. The goal was for Resident #1 to maintain a sense of dignity by being clean, dry, odor free, and well-groomed. Intervention was to assist resident with personal hygiene, toileting, bed mobility, transfer, dressing, locomotion on and off the unit. On 11/10/2023 at 4:43am during observation of incontinent care. CNA B performed incontinent care on Resident #1. CNA B wiped Resident #1's perineum at the front and at the back. She wiped resident's bottom but failed to separate resident's bottom fold to clean the anus. CNA B reached out to pick the zinc oxide ointment to be applied to resident's perineum area when Surveyor intervened and stopped the CNA B. Surveyor told CNA B that she did not clean the Resident #1 very well all the way to the anus, and that she needed to perform hand hygiene after cleaning the resident before reaching out to the ointment. CNA B looked at Surveyor and stated oh!. CNA B separated Resident #1's bottom fold and cleaned Resident #1's anus. Observation revealed there was a smear of bowel movement on the wipe CNA B used for cleaning Resident #1. Review of face sheet revealed Resident #2 was a [AGE] years old female who was initially admitted to the facility on [DATE]. Her current admission was on 07/09/2023. Her diagnoses included congestive heart disease (heart cannot pump blood well enough to meet body's needs.), morbid obesity (overweight with one or more health conditions), obstructive sleep apnea (breathing interrupted during sleep), Chronic Kidney disease, asthma (lung disease affecting breathing), Acute respiratory failure (sudden difficulty breathing as a result of diseases). Review of Resident #2's MDS dated [DATE], section G revealed Resident #2 required one-to-two-person extensive assistance with toilet use and personal hygiene. Review of Resident #2's Care plan dated 06/15/2023 revealed resident had an ADL self-care performance deficit related to dementia and congestive heart failure, and she required 1 to 2 person assistance with personal hygiene, toileting, bed mobility, personal hygiene. The goal was for Resident #2 to maintain a sense of dignity by being clean, dry, odor free, and well-groomed. Intervention was to assist resident with personal hygiene, toileting, bed mobility, transfer, dressing, locomotion on and off the unit. On 11/10/2023 at 4:52am in an observation of incontinent care performed by CNA B on Resident #2. CNA B cleaned Resident #2's perineum area, and she picked the Vitamins A & D ointment to apply on Resident #2 bottom when Surveyor intervened and stopped CNA B. Surveyor told CNA B that she needed to perform hand hygiene after cleaning Resident #2. CNA B immediately discarded the Vitamins A & D together with her gloves and she sanitized her hands. On 11/20/2023 at 9:29am in an interview with CNA B, she said she had received training on incontinent care. She also stated it was important to wipe the residents well and to perform hand hygiene during incontinent care, in order to stop the spread of germs and to prevent infections for the residents. On 11/20/2023 at 5:35pm in an interview with the DON, she stated the failure of CNA B to clean Resident #1 properly and to perform hand hygiene during the incontinent care for Residents #1 and Resident #2 exposed the residents to risk of infection. Review of policy titled 'Incontinence Care' dated 'Review Date 4-10-17' revealed in part, . Put on non-sterile, latex-free gloves .Cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Remove linen/underpad and discard. Remove and discard gloves. Wash hands. Apply clean linen/underpad, brief or other incontinent products, as needed Review of policy titled 'Infection Prevention and Control Program' dated 'Date Reviewed/Revised: 4/12/2023' revealed in part, .All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents reviewed (Residents #3 and #4) for infection control., in that: 1. CNA B failed to wash her hands after performing incontinent care for Resident #3. 2. LVN A failed to don PPE when entering Resident #4's room. These failures could place residents at risk of contracting a communicable disease. Findings included: Resident #3 1. Record review of Resident #3's face sheet revealed reflected a [AGE] year-old male who was admitted into the facility on [DATE] and had diagnoses which included with stage 4 chronic kidney disease and benign prostatic hyperplasia. Record review of Resident #3's MD orders, dated 11/02/2023, revealed the resident was ordered to be on contact isolation precautions for C. Diff (Clostridioides difficile) that causes inflammation of the colon and can be transmitted from person to person by spores. The order was started on 09/15/2023 with no end date. Observations of Resident #3's room on 09/16/2023 at 4:00 PM revealed CNA B entered the room, to provide incontinent care, there was no soap available to use for handwashing in the room. CNA B doffed her used PPE and left Resident #3's room to wash her hands in a handwashing station across the hall . In an interview with CNA B on 09/16/2023 at 4:15 PM, she stated she was told yesterday Resident #3 had C. Diff. She stated she had to come out of the room to wash her hands because there was no soap in the room. She stated her leaving the room to wash her hands was an infection control issue . She said she was not sure who was in charge for keeping the soap in stock, but she believed it was an activities staff. In an interview with the ADON on 09/16/2023 at 4:20 PM, she stated if CNA B went from touching Resident #3 to the handwashing station across the hall without performing hand hygiene in between, that was an infection control hazard. She stated whoever last realized there was no soap should have notified the housekeeping department to refill the soap in Resident #3's bathroom. Resident #4 2. Record review of Resident #4's face sheet revealed reflected an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with diagnoses which included heart failure, acquired absence of right leg above knee and benign prostatic hyperplasia. Record review of Resident #4's MD order, dated 11/02/2023, revealed the resident was ordered to be on isolation precautions for Shingles, a reactivation of chicken pox virus in the body that causes a rash. The order for isolation was started on 10/25/2023 and was ordered to end 10 days later on 11/04/2023. Record review of Resident #4's MDS, dated [DATE], revealed the resident's BIMS score was 0, which indicated the resident was able to complete the BIMS assessment and had no evidence of acute change in mental status. In an interview with Resident #4 on 10/25/2023 at 4:24 PM, he stated he was placed under quarantine this morning because he got a bump on his nose. Observations of Resident #4's room on 10/25/2023 at 4:40 PM, revealed RN A walked into his room without donning PPE from the PPE station that was hanging on the door. She turned off Resident #4's call light and asked Resident #4 if he needed help. She did not assist the resident at the time but proceeded out of the room without performing hand hygiene . In an interview with RN A on 10/25/2023 at 4:40 PM, she stated she was unaware Resident #4 was under contact isolation precautions. She stated her not being aware of the precautions places her at risk of transmitting a disease . In an interview with the DON and the Regional RN on 10/25/2023 at 4:49 PM, the Regional RN stated a shingles infection required contact isolation precautions and RN A would be re-educated on infection control. The DON stated RN A was placing other residents at risk of acquiring shingles by not using PPE or failing to wash her hands when coming into close contact with Resident #4. The DON stated CNA B also placed other residents at risk of infection by touching surfaces along the way to the hand washing station after caring for Resident #3 who had C. Diff. Record review of the facility's policy on infection control, revised 4/12/23, it reflected, . 2) All staff are responsible for following all policies and procedures related to the program. 3) Surveillance: A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards . Standard Precautions: a) All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b) Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c) All staff shall use personal protective equipment (PPE) according to established facility policy . 5) Isolation Protocol (Transmission-Based Precautions): a) A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, 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 15 residents (Resident #1) reviewed for pressure ulcers. 1. The facility failed to ensure Resident #1, who admitted on [DATE] with a stage 4 pressure wound of the sacrum, stage 3 pressure wound of the right heel, stage 3 pressure wound of the left heel, stage 3 pressure wound of the right elbow, and skin tear wound of the left elbow, had documented and individualized wound care orders until 08/17/2023. Resident #1's wounds were not assessed by a wound care physician until 08/30/2023 and were not consistently tracked or measured for progression/regression. The facility also failed to ensure Resident #1 had weekly skin assessments on 08/12/2023, 08/19/2023, and 09/02/2023, and daily wound care treatments on 08/18/2023, 08/19/2023, 08/21/2023, 08/27/2023, 08/30/2023, 08/31/2023, and 09/02/2023, and resulted in wound deterioration, drainage, and odor. 2. Treatment LVN A falsely documented that Resident #1's wounds were treated as ordered by his physician on 08/25/2023, 08/30/2023 and 08/31/2023, when they were not. An Immediate Jeopardy (IJ) situation was identified on 09/06/2023 at 12:08 p.m. While the IJ was removed on 09/08/2023, the facility remained out of compliance at a scope of a pattern with actual harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of experiencing worsening wounds, infection, pain, and possibly death. Findings include: Record review of Resident #1's face sheet, dated 09/01/2023, revealed a [AGE] year-old male who was admitted to the facility from an acute care hospital on 08/04/2023. He had diagnoses which included quadriplegia (paralysis of all four limbs), protein-calorie malnutrition (the state of nutrition in which a deficiency or excess of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form ad function), stage 4 pressure ulcer of the sacral region, and osteomyelitis (inflammation of bone caused by infection) of the sacral and sacrococcygeal region. Record review of Resident #1's admission MDS, dated [DATE], revealed he had a BIMS score of 15, which indicated the resident was (cognitively intact. He exhibited behaviors of rejection of care 1 to 3 days; he required extensive physical assistance from at least one staff for bed mobility, dressing, eating, and personal hygiene. Resident #1 was totally dependent on staff (1 staff) for toilet use and bathing; he used a wheelchair for mobility; he had an indwelling catheter and was always incontinent of bowel. Resident #1 frequently experienced pain; and he had four stage 3 pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) and one stage 4 pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Record review of Resident #1's care plan, revised on 08/23/2023, revealed the following care areas: * Resistance to Care: Resident #1 is resistant to care and at risk for injury, a decline in functional abilities, and not having his needs met in a timely manner. Resistance is related to: refuses shower, care, and medications. Goals included: Resident will be clean, well groomed, and episodes of resistance will decrease to less than weekly. Interventions included: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log; and Provide resident with opportunities to make decisions during ADL care and daily routine. * Pressure Ulcer: Resident #1 has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities. Date initiated: 08/19/2023. Goals included: Resident's pressure ulcer will be free from infection and the risk for infection will be minimized. Interventions included: Notify physician and responsible party of change in status; Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling; Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse; Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Observation and interview with Resident #1 on 09/01/2023 at 10:30 a.m. revealed he was alert, oriented, and in bed on an air mattress. Both of Resident #1's arms were contracted, and both of his feet were in protective boots. Treatment LVN A entered Resident #1's room and asked for his pain level so he could be medicated before she started his wound care. Resident #1 stated he did not get wound care on the previous day, 08/31/2023. Resident #1 stated on 08/30/2023, he had a virtual wound care visit with a wound care doctor. He said Treatment LVN A came in and uncovered all of his wounds so the wound care doctor could see them, and Treatment LVN A covered the wounds back up, without cleaning them. He said he also had a wound on his backside, which was not cleaned on 08/30/2023. He said Treatment LVN A told him she was not going to be able to do his wound care daily because he was in too much pain. He said he was mostly in pain when staff rolled him to the left, onto his bad shoulder. He said staff should roll him towards the door during wound care to avoid his painful left shoulder. LVN B assisted for observation of Resident #1's wound dressings. Resident #1's dressings on both elbows and both heels were dated 08/29/2023. Resident #1's right and left elbow dressings, dated 8/29/2023, were soiled with yellow and brown drainage. There were large pools of yellow and brown drainage on the pillows underneath both elbow wounds. Both of Resident #1's heel wound dressings, dated 8/29/2023, were soiled with yellowish-clear fluid mixed with blood. Both protective boots were also stained with yellowish-clear and red drainage. Resident #1's sacral wound dressing, dated 8/30/2023, was wet with clear, yellow and brown drainage mixed with blood. When LVN B rolled Resident #1 over on his right arm to expose the sacral wound dressing, there was a very foul odor from the area. Resident #1 said two to three weeks prior (he could not recall the dates) he did not receive wound care for five continuous days. He said during that time period, there were nine days when he only received wound care for two days. He said he spoke to the ADON after not receiving wound care multiple days and she said she would be doing his treatments daily. He stated he also spoke to the Previous Administrator, who said she was told he refused wound care. Resident #1 said he never refused wound care, but he did ask staff (various unidentified staff) to come back to do his wound care if he was in too much pain at that time, but the staff never came back. At approximately 11:00 a.m., Treatment LVN A returned to Resident #1's room. Treatment LVN A said she did not complete Resident #1's wound care the day before on 08/31/2023 because he was in pain when she attempted to do it. Treatment LVN A said Resident #1 was asleep the morning of 08/31/2023 and he told her he was in a lot of pain. Treatment LVN A said when she returned, Resident #1's pain level was still high, so she did not do wound care. Resident #1 said that incident happened the day before on 08/30/2023, not 08/31/2023 and he said he told Treatment LVN A to go ahead and do the wound care to get it over with. Treatment LVN A said if she did not complete wound care by the end of the day, she let the nurse know Resident #1 wanted someone to come back, so they could complete wound care on their shift. Resident #1 said he knew Treatment LVN A did not attempt wound care on 08/31/203 because he had a visitor that morning who fed him and stayed with him for some time. Treatment LVN A stated she did not know why she dated some of Resident #1's wounds 08/29/2023 and the sacral wound was dated 08/30/2023. Interview and observation of Resident #1's wound care on 09/01/2023 at 11:30 a.m. revealed Treatment LVN A completed the treatments according to physician's orders. When Resident #1 was turned towards the door, onto his right arm, there was a foul odor and a large amount of drainage from his sacral wound area. Treatment LVN A said the foul odor came from Resident #1's sacral wound. Treatment LVN A said the odor was from old blood and drainage that pooled because the wound had not been treated the day before. Treatment LVN A pointed to white edges around the very large sacral wound and stated that was where the wound retained fluid. Record review of Resident #1's hospital records, dated 07/20/2023, revealed he was admitted to a local acute care hospital on 07/16/2023. No discharge date was listed (08/04/2023). The last documented description and treatment of Resident #1's sacral wound and left posterior elbow pressure injury was 07/17/2023 and revealed the following: Pressure Injury Sacrum: Pressure Injury: Stage (4); Exposed Structure (Bone); Wound Length (11 cm); Wound Width (13 cm); Wound Depth (0.5 cm); Drainage Amount (Small); Drainage Odor (None); Wound Cleanse (Hypochlorus acid); Secondary Dressing (Foam); Peri-Wound Treatment (Liquid film barrier). Left Posterior Elbow Pressure Injury: Stage (Unstageable); Shape (Circular); Wound Length (1.6 cm); Wound Width (1.6 cm); Drainage Amount (Small); Drainage Odor (None); Wound Cleansed (Cleansed); Secondary Dressing (Foam). Record review of Resident #1's, Admit/Readmit Evaluation dated 08/04/2023 revealed, . C. Skin Integrity . Wound Types present on admission: 1. Skin wound Ulcer: Open Wound . Right Elbow. Type: Pressure. Left Elbow. Type: Pressure. Right heel. Type: Pressure. Left heel. Type: Pressure. Sacrum. Type: Pressure . Comments: Resident has multiple wounds Further review of the document revealed no documentation of wound measurements. Record review of Resident #1's physician progress note, dated 08/19/2023, revealed his primary care physician visited him on 08/19/2023. The document read in part, Chief Complaint/Nature of Presenting Problem: Patient seen for evaluation of multiple wounds, chronic osteomyelitis sacral ulcer, functional quadriplegia, and chronic pain . Physical Exam: . Skin: Right heel unstageable measures 3 cm x 2.5 cm by UTD. Right Achilles ulcer unstageable measures 1 cm x 1 cm by UTD. Left Achilles unstageable ulcer measures 3 cm x 2.5 cm times UTD. Right elbow ulcer 3 cm x 3 cm x 0.2 cm. Left elbow measures 1 cm x 2.5 cm x 0.2 cm. Sacral ulcer measures 11.5 cm x 12.1 cm x 0.2 cm . Record review of Resident #1's physicians orders for August 2023 revealed the following orders: * Cleanse Left Elbow with normal saline/wound cleanser and pat dry. Apply medihoney and calcium alginate then cover with a dry dressing daily every dayshift for wound healing. Communication Method: Verbal. Order Status: Discontinued. Order Date: 08/17/2023. Start Date: 08/17/2023. * Cleanse Left heel with normal saline/wound cleanser and pat dry. Apply medihoney and calcium alginate then cover with a dry dressing daily and PRN every dayshift for wound healing. Communication Method: Verbal. Order Status: Discontinued. Order Date: 08/17/2023. Start Date: 08/17/2023. * Cleanse Right Elbow with normal saline/wound cleanser and pat dry. Apply medihoney and calcium alginate then cover with a dry dressing daily every dayshift for wound healing. Communication Method: Verbal. Order Status: Discontinued. Order Date: 08/17/2023. Start Date: 08/17/2023. * Cleanse Right heel with normal saline/wound cleanser and pat dry. Apply medihoney and calcium alginate then cover with a dry dressing daily every dayshift for wound healing. Communication Method: Verbal. Order Status: Discontinued. Order Date: 08/17/2023. Start Date: 08/17/2023. * Cleanse sacral area wound with normal saline/wound cleanser and pat dry. Apply calcium alginate and cover with a dry dressing daily and PRN every dayshift as needed for wound healing. Communication Method: Verbal. Order Status: Discontinued. Order Date: 08/17/2023. Start Date: 08/17/2023. * Perform head to toe skin assessment. Document any changes in skin integrity in the medical record every dayshift every Saturday for wound prevention/early identification. Notify the physician of any changes in skin integrity. Communication Type: Phone. Order Status: Active. Order Date: 08/04/2023. Start Date: 08/05/2023. * Stage 3 Left Heel: Cleanse area with normal saline or wound cleanser, pat dry. Apply collagen powder and calcium alginate. Cover with island border dressing daily and PRN if soiled in the morning for wound care. Communication Method: Prescriber written. Order Status: Active. Order Date: 08/31/2023. Start Date: 09/01/2023. * Left Elbow Skin Tear: Cleanse area with normal saline, pat dry. Apply collagen powder and calcium alginate. Cover with island border dressing daily and PRN if soiled one time a day for wound care. Communication Method: Prescriber written. Order Status: Active. Order Date: 08/31/2023. Start Date: 09/01/2023. * Stage 3 Right Elbow: Cleanse area with wound cleaner, pat dry. Apply collagen powder and calcium alginate and cover with island dressing daily and PRN if soiled in the morning for wound care. Communication Method: Prescriber written. Order Status: Active. Order Date: 08/31/2023. Start Date: 09/01/2023. * Stage 3 Right Heel: Cleanse area with wound cleaner, pat dry. Apply collagen powder and calcium alginate and cover with island dressing daily and PRN if soiled in the morning for wound care. Communication Method: Prescriber written. Order Status: Active. Order Date: 08/31/2023. Start Date: 09/01/2023. * Stage 4 Sacral Wound: Cleanse area with wound cleaner, pat dry. Apply collagen powder and calcium alginate. Cover with foam border/silicone dressing daily and PRN if soiled in the morning for wound care. Communication Method: Prescriber written. Order Status: Active. Order Date: 08/31/2023. Start Date: 09/01/2023. Record review of Resident #1's TAR for August 2023 revealed the following: * Cleanse Left Elbow with normal saline/wound cleanser and pat dry. Apply medihoney and calcium alginate then cover with a dry dressing daily every dayshift for wound healing. Start Date: 08/17/2023. D/C date: 08/31/2023. Entry boxes were blank on 08/18/2023, 08/19/2023, 08/21/2023, and 08/27/2023, which indicated the wound treatment was not completed on those days. The entry box for 08/25/2023 indicated Treatment LVN A completed the treatment (record review of progress note dated 08/25/2023 indicated Treatment LVN A did not complete the wound care treatment). * Cleanse Left heel with normal saline/wound cleanser and pat dry. Apply medihoney and calcium alginate then cover with a dry dressing daily and PRN every dayshift for wound healing. Start Date: 08/17/2023. D/C Date; 08/31/2023. Entry boxes were blank on 08/18/2023, 08/19/2023, 08/21/2023, and 08/27/2023, which indicated the wound treatment was not completed on those days. The entry box for 08/25/2023 indicated Treatment LVN A completed the treatment (record review of progress note dated 08/25/2023 indicated Treatment LVN A did not complete the wound care treatment). * Cleanse Right heel with normal saline/wound cleanser and pat dry. Apply medihoney and calcium alginate then cover with a dry dressing daily every dayshift for wound healing. Start Date: 08/17/2023. D/C Date: 08/31/2023. Entry boxes were blank on 08/18/2023, 08/19/2023, 08/21/2023, and 08/27/2023, which indicated the wound treatment was not completed on those days. The entry box for 08/25/2023 indicated Treatment LVN A completed the treatment (record review of progress note dated 08/25/2023 indicated Treatment LVN A did not complete the wound care treatment). * Cleanse sacral area wound with normal saline/wound cleanser and pat dry. Apply calcium alginate and cover with a dry dressing daily and PRN every dayshift for wound healing. Start Date: 08/17/2023. D/C Date: 08/31/2023. Entry boxes were blank on 08/18/2023, 08/19/2023, 08/21/2023, and 08/27/2023, which indicated the wound treatment was not completed on those days. The entry box for 08/25/2023 indicated Treatment LVN A completed the treatment (record review of progress note dated 08/25/2023 indicated Treatment LVN A did not complete the wound care treatment). * Cleanse Right Elbow with normal saline/wound cleanser and pat dry. Apply medihoney and calcium alginate then cover with a dry dressing daily every dayshift for wound healing. Start Date: 08/17/2023. D/C Date: 08/31/2023. Entry boxes were blank on 08/18/2023, 08/19/2023, 08/21/2023, and 08/27/2023, which indicated the wound treatment was not completed on those days. The entry box for 08/25/2023 indicated Treatment LVN A completed the treatment (record review of progress note dated 08/25/2023 indicated Treatment LVN A did not complete the wound care treatment). * Perform head to toe skin assessment. Document any changes in skin integrity in the medical record every dayshift every Saturday for wound prevention/early identification. Notify the physician of any changes in skin integrity Start Date: 08/05/2023. Entry boxes were blank on 08/12/2023 and 08/19/2023, which indicated skin assessments were not completed on those days. Record review of Resident #1's TAR for September 2023 revealed the following: * Left Elbow Skin Tear: Cleanse area with normal saline, pat dry. Apply collagen powder and calcium alginate. Cover with island border dressing daily and PRN if soiled one time a day for wound care. Start Date: 09/01/2023. The entry box for 09/02/2023 was blank, which indicated the wound treatment for that day was not completed. * Perform head to toe skin assessment. Document any changes in sin integrity in the medical record every dayshift every Saturday for wound prevention/early identification. Notify the physician of any changes in skin integrity Start Date: 08/05/2023. The entry box for 09/02/2023 was blank, which indicated the skin assessment for that day was not completed. * Stage 3 Left Heel: Cleanse area with normal saline or wound cleanser, pat dry. Apply collagen powder and calcium alginate. Cover with island border dressing daily and PRN if soiled in the morning for wound care. Start Date: 09/01/2023. The entry box for 09/02/2023 was blank, which indicated the wound treatment for that day was not completed. * Stage 3 Right Elbow: Cleanse area with wound cleaner, pat dry. Apply collagen powder and calcium alginate and cover with island dressing daily and PRN if soiled in the morning for wound care. Start Date: 09/01/2023. The entry box for 09/02/2023 was blank, which indicated the wound treatment for that day was not completed. * Stage 3 Right Heel: Cleanse area with wound cleaner, pat dry. Apply collagen powder and calcium alginate and cover with island dressing daily and PRN if soiled in the morning for wound care. Start Date: 09/01/2023. The entry box for 09/02/2023 was blank, which indicated the wound treatment for that day was not completed. * Stage 4 Sacral Wound: Cleanse area with wound cleaner, pat dry. Apply collagen powder and calcium alginate. Cover with foam border/silicone dressing daily and PRN if soiled in the morning for wound care. Start Date: 09/01/2023. The entry box for 09/02/2023 was blank, which indicated the wound treatment for that day was not completed. Record review of Resident #1's wound care physician's progress notes revealed the following: * Date of Service: 08/14/2023. Note: The patient's visit has been rescheduled. * Date of Service: 09/04/2023 (actually for 08/21/2023). Note: After discussion with the administrator on 08/21/2023, the patient's visit has been rescheduled at the request of the facility. * Date: 08/30/2023. Wound Care Telemedicine Follow Up Evaluation. The document read in part, Today's visit was requested by the patient (or responsible party) who has consented to wound care services via telemedicine. Services were furnished through our HIPAA-compliant telecommunication system utilizing real time, two-way audio/video communication. Patient is in their place of residence; provider is licensed and enrolled to render services within the respective state . Stage 4 Pressure Wound Sacrum Full Thickness: Wound Size (13.9 x 9 x 0.8 cm); Surface Area (125.10 cm2); Exudate (Moderate Serous); Wound Progress (Not improved) . Skin Tear Wound of the Left, Posterior, Medial Elbow Full Thickness: Wound Size (2.1 x 1.3 x .2 cm); Exudate (Moderate Serous [clear to yellow fluid that leaks out of a wound]); Wound Progression (Improved evidenced by decreased depth) . Stage 3 Pressure Wound of the Right Heel Full Thickness: Wound Size (1 x 2 x 0.1 cm); Exudate (Light Serous) . Stage 3 Pressure Wound of the Right Elbow Full Thickness: Wound Size (2.5 x 2.2 x 0.1 cm); Exudate (Moderate Serous) . Stage 3 Pressure Wound of the Left Heel Full Thickness: Wound Size (0.5 x 0.5 x 0.1 cm); Exudate (Moderate Serous) * Date: 09/06/2023. Wound Care Telemedicine Follow Up Evaluation. The document read in part, Today's visit was requested by the patient (or responsible party) who has consented to wound care services via telemedicine. Services were furnished through our HIPAA-compliant telecommunication system utilizing real time, two-way audio/video communication. Patient is in their place of residence; provider is licensed and enrolled to render services within the respective state . Stage 4 Pressure Wound Sacrum Full Thickness: Wound Size (13.5 x 15.0 x 0.8 cm); Surface Area (202.50 cm2); Cluster Wound (open ulceration area of 182.25 cm2); Exudate (Moderate Sero-sanguinous [both blood and liquid part of blood]); Wound Progress (Exacerbated due to generalized decline of patient) . Skin Tear Wound of the Left, Posterior, Medial Elbow Full Thickness: Wound Size (1.0 x 1.0 x .3 cm); Exudate (Moderate Sero-sanguinous); Wound Progression (Improved) . Stage 3 Pressure Wound of the Right Heel Full Thickness: Wound Size (1.5 x 1.5 x 0.1 cm); Exudate (Light Sero-sanguinous) . Stage 3 Pressure Wound of the Right Elbow Full Thickness: Wound Size (2.5 x 2.7 x 0.1 cm); Exudate (Light Sero-sanguinous); Wound Progress (Not Improved)) . Stage 3 Pressure Wound of the Left Heel Full Thickness: Wound Size (2.2 x 2.0 x 0.1 cm); Exudate (Moderate Sero-sanguinous); Wound Progress (Exacerbated due to need to offload) Record review of Resident #1's progress notes for August 2023 revealed the following notes regarding wounds and wound care: * On 08/04/2023 at 10:47 p.m., LVN F wrote, . Pt. is alert and is able to verbalize needs. Pt. is contracted on RUE with open area on the right lateral/outer elbow . Pt. is unable to make use of his BUE and will continue to need assist with ADLs Q-shift. Pt. has wounds on the following other areas: - Right Achilles, Right heel, Left Achilles, Left inner elbow. Open area on sacral area, approximately 30.0 cm by 25.0 cm . * On 08/07/2023 at 10:14 p.m., LVN F wrote, . Pt. declined wound care on this shift . * On 08/09/2023 at 11:15 a.m., LVN F wrote, . Pt. has sacral decubitus with dry dressing in place. MD's NP assessed pt. on this shift and gave orders as follows: - Air mattress Q-shift due to multiple wounds . * On 08/10/2023 at 7:52 p.m., RN H wrote, . Wound care continued daily due to multiple wounds on sacrum, bilateral elbows, and bilateral heels and Achilles . * On 08/17/2023 at 12:36 p.m., RN H wrote, . Resident seen by wound care treatment nurse. * On 08/20/2023 at 1:46 p.m., LVN F wrote, Wound care continued daily due to multiple wounds, with dry dressing in place . * On 08/21/2023 at 8:10 p.m., LVN F wrote, . Wound care continued with dry dressing in place . * On 08/25/2023 at 4:02 p.m., Treatment LVN A wrote, Attempting to provide wound care services as ordered, pain assessment completed prior to start of treatment. Patient verbalized pain 8- 9/10. Moaned and cried with any attempts to move extremities. Wound care not completed at this time, notified charge nurse to re-evaluate patient's pain level in the next hour to offer wound care as ordered. * On 08/27/2023 at 6:51 p.m., LVN F wrote, . Wound care was performed in the a.m. shift and pt. tolerated well . * On 08/28/2023 at 6:07 p.m., LVN F wrote, . Dry dressings are intact on wound area: bilateral elbows, bilateral heels, and Achilles, and sacrum. Pressure relieving boots are in place on BLE as ordered . * On 08/30/2023 at 11:36 a.m., Treatment LVN A wrote, Patient was seen by Wound Care Doctor D to evaluate wound care and/or treatment. New orders received to discontinue medihoney for bilateral elbows and heels due to mild debridement being successful and evident by all wounds having meaty red center, moderate amount of sero-sanguinous drainage with odor. Updated orders received and uploaded . Further review of Resident #1's records revealed no documentation which indicated any of Resident #1's wounds were unavoidable. Record review of an undated facility document titled, Quality Assurance Performance Improvement Report revealed it listed the number of new pressure wounds (two admitted with on 08/07/2023), new neuropathic/diabetic wounds (0), new arterial, venous, and mixed vascular wounds (one recurring on 08/07/2023), new surgical wounds (one admitted with on 08/07/2023), new skin tears (three acquired on 08/07/2023), and other new wounds (one on 08/07/2023) the facility had for the time period of 08/01/2023 thru 08/28/2023. Further review of the document revealed no information regarding why the PIP was initiated, no information on what issues were identified, no information on specific residents, no mention of residents not being seen by the wound care doctor, and there was no resolution or proposed plan for whatever the issue was. In an interview with the Corporate Nurse on 09/01/2023 at 4:00 p.m. and with the Treatment LVN A on 09/05/2023 at 9:15 a.m., they were asked to provide documentation of Resident #1's weekly skin assessments completed on 08/05/2023 and 08/26/2023, none were ever received. In an interview with Treatment LVN A on 09/01/2023 at 12:09 p.m., she stated she was hired on 08/16/2023 or 08/17/2023. She said she did a skin sweep for the entire building on Saturday, 08/19/2023 and her first official day doing wounds was Monday, 08/21/2023. She stated blanks on the TAR meant a particular treatment was not done. Treatment LVN A looked in the facility's computer system at Resident #1's TAR and said the blanks meant nobody did Resident #1's wound treatments on those days. She said she did not know why there were blanks on Resident #1's TAR on some of the days she was supposed to do his wound care. She said she did rounds with the wound care doctor on Monday, 08/21/2023. She said 08/21/2023 was her first day meeting the wound care doctor, Wound Care Doctor C and that was his last day at the facility. She said the facility had been having issues with Wound Care Doctor C not completing rounds with all of the residents with wounds. She said Wound Care Doctor C was not giving aides time to get residents back to their rooms and in bed and he would not see those residents on those days. Treatment LVN A said on 08/21/2023, Wound Care Doctor C did not see Resident #1 because rounds took 4.5 hours and he said he ran out of time. She said Wound Care Doctor C wanted to see some of the residents and not others. She said there was also a communication issue regarding new residents because after she did the skin sweep for the building, she assumed Wound Care Doctor C knew about all the residents with wounds, but he did not. She said Wound Care Doctor C did not know Resident #1 had wounds. She said the facility administration was not happy with Wound Care Doctor C, so they fired him after rounds on 08/21/2023. She said she called the wound care company and got Wound Care Doctor D to do virtual visits on 08/30/2023 with the residents Wound Care Doctor C did not see on 08/21/2023, which included Resident #1. She said the facility would be getting a new wound care doctor, Wound Care Doctor E, on a permanent basis. Treatment LVN A said she did not currently do weekly skin assessments, but eventually she would. She said there were approximately 20 residents in the building with multiple wounds, so wound care took a long time. She said the facility did not have a wound care nurse since May 2023, so the floor nurses were doing weekly skin assessments. She stated she had not yet become familiar with the building's wounds, so the process took a long while. Documentation of Treatment LVN A's skin sweep was requested at that time but was never received. In an interview with the Corporate Nurse on 09/01/2023 at 4:30 p.m., she stated she and the administrator put a PIP in place on 08/21/2023, after they determined the wound care doctor was not visiting all their wound residents. The Corporate Nurse said the Administrator, who was not present, had the PIP and she (the Corporate Nurse) could not locate it. The Corporate Nurse stated they provided a copy of the PIP to the state survey team who completed a full-book survey on 08/25/2023. The Corporate Nurse and the ADON searched thru binders in the Administrator's office but stated they could not find the PIP. In an interview with Treatment LVN A on 09/05/2023 at 9:15 a.m., she stated she did document completion of Resident #1's wound care treatment before she actually did the treatments on 08/30/2023 and 08/31/2023. She said she knew she had to stop doing that, as she had done it before. She said Resident #1 was back and forth with his pain levels and eventually told her he wanted wound care done in the evening. She said she had already documented on his TAR while she was outside his door preparing for the treatment. She said the oncoming nurse (she did not name the nurse) said he would do Resident #1's wound care, but he did not. She said she also documented completion of the wound care treatment on 09/01/2023 before she entered Resident #1's room because she did not know the State Surveyor was in the room with the resident. She said she measured the wounds on 08/30/2023 when Wound Care Doctor D did virtual rounds. She said some residents, which included Resident #1, were at the facility for a while and had never been seen by Wound Care Doctor C, so she needed an emergency visit from Wound Care Doctor D. She said 08/30/2023 was the first day Resident #1 was assessed by a wound care physician, and he was admitted on [DATE]. She said if wound care was not provided daily or according to physician's orders, they could get worse, increase in size, get infected, or more wounds could develop. Documentation of Treatment LVN A's skin sweep and wound care tracking information were requested again at that time but were never received. In an interview with LVN B on 09/05/2023 at 1:15 p.m., she stated she often cared for Resident #1 as his assigned nurse. She said before Treatment LVN A was hired, she guessed she and the other nu [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that residents who needs respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the residents goals, and preference for 3 of 19 residents (CR #1, Resident #2 and Resident #23) reviewed for tracheostomy care in that: -The NF failed to ensure all Nursing staff caring for residents with tracheotomies had been trained on maintaining artificial airway if a trach dislodged. -The NF failed to have emergency tracheostomy equipment at CR #1's bedside at all times when CR #1 trach dislodged. -The NF failed to order sufficient tracheostomy/respiratory equipment for residents with tracheotomy in the event of an emergency. CR #1 was found in bed on [DATE] with trach dislodged. CR #1 was transported to the hospital via EMS where he passed away shortly after arriving at the hospital. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:58pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of K and a severity level of a K because all staff had not been trained on trach dislodgement/respiratory care. This failure has the potential to place residents with tracheostomies as well as other residents requiring respiratory care at risk of not receiving the necessary care and services needed to meet their medical goals resulting in a decline in health or harm. Findings included: CR #1 Record Review of CR #1's face sheet revealed a 34year old male admitted to the NF on [DATE] and discharged on [DATE]. CR #1 was admitted to the NF with the following diagnoses; cerebral infarction (stroke-damage to brain from interruption of its blood supply), type 2 diabetes mellitus, hyperlipidemia (elevated cholesterol), hypertension (high blood pressure), heart failure, acute respiratory failure with hypercapnia (elevated carbon dioxide), muscle wasting (loss of tissue), dyspnea (shortness of breath), and hypertrophic cardiomyopathy (heart muscle becomes abnormally thick). Record review CR #1's MDS dated [DATE] revealed CR #1 had a BIMS score of 5 indicating that CR #1 cognition was severely impaired. Further review revealed that CR #1 required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and totally dependent upon staff for eating. Further review revealed that resident was receiving special treatment for oxygen therapy and tracheostomy care. Record review of CR#1 Physician Order Summary Report revealed the following orders: -dated [DATE] suction trach every shift and PRN -dated [DATE] albuterol sulfate nebulization solution 2.5mg/0.5ml 1 application via trach every 6 hours as needed for SOB -dated [DATE] trach care BID and PRN -dated [DATE] trach type Portex 6.0 Record review of CR #1's MAR for the month of [DATE] revealed that the medication albuterol sulfate nebulization 2.5mg/0.5ml 1 application via trach every 6 hours PRN for SOB was administered 1 time on [DATE]. Record review of CR #1's Care Plan dated [DATE] revealed that CR #1 was care planned for a tracheostomy. The interventions included the following: -Provide oxygen, humidity, tracheostomy care, and tubing changes as indicated by physician orders -Ensure that trach ties are secured at all times -Suction as needed for increase secretions and congestion -Keep extra trach at bedside. If tube is coughed out and tube cannot be inserted obtain medical help immediately. Monitor/document for signs of respiratory distress elevate head of bed and stay with resident. Record review of CR #1's Nursing Progress Notes dated [DATE] documented by LVN W revealed in part: .12:40pm Primary Chief Complaint: Trach Issue .34year old man with tracheostomy on TC. He has hard secretions in the tracheostomy site not allowing suction catheter to pass. DON wants to transfer patient to ED so a new trach can be performed .Doctor order to send resident to ER to get trach switched out . Observation on [DATE] at 11:00am on 200 Hall was CR #1 resting in bed awake having a tracheostomy tube connected to oxygen. The dressing around resident trach site was clean with no secretions. Further observation was made of suctioning kit, tubing, and inner cannulas at CR #1's bedside along with an Ambu bag. Interview on [DATE] at 11:00am with CR #1 when asked how he was doing, CR #1 communicated by giving thumbs (doing okay). Further interview with CR #1's family member who was present in room at the time said CR #1 had gone to the hospital on Sunday [DATE] due to respiratory distress and the doctor said resident inner cannula was clogged due to CR #1 trach not being suctioned and changed. The family member said he did not remember the date but had asked a nurse to change CR #1's inner cannula and the staff member whose name he did not know told him the facility did not have any inner cannulas. The family member said the family of CR #1 had to constantly stay on the staff to provide trach care and that these concerns had been shared with the Administrator at the NF. The family member said the staff was very slow to answer CR #1's call light and they would sometimes have to go and look for staff to assist CR #1. Observation on [DATE] at 11:05am revealed CR #1's call light was turned on by surveyor with staff coming on the unit at 11:42am, but not into CR #1's room. The surveyor saw a staff member in the hallway. CR #1's call alarm was still alarming. CR #1 was not in any distress. Observation on [DATE] at 12:05pm the surveyor was leaving Hall 200. Observation revealed CR #1 call alarm still sounding. Interview on [DATE] at 12:09pm CNA SS said she was the CNA assigned to Halls 100 (rooms ,d+[DATE]), 200, and Hall 300 (rooms ,d+[DATE]). CNA SS said she had to do her rounds and feed other residents. CNA SS said she had already provided incontinent care for CR #1. CNA SS said when a resident light is on the staff were supposed to go in the resident (s) room and see what the resident needed and addressed the need. CNA SS said if she did not go to a resident room to answer or acknowledge the resident alarm it would be considered neglect. Further interview with CNA SS she said when she saw the surveyor in CR #1's room, she was on her way to get some gloves. Record review of CR #1's Nursing Progress Notes dated [DATE] revealed that CR #1 was readmitted from hospital after being admitted on [DATE]. The NF did not provide hospital record or a discharge summary. Record review of CR #1's Nursing Progress Notes dated [DATE] documented at by LVN T revealed in part: . Patient trach dislodged 10:10pm. Patient is alert and is able to provide appropriate response to verbal commands. Pt. has 6 trach and continues on room air without s/s of respiratory distress. Pt. stated he might have coughed hard thereby dislodging his trach. Pt. experienced shortness of breath about 10 minutes after trach dislodged. EMS personnel were by the bedside when Pt.'s O2 sat started to plummet down to 86% on 15L of O2 via Ambu bag (hand held self-inflating bag use to assist with breathing when one is not breathing or breathing adeauately) . Pt. was transferred to hospital for evaluation and treat. MD, RP, and Admin are all aware . Interview on [DATE] at 10:06am with family member of CR #1 said she spoke with the hospital ER doctor on [DATE] who said CR #1 died from a mucus plug. The family member said the ER Doctor told her he tried to get the trach back in but was unsuccessful. The family member said she had visited with CR #1 on [DATE] at the NF and CR #1 was wheezing. The family member said she asked the nurse who name she could not remember to give CR #1 a breathing treatment which the nurse gave. The family member said she had also asked the nurse to change CR #1's inner cannula but never saw the nurse replace the inner cannula. The family member said after CR #1 received the breathing treatment, the wheezing stopped. The family member said she went home. Further interview with family member said after CR #1 had passed away, a staff member at the NF had informed her that on [DATE] the NF had fliers up in the facility that all staff had to be trained on tracheotomy care. Record review of CR #1's hospital records dated [DATE] revealedin part: .Glide scope/ET (tool used to see airway/edotracheal tube) was attempted 4 (four) times unsuccessful, could not advance tube past vocal cords, was meeting resistance .Unfortunately patient did not seem to respond to our efforts during final code (emergency that indicates cardiopulmonary arrest (no heart rate and not breathing) .Patient CPR was carried out to more than a total of 70 minutes between EMS and our efforts .Despite patient's young age, too much time had elapsed and patient was unlikely to have a good neurologic outcome, assuming he would not succumb to other end-organ damage .CPR efforts were stopped and patient's time of death was announced at 1:08am . Interview on [DATE] at 11:29am with the Administrator regarding CR #1, he said he had called in a facility self-report because the hospital was insinuating lack of care on the NF side. The Administrator said CR #1 had blockage and that the hospital tried to intubate but the resident had a mucus plug (a buildup of dried or thick secretions in the airway blocking trach tube that allows for one to breathe). The Administrator was asked for the last training of the Nursing staff regarding tracheotomy care and trach dislodgement. Interview on [DATE] at 11:53am the NF Medical Director said after reviewing CR #1's records (Nursing Progress Notes dated [DATE]) CR #1 was stable, could talk, and cognizant. The Medical Director said CR #1's oxygen saturations were 100%. The Medical Director said it was not until EMS was beginning to transfer CR #1 from the bed to the stretcher, CR #1 oxygen saturations began to drop. The Medical Director said CR #1 might have had a mucus plug that could have moved during transfer. The Medical Director said a for sure sign of a of a mucus plug was decrease in oxygen saturation. The Medical Director said the only way to remove a mucus plug is having a bronchoscopy (a procedure that let the doctor look at the lungs and airway passages). The Medical Director said mucus plugs were not uncommon and residents could get small ones all the time. The Medical Director said CR #1 had coughed and dislodged the trach and staff was unable to place the trach back in. The surveyor asked the Medical Director what was the NF protocol if the nurse could not reinsert the same size trach and should a smaller size be used? The Medical Director said it was not the NF protocol to have a smaller trach size at the bedside when having difficulty inserting the initial size but to call EMS. The Medical Director said that protocol was done in the hospital system. The Medical Director said the NF had a total of 3 residents with tracheostomy and one was her resident that was doing good. The Medical Director said she had been the NF Medical Director at the NF since [DATE]. The Medical Director said she was not familiar with the NF protocol regarding trach dislodgement and maintaining artificial airway and would have to review their policy. Interview on [DATE] at 1:40pm with the Central Supply Manager said the NF currently had 3 residents with tracheostomies that used a #6 Shiley trach. Observation on [DATE] at 1:40pm of the NF Central Supply Room revealed it had 10 #6 Shiley cannulas in a box. Observation of a nurse (name not identified) coming to the supply room to get #6 Shiley cannulas. The Central Supply Manager said she had on hand also the disposable Portex #8 disposable cannulas with a total of 12 on hand which none of the residents with trachs were using. The Central Supply Manager said she had 1 #6 inner cannula of the Portex brand. The Central Supply Manager said 1 resident in the NF was using the #6 inner cannulas. Central Supply Manager said she ordered the #6 inner cannulas about 2 weeks ago and usually ordered 10 boxes at a time with 10 in a box, but the Portex brand she had to order individually and did not come in bulks. The Central Supply Manager said another brand she ordered for the inner cannulas was the Phoneris #6 inner cannulas that came in a box of 10 which the NF had 1 box with 10 inner cannulas. Further observation was made of the NF having size #4 inner cannulas brand name Phoneris with 10 in a box. The Central Supply Manager said she stocked the resident rooms who had trachs with supplies that included extra inner cannulas that she would place in the resident (s) rooms at bedside. The Central Supply Manger said she had never been told to stock with a smaller inner cannula but to just stock with the size the resident was using. The Central Supply Manager said extra trach supplies were stocked on the nurse carts that included trachs and inner cannula sizes of the residents. The Central Supply Manager said she ordered trach supplies every two to 3 weeks which included supplies for tracheotomies. The surveyor asked the Central Supply Manager for a copy of her last order summary report. The Central Supply Manager never provided a copy. On [DATE] at 1:50pm The Surveyor requested from the interim DON the NF staff training regarding tracheotomy/trach dislodgement. Interview conducted on [DATE] at 1:56pm with LVN T regarding CR #1. LVN T said the time was around 10:10pm on [DATE] on a Sunday when a CNA whose name he could not remember but believed the CNA was an Agency CNA. LVN T said the CNA came to him telling him that CR #1 wanted to speak with him. LVN T said the first thing he saw when he entered CR #1's room was CR #1 trach laying on his neck area and the right side of CR #1's trach collar was completely undone. LVN T said he asked CR #1 what happen? and CR #1 told him that he felt something on his neck and thought he coughed the trach out. LVN T said he tried to reinsert the trach but met resistance. LVN T said while he tried to reinsert the same trach that had dislodged, CR #1 complained of pain at the trach site. LVN T said he called from the hallway for extra assistance and then went to look for a size 4 inner cannula. LVN T said he looked in the supply room by the nurse station for a smaller size trach and did not find one. LVN T said during this time, CR #1 was not showing any signs of distress. LVN T said he had been working at the NF since 2015 of December and had taken care of residents with trachs before. LVN T said he had been in-serviced on trach care. LVN T said CR #1 was not connected to oxygen and that his trach was capped. LVN T said to his knowledge normally a smaller size trach size is kept at the resident bedside in case the trach dislodged. LVN T said EMS had been called and when they arrived, they tried to insert the resident's trach but was unsuccessful. LVN T said EMS inserted a rubbery device in CR #1's nostril and when they transferred CR #1 to the stretcher, CR #1 oxygen saturation dropped in the 80's. LVN T said the last time he had checked on CR #1 was 5 minutes prior to finding trach dislodged. Interview on [DATE] at 2:20pm the NF MDS Coordinator said the NF did not have an on staff Respiratory Therapist. The MDS Coordinator said the NF utilized the Corporate Respiratory Therapist when needed. Interview on [DATE] at 6:44pm via phone CNA SS said she no longer worked at the NF as of [DATE] (resigned). CNA SS said LVN T was not concerned about suctioning CR #1 or checking on CR #1. CNA SS said the family of CR #1 had to constantly stay on LVN T to provide trach care for CR #1. CNA SS said on Sunday, [DATE], she worked a double shift 6am-2pm to 2pm-10pm. CNA SS said she cared for CR #1 on the 6am-2pm shift and that CR #1 was doing good. CNA SS said although she was not CR #1's CNA for the 2pm-10pm shift, she was still working on the Hall that CR #1 was residing on and would answer his light if CR #1 called. CNA SS said the resident was doing good on the 6am-2pm shift as well as the 2pm-10pm shift until around 10pm. CNA SS said CR #1's room was right by the nurse station. CNA SS said CR #1 was very alert and oriented and could communicated with staff although his trach was capped. CNA SS said it was around 10pm when CR #1 had put on his call light, and she went to his room to see what he needed. CNA SS said when she went to CR #1's room, LVN T was also headed to CR #1's room a few steps ahead of her. CNA SS said when she entered CR #1's room, CR #1 did not appear to be in any distress but was pointing toward his face that he needed some help. CNA SS said because CR #1 was communicating with LVN T, she left the room. CNA SS said LVN T was in CR #1's room approximately ,d+[DATE]minutes. CNA SS said she was standing at the nurse station and saw LVN T come out of CR #1's room headed toward the nurse station. CNA SS said she asked LVN T what was going on with CR #1? CNA SS said LVN T shared with her that CR #1 had pulled out his trach and he needed to call 911. CNA SS said LVN T said he did not want CR #1 to see that he was nervous. CNA SS said LVN T said he tried to reinsert the trach but could not get it in because it was the wrong size. CN A SS said LVN T then placed a call to 911 and after that went to the supply room to try and find another trach. CNA SS said at this time, she did not see any other nurses at the nurse station. CNA SS said she did not know if LVN T found what he was looking for but did see LVN T go back to CR #1's room. CNA SS said she never went back to CR #1's room. Interview on [DATE] at 9:20am with ADON B said she had been working at the NF for 2 weeks. The ADON B said it was general practice to have a trach size up or down at the resident bedside and this was done if the trach dislodged. ADON B said when trying to reinsert the trach, if resistance is met, the nurse could use a smaller trach to maintain airway. Interview on [DATE] at 9:28am with the MDS Coordinator said she had been working at the NF for [AGE] years. The MDS Coordinator said residents who had trachs, emergency trach supplies were to be kept at resident bedside in case the trach dislodged or started to experience any respiratory distress. The MDS Coordinator said the Shiley brand for trach's was the original brand. The MDS Coordinator said the NF had both brands the Shiley and the Portex but was unsure if they there was difference in the brands or if they could be used interchangeable. The MDS Coordinator said although she did not work the floor anymore, she had received in-service about 2 weeks ago on trach care. The MDS Coordinator said she believed that in the in-service it was told that a smaller trach size needed to be kept at the bedside in the event of an emergency. Interview on [DATE] at 12:26pm LVN T said the CNA that first responded to CR #1's call light was the CNA on the 10pm-6am who was Agency, and the time was around 10pm. LVN T said when he went to CR #1's room, he found CR #1 trach dislodged with the right side of the Velcro around neck was completely undone. LVN T said he immediately tried to insert CR #1's trach (#6 Shiley) and was unsuccessful. LVN T said he stepped in the hall and called for the assistance of the other nurse that was working with him who was a female nurse, RN U, that was at the nurse station. LVN T said he told RN U to bring a pulse oximeter (device use to monitor a person level of oxygen) and come to CR #1's room. LVN said CR #1 did not have a smaller size trach in room. LVN T said CR #1 did not appear to be in any distress and his pulse oximeter was ,d+[DATE]% on room air therefore did not place CR #1 on oxygen. LVN T said RN U attempted to reinsert trach but could not get the trach in and like him kept meeting resistance. LVN T said he left resident room to call 911 and notify the physician. LVN T said he told the physician that CR #1 appeared to be stable, and that the physician said to cover CR #1's stoma site with a 4x4 and continued to monitor CR #1 and CR #1 did not have to send CR #1 to the hospital. LVN T said he was concerned about resident and the A, B, C's (airway, breathing, and circulation) and the doctor said go ahead and send CR #1 to the hospital. LVN T said he began to look for some k-y jelly and a smaller size trach but could not find either. LVN T said EMT tried to stabilize resident by using an Ambu bag along with an oxygen nonrebreather mask. LVN T said when he tried to reinsert the trach, he did not use an obturator to help guide it because he did not have one. LVN T said he received in-service on tracheostomy care and dislodgement 3 days after the incident by the Respiratory Therapist. LVN T said at this time he brought the question up with the RT about necessary trach supplies that needed to be kept at resident bedside with a tracheotomy. LVN T said the RT told him that a smaller size trach and Ambu bag always needed to be at the bedside in case the resident started having respiratory distress. Interview on [DATE] at 12:44pm RN V said when she arrived to work on [DATE] after 10:00pm, CR #1 was still in the room, RN V said she believed EMS had been called. RN V said it was a male and female in CR #1's room and initially CR #1 was not in any distress. RN V said she did not attempt to insert CR #1's trach or administer oxygen to CR #1. RN V said it was EMS that began bagging CR #1 when CR #1 went into distress when they were beginning to move CR #1. Interview on [DATE] at 2:15pm CNA S said she worked at the NF on [DATE] on the 2pm-10pm shift and was the CNA for CR #1. CNA S said she was Agency, and it was her first time working at the NF. CNA S said she arrived too the NF around 2:00pm and had to wait on her assignment. CNA S said when she got her assignment, she began to make her rounds. CNA S said she arrived too CR #1's room around 2:50pm and found CR #1 with mucus secretions all around his trach site gasping for air. CNA S said she tried to remove the mucus from around CR #1's trach site and went to tell the nurse who was a male nurse. CNA S said she continued to go and check on the other residents and in doing so, she saw a female nurse and told her what she saw regarding CR #1. CNA S said the female nurse told her that CR #1 probably just needed to be suctioned. CNA S said she checked on CR #1 again around 3:30pm because she was concerned and wanted to make sure he was okay. CNA S said CR #1 appeared to be okay resting quietly. CNA S said at this time she provided incontinent care for CR #1 with the assistance of another female staff who she believed was nurse. CNA S said at 5:00pm or a little after, she went to CR #1's room to feed his roommate and that CR #1 continued to rest quietly not appearing to be in any distress. CNA S said at one time during the shift, a female visitor was in CR #1's room. CNA S said she made her last round on CR #1 at 8:30pm and at this time CR #1 did not require any incontinent care but continued to rest quietly. CNA S said this was the last time that she saw CR #1. Resident 2 Record review of Resident # 2 face sheet revealed a 29year old female admitted to the NF on [DATE] with the following diagnoses that included acute and chronic respiratory failure, tracheostomy, dysphagia (difficulty swallowing), and anoxic brain damage (lack of oxygen to the brain). Record review of Resident #2's Physician Order Summary Report revealed order dated [DATE] for Trach size 8 with trach care every shift and PRN. Record review of Resident #2 MDS dated [DATE] revealed a BIMS score of 0 indicating cognition level severely impaired. Further review revealed resident was receiving the following therapies: oxygen, suctioning, and tracheostomy care. Further review revealed that the MDS did not address gastrostomy feedings. Record review of Resident #2's Care Plan dated [DATE] revealed that Resident #2 was being care planned for a tracheostomy trach size 8. Resident #3 Record review of Resident #3 face sheet revealed a 34year old male admitted to the NF on [DATE] diagnoses included chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or get rid of enough carbon dioxide (odorless nonflammable gas) from the body) and tracheostomy. Record review of Resident #3's MDS dated [DATE] revealed that Resident #3 was receiving oxygen therapy, suctioning, and tracheostomy care. Record review of Resident #3's care plan dated [DATE] revealed that resident was being care planned for a tracheostomy that included the following interventions: -Provide oxygen, humidity, tracheostomy care, and tube changes as indicated by physician orders -Ensure that trach ties are secured at all times -Suction as needed for increase secretions and congestion -Keep extra trach (size 6) at bedside. If tube is coughed out and tube cannot be reinserted obtain medical help immediately. Monitor/document for signs of respiratory distress, elevate head of bed and stay with resident Record review of Resident # 3's Physician Orders revealed an order dated [DATE] trach type size #6. Further review of an order dated [DATE] replace disposable inner cannulas every day and PRN. Record review of Resident #3's TAR for the month of [DATE] revealed that the staff was documenting that they were following Physician Orders regarding trach care. Observation [DATE] at 10:07am of Resident #2 resting in bed awake with the head of bed elevated receiving continuous gastrostomy feedings. Resident #2 had a trach connected to oxygen. Further observation was made of resident not having an Ambu bag at the bedside. Interview and observation on [DATE] at 10:12am with LVN Q said she was the nurse for Resident #2. After LVN Q looked in Resident #2's room for trach supplies (inner cannulas and emergency trach kit), LVN Q said she did not have any inner cannulas at resident bedside nor an emergency trach kit. LVN Q said she did have inner cannulas on her cart of different sizes but did not know the size of Resident #2's trach unless she changed it. LVN Q could not explain why Resident #2 did not have an Ambu bag at the bedside or any of the other trach supplies. LVN Q said these supplies should be kept at the bedside of all residents that had a tracheotomy in the event of an emergency. LVN Q said it was the responsibility of Central Supply and the nurses to stock the resident rooms who had trachs with trach supplies. LVN Q said she had been working at the NF for about 8 months and had never observed trach supplies or Ambu bags at the bedside of residents who had trachs. LVN Q said she had received in-service on trach care about ,d+[DATE] weeks ago but did elaborate on the specifics of training provided. At 10:20am LVN Q checked her cart and found 1 inner cannula Shiley size 5.5mm and 2 Portex brand inner cannulas 5.0mm. LVN Q searched the NF for Ambu bags and could not find any on Station A or Station B, nor any in the supply rooms. LVN Q was able to find one 1 emergency trach kit with an obturator (a device used to insert a tracheostomy tube). LVN Q was informed by surveyor that suctioning of Resident #2's trach wanted to be observed. Observation on [DATE] at 10:25am Resident #3 having 2 Ambu bags in the room, one hanging on the wall and the other one inside of a drawer. Interview on [DATE] at 10:55am the MDS Coordinator said she would think it was the nurse responsibility to ensured that when caring for residents with a tracheotomy to have all necessary emergency supplies at resident bedside to maintain airway. Observation on [DATE] at 11:00am Resident #2's door was closed. When the surveyor entered the room, Resident #2's curtains were pulled. The surveyor pulled the curtains back and observed a female on the right side of the resident bed wearing a white lab coat with the initials NP on it. Further observation was made of LVN Q standing on the opposite side of the resident bed. The female with the white lab coat had a white drape across Resident #2's upper body torso with suctioning tubing in hands appearing to prepare for suctioning Resident #2 while LVN Q was observing. Further observation was made of a Ambu bag now present in Resident #2's room at the head of bed attached to the wall. Interview on [DATE] at 11:20am with LVN Q asking her where did the ambu bag hanging at the head of Resident #2's bed come from? LVN Q said she got the Ambu bag from Resident #3's room who had 2 Ambu bags in their room. Interview on [DATE] at 1:13pm with the Administrator regarding NF Policy on Trach dislodgement with training. The Administrator said the NF did not have a policy and was waiting on Corporate to send. Interview on [DATE] at 1:20pm the Respiratory Therapist with Corporate Office said she was just assigned to the NF and had come to the NF the first time on [DATE] to set up rooms for pending trach residents. The RT said she returned to the NF on [DATE] to conduct training check off with the Nursing staff on Trach care that included having same size trach and a smaller one at the bedside including Ambu bags, in case of an emergency and how to maintain an artificial airway. The RT said she had the staff to demonstrate to her on a mannequin when a trach became dislodged, how to insert the trach back by using an obturator to help guide with reinsertion and removing the obturator immediately after inserting the trach so that resident could breathe. The RT said due to the obturator being a plastic solid piece, no air exchange could occur if left in. The RT said it was also important to check the resident lung sounds to see if there was any air exchange after a trach is dislodge. The RT said the difference between the 2 trach brands Shiley and Portex inner canulas was that one was clear, and the other was white but was inter-changeable. The RT said she would have to research what other differences there was between the brands. The RT said if reinsertion was not successful, the resident should be given oxygen. The RT said a new trach with dislodgement could close quickly. Interview on [DATE] at 2:30pm LVN R the oncoming nurse on Station for the evening shift 2p-10p said she would be the nurse for Resident #3. LVN R said if Resident #3's trach became dislodged, she would not know how to reinsert it. Observation was made of Resident #3 having the obturator at the bedside along with other trach supplies. LVN R said she did not know how to use the device. LVN R said the last time she had been trained on trach care was in Nursing School. LVN R said she had been a nurse for a year and started working at the NF on last week. Interview on [DATE] at 2:45pm via phone with the Central Supply Manager said she had never ordered any trach insertion kits for emergency trach dislodgement. The Central supply Manager said she only ordered what was told to her to order by the Respiratory Therapist. The surveyor asked the Administrator on [DATE] at 3:30pm for the NF Policy on Trach Dislodgement. The Administrator said he was told by staff that the surveyor wanted a policy on mucus plugs. Record review of the NF in-services regarding Trach Care that the Administrator submitted to the surveyor did not include Trach dislodgment was on [DATE]. Interview with [DATE] at 12:55pm the Administrator said he spoke with the Regional [NAME] President of Operations and was informed that the NF did not have a policy at present on Trach Dislodgement and how to Maintain Artificial Airway. The Administrator said Central Supply Manager was responsible for ordering all respiratory and tracheostomy supplies. The Administrator said when the RT came to the NF, the RT was responsible for ensuring that all tracheostomy supplies were readily available to care for the residents. The Administrator s [TRUNCATED]

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for two of seven residents (CR #1 and Resident #2) reviewed for administration. The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect for CR #1 and Resident #2. The Administrator failed to ensure the DON carried out her responsibilities in the areas of staff training/monitoring, to provide the appropriate treatment, complete assessment and implement preventive measures to avoid the worsening of pressure sores or the development of new pressure sores. The DON failed to provide staff training/monitoring, to implement measures to provide the appropriate treatment, complete assessment and implement preventive measures to prevent the worsening of pressure sores or avoid the development of new pressure sores. An Immediate Jeopardy (IJ) was identified on 03/01/2017. While the IJ was lowered on 03/02/2017, the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected 1 CR and one resident (Resident #2) at the facility and could place 5 residents identified with pressure ulcers at risk for new pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and pain. Findings include: Intake # 4/TX 402 In an interview on 3/2/2017 at 3:47 p.m. with the Administrator, he stated that facility had IDT meetings every morning and that at that time, the IDT reviews the 24 hour report for any changes in condition. Administrator further said that Wound Care Nurse A was part of the IDT meetings and that she was required to bring her wound care reports. He then said that any changes in condition are shared among the IDT members including changes in condition of wounds. Administrator further said that Wound Care Nurse A did not relay any concerns that CR #1's wound was getting worse. Administrator continued saying that he did not know about CR #1's wound getting worst before he was send out to the hospital. When asked how did he think this incident of IJ came about, the Administrator said It came down due to a lack of communication between the Wound Care Nurse and the IDT. DON did not know about CR #1's wound condition until he was ready to go out to the hospital. Administrator then said that the DON was responsible to review the weekly skin reports, Braden Assessments and skin assessments. In an interview on 3/2/2017 at 4:07 p.m. with the DON, she stated that the staff would communicate changes in condition using the 24 hour book and that the Wound Care Nurse was supposed to write down any information regarding wounds that were not healing in the 24 hours book so the MD would be notified, PT would evaluate for positioning and the rest of the IDT members could be involved as well. DON further said that Wound Care Nurse A did not write any information regarding CR #1's wound deterioration. When asked how did she think this incident of IJ came about, the DON stated There was a failure in the system somewhere, Braden assessments, care plans not completed timely. We are re-training the new Wound Care Nurse, we will go over the entire wound system, assessments and policies. We will include information on communication to the IDT members during the daily meetings so the IDT members can assess the problem and intervene. CR #1 Record review of the medical record face sheet revealed CR #1 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of CR #1's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 11/23/2016 revealed a score of 16 indicating mild risk to develop pressure sores. Further record review revealed no further Branden Scale for Predicting Pressure Sore Risk assessments. Record review of CR # 1's admission MDS assessment with 12/05/2016 ARD revealed that he was cognitively intact with a BIMS score of 12 out of a possible 15. CR #1 required extensive assistance of two staff or more for bed mobility, and he was total dependent of two staff or more for transfers, locomotion on unit and off unit, dressing, toilet use, personal hygiene and bathing. He was total dependent on one person for eating. CR #1 had impairment on both sides of upper and lower extremities. He was always incontinent of bowel and had an indwelling catheter. Further record review revealed that CR #1 was at risk of developing pressure sores and had 1 Stage 3 pressure ulcer that was present upon admission to the facility that measured 4.3 x 3.0 x 0.3 c.m. (LWD). Further record review of the MDS section that read Skin and Ulcer Treatment revealed that CR #1 was not checked to be on a turning/repositioning program. Record review of CR #1's Plan of Care initiated 12/05/2016 revealed in part: -Problem/Need: CR #1 is at risk for skin breakdown related to immobility and physical impairment. -Goal: CR #1's skin will remain intact without evidence of breakdown over the next 90 days. -Interventions: Assist with repositioning as needed, using padding between pressure areas, monitor for skin break down, report to MD and RP, Licensed Nurse to perform weekly skin assessments and document any skin breakdown . Further record review revealed no care plan for CR #1's actual pressure ulcer Stage 3 to sacral region (large triangular bone at the base of the spine) with interventions to promote healing and prevent infection. Record review of CR #1's wound care specialist evaluation dated 1/20/2017 revealed in part; -Stage 3 pressure wound Coccyx (tail bone). Etiology (quality): Pressure Objective: healing -Size: 3.5 x 3.0 x 0.3 c.m. (LxWxD) Surface area: 10.50 square centimeter. -Exudate (drainage): Light serous -Granulation tissue (healing surface): 100% -Wound progress: No change -Assessment and Plan of Care Recommendations: Discontinue collagen dressing. Add medicated honey dressing - once daily and as needed, dry protective dressing - once daily an as needed. Record review of CR #1's physician telephone orders dated 1/20/2017 revealed in part; - Cleanse stage 3 sacral ulcer with normal saline, pat dry. Apply medicated honey gauze to wound bed. Apply [MEDICATION NAME] paste (sealing protective paste) to entire periwound area cover with adhesive dressing daily and as needed if soiled or dislodged . Record review of CR #1's wound care specialist evaluation dated 1/27/2017 revealed in part; -Stage 3 pressure wound Coccyx (tail bone). Etiology (quality): Pressure Objective: healing -Size: 3.4 x 3.0 x 0.2 c.m. (LxWxD) Surface area: 10.20 square centimeter. -Exudate (drainage): Light serous -Thick Adherent devitalized necrotic (dead) tissue: 10% -Granulation tissue (healing surface): 90% -Procedure: Surgical excisional debridement. Indication: Remove necrotic tissue and establish the margins of viable tissue. Description: 15 blade was used to surgically excise 1.02 square centimeter of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2 c.m. -Wound progress: Improved evidenced by decreased surface area. -Assessment and Plan of Care Recommendations: medicated honey dressing - once daily and as needed, dry protective dressing - once daily an as needed. Add: Skin prep - once daily (protective film). Record review of CR #1's wound care specialist evaluation dated 2/03/2017 revealed in part; -Stage 3 pressure wound Coccyx (tail bone). Etiology (quality): Pressure Objective: healing -Size: 3.2 x 3.1 x 0.2 c.m. (LxWxD) Surface area: 9.92 square centimeter. -Exudate (drainage): Light serous -Thick Adherent devitalized necrotic (dead) tissue: 10% -Granulation tissue (healing surface): 90% -Procedure: Surgical excisional debridement. Indication: Remove necrotic tissue and establish the margins of viable tissue. Description: 15 blade was used to surgically excise 0.99 square centimeter of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3 c.m. -Wound progress: Improved evidenced by decreased surface area. -Assessment and Plan of Care Recommendations: medicated honey dressing - once daily and as needed, dry protective dressing - once daily an as needed and skin prep. Coordination of care: This patient's care was discussed with another healthcare provider Director of Nursing, Nursing staff member during this visit. Record review of CR #1's nurses notes revealed in part; -2/6/2017 at 11:00 a.m. signed by Wound Care Nurse A .Sacrococcygeal (relating to both sacrum and coccyx) ulcer presented as deteriorated as evidenced by 25% black necrotic tissues to wound bed, slight malodor (unpleasant smell) noted. MD A notified, RP notified . Further record review of the nurses notes revealed no information of what the MD recommended or interventions placed due to the change in condition of the pressure ulcer. Continued record review revealed that the care plan was not updated with interventions in place to addressed the change in condition of the pressure ulcer. Continued record review of the nurses notes revealed in part; -2/8/2017 at 10:30 a.m. Wound Care Nurse A Sacrococcygeal ulcer continued to deteriorate, increased necrosis, malodor. New orders to discontinue previous treatment orders. New orders received by wound care MD to cleanse ulcer and apply Santyl ([MEDICATION NAME] ointment) and calcium alginate (absorbent dressing derived from seaweed) daily and as needed. CR #1 educated to try to stay completely side to side to prevent pressure. MD A gave orders to allow CR #1 to sit up in chair for only 2 hours, nothing more. CR #1 verbalized understanding. Wedge pillows placed on back to maintain side to side positioning . Record review of CR #1's physician's telephone orders dated 2/8/2017 at 2:15 p.m. revealed in part; -CR #1 to sit up in chair for only 2 hours at a time related to sacral ulcer. -Discontinued previous wound care orders. New orders: Cleanse sacrococcygeal unstageable ulcer, pat dry, Apply Santyl ointment (enzymatic [MEDICATION NAME] ointment) to necrotic tissue. Apply Calcium Alginate to wound bed. Apply marathon skin prep to surrounding tissues. Cover with protective dressing every day. -Physical Therapy to evaluate and treat using MIST (ultrasound) therapy related to sacral ulcer. (low frequency ultrasound delivered through a noncontact saline mist) Record review of CR #1's wound care specialist evaluation dated 2/10/2017 revealed in part; -Stage: Unstageable Necrosis pressure wound Coccyx (tail bone). Etiology (quality): Pressure Objective: healing -Size: 3.7 x 3.6 x Not Measurable c.m. (LxWxD) Surface area: 13.32 square centimeter. -Exudate (drainage): Light serous -Thick Adherent devitalized necrotic (dead) tissue: 80% -Granulation tissue (healing surface): 20% -Wound progress: Deteriorated due to infection. -Procedure: Surgical excisional debridement. Indication: Remove necrotic tissue and establish the margins of viable tissue. Description: 15 blade was used to surgically excise 10.66 square centimeter of devitalized tissue and necrotic muscle and surrounding fascial fibers were removed at a depth of 1.2 c.m. -Investigations: Deep swab technique performed on unstageable due to necrosis coccyx on 2/10/2017. -Assessment and Plan of Care Recommendations: Discontinued: medicated honey dressing - once daily and as needed, dry protective dressing - once daily an as needed and skin prep. Continue: Santyl - once daily and as needed, dry protective dressing - once daily and as needed, Calcium Alginate - Once daily and as needed. Recommendations: Limit sitting to 60 minutes. Additional information: CR #1 has been sitting up for longer periods of time as per nursing staff. Coordination of care: This patient's care was discussed with another healthcare provider Director of Nursing, Nursing staff member during this visit. Record review of CR #1's care plan dated 2/10/2017 revealed in part: -Problem/Need: Alteration in skin integrity: Sacral / coccyx 3.7 x 3.6 unstageable. -Goals: CR #1 will have no sign and symptoms of infection. CR #1 will heal without complications next 90 days. -Approach: Monitor for sign and symptoms of infection, notify physician with any change, protein supplements, dietary consult, provide pressure relieving and positioning devices as needed, low air loss mattress, pressure relieving wheelchair cushion, PT/OT/ST Mist (ultrasound) Therapy by Physical Therapy Record review of CR #1's nurses notes revealed in part; -2/13/2017 at 10:30 a.m. signed by Wound Care Nurse A . Measurements (sacral /coccyx pressure sore) approximately 5.5 c.m. x 4.5 c.m. x unable to assessed due to thick adherent necrosis with areas of depth notable at approximately 1.5 c.m., large serous drainage, [DIAGNOSES REDACTED] and swelling present to periwound radius. Mist therapy provided, DON and wound care nurse discussed benefits of transferring CR #1 for more aggressive wound care. MD A gave orders to send CR #1 to a local hospital to evaluate CR #1 at bedside as soon as possible. RP notified. Will contact local hospital caseworker for evaluation . Record review of CR #1's physician's telephone orders dated 2/13/2017 at 5:00 p.m. revealed in part; -local hospital to evaluate and treat CR #1 related to unstageable sacrococcygeal ulcer, hyperbaric candidate? ( Pertaining to pressure of ambient gases greater than one atmosphere.). -reposition resident every 2 hours from side to side completely, using wedge pillow, away from sacral ulcer Further record review of CR #1's nurses notes revealed in part: -2/14/2017 at 10:30 a.m. signed by Wound Care Nurse A specialty local hospital present for evaluation of CR #1. RP at the bedside. RP and local hospital representative making arrangements to transfer CR #1 for direct admit related to unstageable sacrococcygeal ulcer . Record review of CR #1's physician's telephone orders dated 2/14/2017 at 11:45 a.m. revealed in part; direct admit to specialty hospital related to sacral ulcer. Record review of CR #1's hospital history and physical dated 2/15/2017 revealed in part; admitted : 2/14/2017. [AGE] year old male with past medical history of [REDACTED]. Initially, it was a stage 2 which gradually progressed into stage 3/stage 4 ulcer. The wound is not healing hence was referred to Specialty for wound care. No cultures were done recently on the wound and not had any antibiotics in the recent past also. Assessment Plan: Nonhealing stage 3 sacral decubitus ulcer with probable superadded infection. Culture positive for Escherichia coli (bacteria that lives in the digestive tracts of humans) and Pseudomonas (Gram-negative bacteria). Plan Continued antibiotics per Infectious Disease MD, probably will need a [DEVICE] (negative pressure wound therapy) .[MEDICATION NAME] (intibiotic) 50 ml at 100 mls/hr every 8 hours intravenous Wound: Pressure ulcer Coccyx. 4.5 x 5.5 x 2.5 c.m. (LWD) Unstageable pressure injury obscured full thickness skin and tissue loss . Observation on 2/28/2017 at 1:50 p.m. revealed CR #1 was in a local hospital. He was lying on an air loss mattress on his side. In an interview with the CR #1's RN, she stated that CR #1 was admitted for pressure ulcer infection and that the infection had spread to his bone causing osteo[DIAGNOSES REDACTED]. RN further said that CR #1 was receiving IV antibiotics for wound infection. Further observation and interview at that time revealed CR #1's pressure sore to his coccyx area approx 6 centimeters in diameter and a depth of approx 2.0 c.m. wound base was covered with black slough. Surrounding site was pink. RN stated Pressure sore is pretty deep, the plan is to get rid of all dead tissue and the infection and then place a [DEVICE] next week. In an interview on 2/28/2017 at 2:10 p.m. with CR #1, he stated that he would spent long hours in his chair while he was at the facility and further said I would be up from about 11:30 a.m. until 7 or 8:00 p.m. I would ask them to put me to bed earlier but they would tell me that they were busy. Then when they put you in the bed, the staff was not conscious about turning you on your side. I never refused to be on my side but they would not turn me. My brief was not checked while I was seated in the chair and no staff would reposition me when I was seated on my chair. Many times my buttocks would hurt when I was seated on the chair. In an interview on 2/28/2017 at 3:15 p.m. with the DON, she stated that Wound Care Nurse A left the facility approx 2 weeks ago. DON further said that at that time she could not find CR #1's TAR (treatment Administration Record) for February 2017. Further interview on 2/28/2017 at 3:52 p.m. with the DON, she said while looking at CR #1's nurses notes CR #1's wound started deteriorating on 2/6/2017. When asked what the facility did different for CR #1 when his wound started deteriorating on 2/6/2017, the DON stated I don't remember. Wound Care Nurse called MD A but she did not write what the MD said and I don't see that any orders changed on 2/6/2017. I do remember that Physical Therapy was going to start the MIST therapy but I did not see the wound until 2/13/2017, the day when they started the MIST therapy. Continued interview with the DON, she stated that Braden Scale for Predicting Pressure Sore Risk assessments were supposed to be completed upon admission, then weekly times 4 or when a resident had a change in condition including wound changes of condition. When asked if CR #1 had any further Braden Scale for Predicting Pressure Sore Risk assessments after admission, the DON stated as she flipped over CR #1's chart CR #1 had an assessment for Braden Scale for Predicting Pressure Sore Risk on 11/23/2016 upon admission and I don't see any other assessments. Further interview with the DON on 2/28/2017 at 4:05 p.m., the DON said that when a resident is admitted with a pressure sore, the facility initiated a care plan for actual pressure sore with intervention in place to help heal the pressure sore and that care plan is updated upon any changes of the wound with new interventions in place. When asked about CR #1's initial care plan for his wound, the DON said while looking at CR #1's chart I don't see a care plan for CR #1 when he was admitted . When asked if CR #1's had any care plan updated when his wound started showing necrotic tissue on 1/27/2017 or when CR #1's started showing signs of deterioration on 2/6/2017, the DON said as she flipped thru CR #1's chart I don't see any admission care plan for his pressure sore. His care plan was initiated until 2/10/2017. I don't know why CR #1 did not have a care plan before. DON continued saying that she saw CR #1's wound on 2/13/2017 and that the wound base had slough and had a depth. DON then said that there were conversations about sending CR #1 out to the hospital for the wound care at that time and that CR #1 was a direct admission to a local hospital that the RP choose for wound care the next day. DON further said that she had not talked to the hospital to follow up on CR #1 condition. DON further said at that time that the Wound Care Nurse was responsible to complete the Braden Scale for Predicting Pressure Sore Risk assessments and that the MDS nurse was responsible to complete the care plans. DON then said that she was responsible for monitoring that Braden Scale for Predicting Pressure Sore Risk assessments and the care plans were completed. Attempted a phone interview on 2/28/2017 at 4:15 p.m. with Wound Care Nurse A. She did not return call to surveyor. In a second interview on 2/28/2017 at 4:45 p.m. with the DON, she stated that whenever a wound changed in condition the wound care nurse was supposed to notify the MD, RP and the DON. DON further said that in addition, the Wound Care Nurse was supposed to report the information to the IDT meeting during morning meetings and further said I did not know about the wound getting worse until 2/13/2017 when ADON B called me to his room. It was the day when Physical Therapy started the MIST therapy. I was supposed to know that the wound was deteriorating before. I am speculating that it was a communication failure. I don't remember being aware before 2/13/2017 about CR #1's wound deteriorating condition. When asked if the wound care MD talked to her on 2/10/2017 about CR #1's wound being deteriorated due to infection (Surveyor showed DON wound MD notes for 2/10/2017), the DON said I don't remember that the wound care MD talked to me about CR #1's wound. In an interview on 2/28/2017 at 5:10 p.m. with MDS/LVN C, she stated that MDS nurse was responsible to do a care plan for residents during an annual assessments or significant change of condition. She further said that the wound care nurse was responsible for any care plans pertaining to wounds because the wound care nurse was on the floor with the residents and she would know what interventions to place in order to promote healing on the wounds and that the residents will have different interventions. She then said that wound care plans needed to be individualized and that the MDS nurse did not know how to individualized the care plans because they were not treating the wounds of the residents and then said We do care plans for at risk for wounds but not for the actual wounds, residents who have pressure sores will not have a genetic care plan. In an interview on 3/1/2017 at 8:30 a.m. the DON stated that she was still not able to find CR #1's Treatment Administration Record for February 2017 and that the facility staff had already looked all over the place in the facility including medical records and that they could not locate the records. Further interview on 3/1/2017 at 10:35 a.m. with the DON, when asked how she monitored the wound care nurse, the DON responded Wound care nurse was supposed to submit a weekly skin report with information on each of the wounds of the residents in the facility. When asked if the weekly skin report for 1/27/2017 and 2/3/2017 had any information that CR #1's wound had 10% of necrotic tissue, the DON stated No, should the wound care nurse had communicated to me any changes in condition on CR #1's pressure sore? Yes, I don't know why she did not communicate any decline of CR #1's wound. I learned on 2/13/2017 when ADON B called me to CR #1's room to see his wound. In an interview on 3/1/2017 at 11:20 a.m. with PTA, PT, PT Regional Director and Director of Rehabilitation, the PT said that CR #1 had MIST therapy for his sacral decubitus wound from 12/1/2016 until 12/27/2016 and that the wound had improved. He further said that CR #1 had the evaluation for the MIST therapy on 2/13/2017 and then the next day CR #1 went to the hospital. PT Regional Director then said Therapy was made aware on 2/9/2017 that CR #1 had orders for MIST therapy but therapy was waiting for the wound MD to come on 2/10/2017 to see the wound and approve the treatment, then the wound MD came on 2/10/2017 but it was a Friday and we needed to monitor his skin integrity so we waited until 2/13/2017 (Monday) to evaluate CR #1. CR #1 then went to the hospital on [DATE] because the wound was worsening. PTA then said that compared to how he saw the wound back on December 2016, CR #1's wound on 2/13/2017 was wider and seemed that the wound had an area that was developing necrosis. In an interview on 3/1/2017 at 4:30 p.m. with MD A, he stated that CR #1 had a decubitus ulcer that was getting better and that then got worse. When asked when was he first made aware of CR #1's wound decline, the MD said that he did not remember but whenever he was made aware, he gave orders. When asked if he remembered being made aware on 2/6/2017 about CR #1's wound deteriorating, the MD said as he reviewed CR #1's nurses notes for 2/6/2017 If the Wound Care Nurse would had called me on 2/6/2017 about the wound getting worse, I would have ordered something like to keep him off the wound. Probable the Wound Care Nurse texted me or faxed me and I did not receive the message but if she called me, I would have said to do something. Continued interview and observation with MD A at that time, the MD A flipped thru CR #1's MD orders and as he was reading the orders dated 2/8/2017 and the nurses notes, MD A said If I gave verbal orders on 2/8/2017, that's when they notified me of the wound getting worse. If she (Wound Care Nurse A) would have called me and told me that CR #1's wound was deteriorating on 2/6/2017, I would have said something, ordered something. I don't think she called me on 2/6/2017. MD A further said that he later gave orders to send CR #1 to the hospital. In an interview on 3/2/2017 at 9:30 a.m. DON stated that they had found CR #1's Treatment Administration Record for the month of February 2017. Record review of CR #1's Treatment Administration Record dated February 2017 revealed orders in part; -Cleanse Stage 3 sacral ulcer with normal saline, pat dry, apply medicated honey gauze to wound bed, apply kareya [MEDICAL CONDITION] paste to entire periwound area. Cover with adhesive dressing daily and as needed if soiled or dislodge. Order was discontinued on 2/8/2017. -2/8/2017 Cleanse unstageable sacral ulcer, pat dry, apply Santyl ointment to necrotic tissue. Cover with Calcium Alginate. Apply marathon skin prep to periwound radius, let dry, cover with protective dressing daily and as needed. In an interview on 3/2/2017 at 11:05 a.m. with ADON B, she stated that she had been doing wound care in the facility since 2/27/2017. ADON B further said that Wound Care Nurse A called her to CR #1's room on 2/13/2017 because she wanted her to see the pressure sore because it had declined. ADON B said that when she saw CR #1's sacral wound, it was approx 5 c.m. long, had brown slough in the wound base with some necrotic tissue and that the pressure sore was unstageable. ADON B further said that the wound had a depth but did not know how deep it was because of the slough. ADON B then said that she told the Wound Care Nurse A at that time that CR #1's wound needed to be debrided and that they needed to send CR #1 out of the facility to get help with the wound because as per her experience, the facility couldn't help CR #1 anymore. Further interview on 3/2/2017 at 11:15 a.m. with ADON B, she further said that she attended the morning meetings in the facility and that she did not remember any discussion during the meetings that CR #1's wound had decline and that Wound Care Nurse A was part of the morning meetings. ADON B then said that all changes in condition are written down on the 24 hour book for nurses to communicate any changes in the resident's condition. ADON B continued saying that she did not remember reading on the 24 hour book regarding CR #1's wound deterioration. In an interview on 3/2/2017 at 1:55 p.m. with ADON D, she stated that she was the ADON for the hallway where CR #1 resided. She further said that she remember CR #1 and said that he was quadriplegic and was total care for all his ADL's. ADON D then said that CR #1 came to the facility with a wound to his coccyx and that the plan was for him to get the wound in better condition so he could be transferred to a rehab hospital. ADON D then said that CR #1 was supposed to be only short term in the facility and that he was there mainly for wound care. ADON D further said that she never saw CR #1's pressure sore. Further interview on with ADON D at that time, she stated that she overheard one day the Wound Care Nurse A saying in the office they shared, that CR #1's wound had been debrided by the wound care MD and that since the wound care MD had debrided the wound, the wound had gotten worse. ADON D continued saying when I heard about the worsening of the wound was probably a week before CR #1 went to the hospital but I just overheard her on the phone, Wound Care Nurse A did not really gave any report to me and I never did rounds with her. Wound Care Nurse A told me a day before CR #1 went to the hospital that CR #1 needed to go to a hospital for the wound but before that time, Wound Care Nurse A did not say anything to me. I was under the assumption that the wound was getting better. When asked if she checked for any follow up a week before when she overheard Wound Care Nurse A saying that CR #1's wound had gotten worse, ADON D said No, because she did not communicate with me about the wound. When asked how Wound Care Nurse A communicated with staff any changes in condition of the wounds, ADON D responded I don't think she wrote on the 24 hour report but she would communicate verbally. In an interview on 3/2/2017 at 3:15 p.m. with C.N.A. E, she stated that she worked in the facility Central supply and staffing and that she also helped with residents. C.NA. E further said that she would help CR #1 to eat from time to time and that sometimes she would help putting him on the bed because the facility was short of staff. C.N.A. E then said that CR #1 would ask staff to assist him to the bed and that sometimes she would help with the transfer because CR #1 used a hoyer lift. When asked how staff know about the care of residents, C.N.A. E stated that the facility used an ADL binder with the names of all the residents and any special care they required. Record review on 3/2/2017 at 3:25 p.m. of an undated document with title ADL Daily Assignment Sheet with C.N.A. E revealed that CR #1 had no information that he required to be turn and reposition while in bed or in his chair or any precautions for his Stage 3 pressure ulcer to sacral region (large triangular bone at the base of the spine). In an interview on 3/2/2017 at 3:30 p.m. with C.N.A. F, she stated that she worked with CR #1 during the 2 to 10 p.m. shift and further said that when she would arrive to work, CR #1 was sometimes in the therapy room. She said that CR #1 would eat dinner in the dining room and in his room and then said CR #1 was alert and oriented, he was total care of 2 people for his ADL's. CR #1 would usually go to bed by or before 6:00 p.m. When asked if there were any special precautions for CR #1, C.N.A. F stated that at the nursing station there was a binder with title C.N.A. daily assignment sheet with information related to the care of each of the residents and then said everybody in the building required to be turned and repositioned every 2 hours. In a phone interview on 3/6/2017 at 1:02 p.m. with CR #1's RP, she stated that CR #1 was still in the hospital receiving antibiotics for wound infection and that the hospital had been working on cleaning the wound to place a [DEVICE] to the pressure sore. CR #1's RP further said that she was informed by Wound Care Nurse A on 2/8/2017 that CR #1's pressure sore was getting a little worst but did not give any details and said that at that time Wound Care Nurse A told her not to worry because CR #1 was going to start MIST therapy for his wound by Physical Therapy. When asked if she was made aware on 2/6/2017 that CR #1's wound was deteriorating, CR #1's RP said No, nobody called me on 2/6/2017. I received a call a Wednesday before CR #1 went to the hospital, on 2/8/2017 and Wound Care Nurse A told me that the wound was a little worst but she

Based on observation, interview, and record review the facility failed to ensure that residents with pressure sores received the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for 1 of 5 residents (Resident # 32) reviewed for pressure sores as evidenced by: Resident # 32 was sent to the hospital on [DATE] with an elevated temperature. Upon the hospital's assessment of the wound it was noted to have a foul odor. The resident was readmitted to the facility on [DATE]. Resident # 32's pressure sore was not cleaned correctly on 8/29/12 and a foam dressing was applied instead of a dry dressing. This deficient practice affected one resident and placed 4 additional residents at risk for a decline in wound healing, infection, and the potential of developing new pressure sores. Findings Include: Resident # 32 Record review of Resident #32's face sheet revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. It further revealed he had the following Diagnoses: [REDACTED]. Record review of the 8/7/2012 Pressure/Vascular Wound log revealed Resident # 32 had a Stage IV sacral pressure ulcer that measured 1.0 cm in length, by 0.5 cm in width by 0.8 cm in depth. Record review of Resident # 32's 8/13/2012 nursing notes revealed that the resident had a temperature of 102.1 at 10:35 p.m. and the doctor was notified. At 11:10 p.m. the doctor was notified that the resident requested to go to the hospital. At 11:30 p.m. the resident was transferred to the hospital. Record review of Resident # 32's 8/14/12 Hospital # 1 Consultation read in part: "...Reason for consultation: Evaluation of sacral wound. History: This is a [AGE] year old... who was admitted to the hospital because of fevers, chills and cough. He was diagnosed with [REDACTED]. Currently, he is being seen by (Dr. # 1) at the Nursing Center where he is at. I did note that there is an order for [REDACTED]. The drainage was a brownish murky color and the calcium alginate was wadded and packed in the wound bed. It really was not doing anything and just creating more of a bed for bacteria to grow... I actually had seen him back in 5/2012. Basically, he has had a sacral ulcer for about a year now. Back in 12/2010 he, because of poor mobility, started getting a small wound there... However, when he got to the nursing center it got progressively worse and was getting larger. He had debridement and then a VAC ([DEVICE]) placed. The VAC was on for about six months and did make some benefit but not completely... However, when I saw him in the hospital (5/12) he still had a modest size wound. It was an arrowhead-shaped wound that was about a couple of centimeters up and down and a couple of centimeters wide. It is a little better than I remembered it then but it is not much improved. It is still macerated around the edges, and it is puckered along with it being very close to the bone... Examination of the sacral area shows there is a large-shaped prior wound that is evidenced with scarring. It is puckered but in the center it still remains open and it is approximately 3 cm up and down and about a centimeter or so wide. The skin around it is macerated and wet with a strong odor. The bed itself has very thin tissue before you hit the bone. This is pretty fibrotic and hard and bleeds profusely so the bacterial burden is way up." Record review of Resident # 32's 8/14/2012 wound culture revealed on 8/16/2012 moderate growth mixed colony times usual skin flora, scant growth gram negative rods. The 8/17/2012 wound culture revealed "probable fecal contamination". Record review of Resident # 32's 8/22/2012 admission orders [REDACTED]. Observation and interview of Resident's #32 incontinent care on 8/29/2012 at 11:15 AM revealed he had a new pressure sore on his left buttock approximately 2 inches below the dressed area on his sacrum. The new pressure sore was dime-sized, red in color with a scant amount of serosanguineous drainage ( drainage that consists of serum and blood). CNA H stated she had not seen a breakdown on this area before that day. Resident #32 stated that the wound nurse was aware of this pressure sore. LVN E was observed providing wound care for Resident # 32 on 8/29/2012 at 2:00 p.m. with assistance from CNA A. While cleaning with wound cleaner and drying the wound she went in a back and forth motion then a circular motion from the inside of the wound out going over some of the same areas with the same piece of gauze. She used two 4 in by 4 inches of gauze to clean the wound and two pieces of the same size to dry the wound. She pressed down when cleaning and drying the wound. The wound did not have a dressing prior to the care as the resident had just been given a whirlpool bath. She applied calcium alginate which she folded and packed over the wound. She covered the wound with a foam bordered dressing. Record review of Resident # 32's August 2012 treatment record revealed the following: Cleanse sacral wound with dermal wound cleanser, dry, apply calcium alginate and cover with dry dressing daily. The start date on this order was 8/22/2012. There was no documentation that this had been completed on 8/22/12, 8/24/12, 8/25/12, and 8/27/2012. In an interview with LVN E on 8/29/2012 at 2:00 p.m. she stated she had been doing the wound care for the facility for a month and a half. She said she did rounds with the wound care doctor and she also had training with the corporate nurse. An interview was conducted with Dr, # 1 on 8/30/2012 at 8:10 a.m. He was asked if he was aware of the new open area on Resident # 32 he said yes it was dime sized and probably from friction or shearing when pulled up in bed. He said he was going to apply cream and leave open to air. In an interview with LVN E on 8/30/2012 at 3:35 PM she stated while performing wound care to Resident #32 she did not cleanse the wound in a side to side motion and did not contaminate the wound. She stated after gathering the trash she removed her gloves and placed the trash at her treatment cart in the hall. She stated she then went to wash her hands. An interview was conducted with the DON on 8/31/2012 at 7:25 a.m. She was asked how wounds should be cleaned. She said they should be cleaned from the inside to the outside without overlapping on the same area. She further stated they should be cleaned gently not to disturb the wound bed. When she was asked what could happen if the wound was wiped back and forth over the same area she said it could cause shearing, infection, and disturb the wound bed. She was asked to read Resident # 32's 8/14/2012 wound progress note. She said she had not seen it. When she was asked about the foam dressing if it promoted wound healing she said no, it is mashing down, a breeding ground and could lead to infection and bacterial growth. In an interview with LVN E on 8/31/2012 at 8:10 a.m. she was asked if she considered the sponge she applied to Resident # 32 a dry dressing she said yes she considered it a dry dressing. At that time she was asked to read the 8/14/2012 consult note. She was then asked if foam dressing promoted wound healing, She said no and it was a breeding bacterial infection. She said the resident's wound was okay before he went to the hospital and without odor. Record review of the facility's undated dressing, cleaning policy and procedure read in part: "...15. Don gloves utilizing aseptic (clean) technique. Moisten gauze pad with wound cleanser or normal saline. Clean wound using circular motions starting from the center towards the outside. Repeat two to three times or as necessary. Clean outward to at least 1 inch beyond where the new dressing will be placed. Note: If the Resident has multiple wounds you need to work from clean to dirty... Treatment wrap-up... 26. Wash hands and scissors with antibacterial soap. Dry and wipe scissors again with alcohol. Wash hands again thoroughly and dry. 27. Discard trash or red bag in hazardous waste closet." According to CMS Form 672 there were 5 residents with pressure sores.

Based on observation, interview and record review, the Administrator and DON failed to use facility resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. The administrator and DON also failed to identify the risk for subsequent accidents or injuries to other residents. The Administrator and DON failed to train staff on how to safely transport residents with wheelchairs without foot rests, and failed to perform skill checks. They also failed to ensure that staff was knowledgeable and aware of the risk for additional accidents of the same type following an incident in the facility on [DATE]. Resident #1 was being pushed down the hall by CNA X in a wheelchair when her foot became caught under the wheelchair, and she fell forward, resulting in two fractured femurs, a fractured wrist and a hematoma. The resident was sent to the hospital and died on [DATE]. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of isolated because additional staff had not yet been trained and the facility had not yet had time to evaluate the effectiveness of their training. This failure could potentially place all 48 residents who utilize wheelchairs without foot rests in the facility at risk for injury from unsafe wheelchair transportation by staff members. Findings include: A review was conducted of Resident #1's facility medical record. The face sheet revealed her original date of admission was [DATE] and her date of readmission to the facility was [DATE]. Resident #1 had the following Diagnoses: [REDACTED]. A review was conducted of the "History and Physical" for Resident #1 from Hospital #1 dated [DATE]. This document read in part; (Resident #1) "...is a [AGE] year-old female who was in a wheelchair, and was going down had slipped and fallen forward. The patient developed a hematoma on the face. She was brought in over here where the patient was found to have multiple fractures. ...X-ray shows [MEDICAL CONDITION] left radial and ulnar metaphysis. ...X-ray of the left femur shows a distal femur fracture. X-ray of the right femur shows right non-displaced vertical [MEDICAL CONDITION] femur." A review was conducted of the facility's "Provider Investigation Report", dated [DATE] . This document read in part: " Description of the Allegation - Caregiver was transporting resident to the dining room in her wheelchair when her feet dropped and the resident fell forward onto the floor as stated by the resident, staff and eyewitness ...Assessment - Resident was lying face down with bleeding noted from laceration on left forehead... Resident complained of pain in left hip, left wrist and left side of her head...The resident was then transported to the emergency room for evaluation and treatment. ...Provider Action Taken Post-Investigation - One-on-one counseling was provided for the caregiver involved in the incident and in-service conducted with staff regarding safety when assisting and transporting resident to ensure continued compliance by all staff members." In an interview with the administrator on [DATE] at 2:45 PM, he stated that the in-service which he reported was conducted was only an overview, telling the staff about the incident. When asked if there was any instruction or training provided during the in-service on [DATE] regarding wheelchair transportation and/or safety, he replied "no". An interview was conducted on [DATE] at 9:40 AM with the DON. She stated the facility did not have a policy and procedure for transporting residents in wheelchairs. On [DATE] at 10:30 AM, the administrator was informed that an Immediate Jeopardy situation existed. An interview was conducted on [DATE] at 10:40 AM with the DON. She stated she did not know if foot rests and/or wheelchair transportation was covered in the resident care plans, she said "I'll have to look". Review of sampled resident's care plans revealed no documentation regarding footrests or wheelchair transportation prior to surveyor intervention. An interview was conducted on [DATE] at 1:30 PM with the DON. She stated the facility could not provide any documentation of training on wheelchair transportation and/or safety having been conducted in the past 12 months. When asked if there was any documentation of training on wheelchair transportation/safety provided between the time of the incident and the time state surveyors entered the facility, she replied "no". She stated she did go to both nursing stations and talked to staff the evening of the incident but she did not have a training. She also stated she spoke with CNA X immediately following the incident and the administrator spoke with CNA X later on. An interview was conducted on [DATE] at 1:00 PM with the DON. She stated CNAs received their training on how to transport residents in a wheelchair during CNA school. She also stated the incident was a "freak accident" and that no resident had ever had their feet caught under a wheelchair before. An interview was conducted on [DATE] at 3:30 PM with the DON. She stated the facility had implemented wheelchair transportation/safety as part of their orientation training for new employees. When asked if this training was in place prior the surveyor intervention, she replied "no". An interview was conducted on [DATE] at 2:45 PM with the Administrator. He stated the facility did not have a policy and procedure for resident wheelchair transportation and/or safety. He stated the in-service which he reported was conducted in the "Provider Investigation Report" was only an overview, telling the staff about the incident. When asked if there was any instruction or training provided during the in-service on [DATE] regarding wheelchair transportation and/or safety, he replied "no". He was not able to provide any documentation of any in-service on [DATE]. He stated there was a planned all staff in-service on [DATE] during which he had planned to train the staff on wheelchair transportation/safety. He stated he did talk with CNA X regarding the incident about how to correctly transport a resident in a wheelchair. He also stated no training on safe wheelchair transportation had been provided to staff prior to the incident. An interview was conducted on [DATE] at 1:45 PM with the Regional Nurse. She stated that they were already doing everything they could do and that she didn't know what else they could do to prevent future accidents because she saw no flaw in their current system. She described the accident as a "freak thing" and an "isolated incident". An interview was conducted on [DATE] at 2:55 PM with CNA X. She stated she did not recall receiving any training on wheelchair transportation prior to the incident. She also stated she did not recall any training following the incident. She did remember talking with the administrator after the incident. An interview was conducted on [DATE] at 1:25 PM with Medication Aide W. She stated she had never been instructed to ask residents to raise their feet during wheelchair transport and she also stated she did not recall ever receiving training from the facility regarding safe wheelchair transportation. An interview was conducted on [DATE] at 2:05 PM with LVN V. She stated she had personally not attended any training regarding safe wheelchair transportation and she was not aware of any training which took place. An interview was conducted on [DATE] at 1:05 PM with CNA Q. He stated he did not remember the last time he received training on safe wheelchair transportation. He also stated he did not remember ever being trained at this facility for safe wheelchair transportation. He stated he had worked at the facility for six months. Throughout the investigation from ,[DATE]-,[DATE], observations were made of staff members pushing residents in their wheelchairs. The following plan of removal was submitted by the facility at approximately 5:00 PM on [DATE]. It was accepted at 6:00 PM on [DATE] and included the following: 2. As staff report to duty they are being in-serviced on safe wheelchair transport by Staff Development Coordinator or designee, completed [DATE]. No employee will be allowed to work until they have completed the required in-service. The key points of the safe wheelchair transport in-service include: a) Ensure the resident has the appropriate wheelchair, with or without footrests. g) Ensure the residents feet, rest on the footrests (if applicable). h) When transporting always propel the wheelchair forward, unless navigating a raised or recessed door jam, in which case the chair should be carefully propelled backward over the indentured area. i) Do not rush or speed, scan the area, and always remain safety aware. j) Watch for obstacles on the floor i.e. water, cords, uneven surfaces, etc. k) Remain aware of any need to reposition the resident and afford the resident the opportunity for interval breaks while in transit. l) Refer to therapy for any concerns or recommendations (including proper footwear) o) Only family members or facility staff trained in safe transport will be permitted to transport residents via wheelchair. 3. Department heads will continue to monitor staff knowledge by observation and skill checking for the proper way to transport a resident via wheelchair. Each staff member has signed and received a copy of the in-service indicating participation and understanding, completed [DATE]. 4. Therapy department has re-screened residents for potential wheelchair risk factors. The screening includes all residents currently using wheelchairs to ambulate...The information is documented and care planned, completed [DATE]. 5. Facility staff has been made aware that residents transporting in wheelchairs are at risk for falls. While the IJ was removed on [DATE] at 2:35 PM, the facility remained out of compliance at a scope of Actual harm that is not immediate jeopardy, and a severity level of isolated, because additional staff still needed training and the facility had not had time to evaluate the effectiveness of their training. There were 48 residents who use wheelchairs without footrests according to a list provided by the DON.

Based on interview and record review, the facility failed to ensure that residents who use wheelchairs independently without foot rests received adequate supervision to prevent accidents for one of six sampled residents who used a wheelchair (Resident #1). The facility also failed to identify the risk for subsequent accidents or injuries to other residents. On [DATE] Resident #1 was being pushed down the hall by CNA X in a wheelchair without foot rests when her foot became caught under the wheelchair and she fell forward, resulting in two fractured femurs, a fractured wrist and a hematoma on her forehead. The resident was sent to the hospital and died on [DATE]. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy and a severity level of isolated because additional staff still needed training and the facility had not yet had time to evaluate the effectiveness of their training. This failure could potentially place all 48 residents who utilize wheelchairs without foot rests in the facility at risk of injury from unsafe wheelchair transportation by staff members. Findings include: A review was conducted of Resident #1's facility medical record. The face sheet revealed her original date of admission was [DATE] and her date of readmission to the facility was [DATE]. Resident #1 had the following Diagnoses: [REDACTED]. The MDS dated [DATE] revealed Resident #1 was alert and oriented. The Physical Therapy progress note dated [DATE] revealed Resident #1 was able to ambulate independently in her wheelchair. A review was conducted of the "History and Physical" for Resident #1 from Hospital #1 dated [DATE]. This document read in part; (Resident #1) "...is a [AGE] year-old female who was in a wheelchair, and was going down had slipped and fallen forward. The patient developed a hematoma on the face. She was brought in over here where the patient was found to have multiple fractures. ...X-ray shows fracture of the distal left radial and ulnar metaphysis. ...X-ray of the left femur shows a distal femur fracture. X-ray of the right femur shows right non-displaced vertical fracture of the right femur." A review of Hospital #1's undated, unsigned "Discharge Summary" revealed that "the case was discussed with patient multiple times. The patient as well as her family felt that the patient should not undergo any further risks and wanted to be comfortable and wanted to pursue hospice care. I discussed the case with the cardiologist and it was felt reasonable that the patient should pursue that because despite surgery which was supposed to be only of left leg the patient will be bedbound has a high risk of infection, pneumonia and other problems, probably it would be reasonable that the patient would not live for more than six months considering the current situation so hospice was consulted." A review was conducted of the facility's "Provider Investigation Report", dated [DATE] . This document read in part: " Description of the Allegation - Caregiver was transporting resident to the dining room in her wheelchair when her feet dropped and the resident fell forward onto the floor as stated by the resident, staff and eyewitness. ...Assessment - Resident was lying face down with bleeding noted from laceration on left forehead. Bleeding stopped when pressure was applied and a towel was placed under her head for comfort. Resident complained of pain in left hip, left wrist and left side of her head. DON assessed resident visually by standing and at floor level per interview to assess physical, cognition/mental status. Resident noted to be alert and oriented x 4, bilateral radial pulse determined to be present. ...The resident was then transported to the emergency room for evaluation and treatment. On [DATE] daughter spoke with DON and wanted to know if her mom would be able to return to her same room...On [DATE] daughter notified the facility that (Resident #1) had expired while in the hospital...Provider Action Taken Post-Investigation - One-on-one counseling was provided for the caregiver involved in the incident and in-service conducted with staff regarding safety when assisting and transporting resident to ensure continued compliance by all staff members." In an interview with the administrator on [DATE] at 2:45 PM, he stated that the in-service which he reported was conducted was only an overview, telling the staff about the incident. When asked if there was any instruction or training provided during the in-service on [DATE] regarding wheelchair transportation and/or safety, he replied "no". An interview was conducted on [DATE] at 12:35 PM with CNA X. She stated she did not usually remind residents to pick up their feet when she transported them in a wheelchair. She stated Resident #1 did not have foot rests on her wheelchair. She also stated she did not remind Resident #1 to lift her feet as she was transported in her wheelchair. She said she had provided a written statement at the time of the accident. A review was conducted of the signed written statement from CNA X. This document was dated [DATE] and read; "I, (CNA X) was rolling (Resident #1) down to the dining room and as I was rolling her down her foot got stuck in the wheel of the wheelchair. So I pushed the chair back to get her foot out of the way and that's when she fell flat on the floor." An interview was conducted on [DATE] at 2:55 PM with CNA X. She stated she did not recall receiving any training on wheelchair transportation prior to the incident. She also stated she did not recall any training following the incident. She did remember talking with the administrator after the incident. An interview was conducted on [DATE] at 9:40 AM with the DON. She stated the facility did not have a policy and procedure for transporting residents in wheelchairs. On [DATE] at 10:30 AM, the administrator was informed that an Immediate Jeopardy situation existed. An interview was conducted on [DATE] at 10:40 AM with the DON. She stated she did not know if foot rests and/or wheelchair transportation was covered in the resident care plans, she said "I'll have to look". Review of sampled resident's care plans revealed no documentation regarding footrests or wheelchair transportation prior to surveyor intervention. An interview was conducted on [DATE] at 1:00 PM with the DON. She stated CNAs received their training on how to transport residents in a wheelchair during CNA school. She also stated the incident was a "freak accident" and that no resident had ever had their feet caught under a wheelchair before. An interview was conducted on [DATE] at 1:30 PM with the DON. She stated the facility could not provide any documentation of training on wheelchair transportation and/or safety having been conducted in the past 12 months. When asked if there was any documentation of training on wheelchair transportation/safety provided between the time of the incident and the time state surveyors entered the facility, she replied "no". She stated she did go to both nursing stations and talked to staff the evening of the incident but she did not conduct any training. She also stated she spoke with CNA X immediately following the incident and the administrator spoke with CNA X later on. An interview was conducted on [DATE] at 3:30 PM with the DON. She stated the facility had implemented wheelchair transportation/safety as part of their orientation training for new employees. When asked if this training was in place prior to the surveyor intervention, she replied "no". An interview was conducted on [DATE] at 2:45 PM with the Administrator. He stated the facility did not have a policy and procedure for resident wheelchair transportation and/or safety. He stated there was a planned all staff in-service on [DATE] during which he had planned to train the staff on wheelchair transportation/safety. He stated he did talk with CNA X regarding the incident about how to correctly transport a resident in a wheelchair. He also stated no training on safe wheelchair transportation had been provided to staff prior to the incident. An interview was conducted on [DATE] at 1:45 PM with the Regional Nurse. She stated that they were already doing everything they could do and that she didn't know what else they could do to prevent future accidents because she saw no flaw in their current system. She described the accident as a "freak thing" and an "isolated incident". An interview was conducted on [DATE] at 1:25 PM with Medication Aide W. She stated she had never been instructed to ask residents to raise their feet during wheelchair transport and she also stated she did not recall ever receiving training from the facility regarding safe wheelchair transportation. An interview was conducted on [DATE] at 2:05 PM with LVN V. She stated she had personally not attended any training regarding safe wheelchair transportation and she was not aware of any training which took place. An interview was conducted on [DATE] at 2:35 PM with CNA U. She stated the last time she had training on safe wheelchair transportation was last year. An interview was conducted on [DATE] at 2:35 PM with CNA T. She stated the last time she had training on safe wheelchair transportation was last year. An interview was conducted on [DATE] at 11:55 AM with CNA S. She stated the last time she received training on wheelchair transportation was last year when she was training to be a CNA. An interview was conducted on [DATE] at 12:10 PM with CNA R. He stated the last time he received training on safe wheelchair transportation was "probably sometime last year". An interview was conducted on [DATE] at 1:05 PM with CNA Q. He stated he did not remember the last time he received training on safe wheelchair transportation. He also stated he did not remember ever being trained at this facility for safe wheelchair transportation. He stated he had worked at the facility for six months. The following plan of removal was submitted by the facility at approximately 5:00 PM on [DATE]. It was accepted at 6:00 PM on [DATE] and included the following: 2. As staff report to duty they are being in-serviced on safe wheelchair transport by Staff Development Coordinator or designee, completed [DATE]. No employee will be allowed to work until they have completed the required in-service. The key points of the safe wheelchair transport in-service include: a) Ensure the resident has the appropriate wheelchair, with or without footrests. g) Ensure the residents feet, rest on the footrests (if applicable). h) When transporting always propel the wheelchair forward, unless navigating a raised or recessed door jam, in which case the chair should be carefully propelled backward over the indentured area. i) Do not rush or speed, scan the area, and always remain safety aware. j) Watch for obstacles on the floor i.e. water, cords, uneven surfaces, etc. k) Remain aware of any need to reposition the resident and afford the resident the opportunity for interval breaks while in transit. l) Refer to therapy for any concerns or recommendations (including proper footwear) o) Only family members or facility staff trained in safe transport will be permitted to transport residents via wheelchair. 3. Department heads will continue to monitor staff knowledge by observation and skill checking for the proper way to transport a resident via wheelchair. Each staff member has signed and received a copy of the in-service indicating participation and understanding, completed [DATE]. 4. Therapy department has re-screened residents for potential wheelchair risk factors. The screening includes all residents currently using wheelchairs to ambulate...The information is documented and care planned, completed [DATE]. 5. Facility staff has been made aware that residents transporting in wheelchairs are at risk for falls. While the IJ was removed on [DATE] at 2:35 PM, the facility remained out of compliance at a scope of Actual harm that is not immediate jeopardy, and a severity level of isolated, because additional staff still needed training and the facility had not had time to evaluate the effectiveness of their training. There were 48 residents who use wheelchairs without footrests according to a list provided by the DON.