Every finding on record at Town Hall Estates - Arlington, Inc.

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 1 of 4 residents (Resident #1) reviewed for infection control.CNA A failed to appropriately change gloves, perform hand hygiene, and provide a clean brief while providing incontinence care to Resident #1 on 06/24/26.This failure could place residents at risk for cross-contamination. Findings included:Record review of Resident #1's comprehensive MDS assessment, dated 04/08/26, reflected a [AGE] year-old female, who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a diagnosis which included hypertension (high blood pressure). The resident's cognition was moderately impaired with a BIMS score of 11, and she was always incontinent for bowel and bladder.Record review of Resident #1's Care Plan, dated 01/12 /26, reflected Resident #1 was incontinent of bowel and bladder. The care plan reflected: Goal: No occurrence of skin breakdown will occur over the next 90 days . intervention: Monitor for incontinence every 2 hours and as needed, change promptly-cleanse and apply a protective skin barrier to skin During an observation on 06/24/26 at 10:39 AM, CNA A entered Resident #1's room to provide the resident with incontinence care. After explaining the procedure to Resident #1, she washed her hands, put on two pairs of gloves, and put supplies together. CNA A then unfastened the resident's brief. She wiped the resident's abdominal folds and perineal area (area between the genitals and anus). She then positioned Resident #1 on her side and wiped the resident's buttocks and thighs. Resident #1's had a bowel movement (feces). While wearing the same gloves, CNA A picked up a clean brief from the floor and placed it on Resident #1 and applied zinc oxide (barrier cream) with the same gloves. She then removed one pair of gloves and fastened the brief. She removed her gloves, washed hands, left Resident #1's comfortable, bed low and call light within reach and left the room. During an interview on 06/24/26 at 10:57 AM, CNA A revealed she forgot to change gloves and perform hand hygiene when she provided care to Resident #1. CNA A stated she was expected to change gloves and wash hands, between care if her gloves were soiled, but she forgot. She also said she was not supposed to put on two pairs of gloves while providing care and she was not supposed to pick up a brief from the floor and put it on Resident #1. CNA A said she was supposed to complete hand hygiene, change soiled gloves, and provide a clean brief during incontinence care to prevent cross contamination. She stated failure to change gloves, when soiled, wash her hands, and provide a clean brief, could lead to cross contamination and infection. During an interview on 06/24/26 at 02:37 PM, ADON B revealed she expected staff to change gloves during incontinence care, when soiled, and not to wear two pairs of gloves. The ADON stated CNA A was supposed to change soiled gloves, complete hand hygiene, and use a clean brief, while providing Resident #1 with incontinence care to prevent cross contamination and infection. ADON B stated the nursing staff were offered in-service training on hand hygiene/infection control, but she could not recall when. Copies of training were provided.During an interview on 06/24/26 at 02:51 PM, the DON revealed she expected staff to complete hand hygiene before, during, and after incontinence care. She said CNA A was supposed to change gloves to perform hand hygiene during care since Resident #1 had a bowel movement, and when moving from dirty to clean. She said she was not supposed to pick a brief from the floor and put it on a resident. She stated she could have picked a clean one. She said staff were expected to change soiled gloves and perform hand hygiene to prevent the spread of infection. The DON stated the nursing staff were offered an in-service training on hand hygiene/infection.Record review of the facility training's on 06/24/26 revealed proper incontinent care procedure training dated 01/30/26 and CNA A was not in attendance.Record review of the facility's Hand washing/Hand Hygiene policy, dated August 2025, reflected: .6.Wash Hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:a. When hands are visibly soiled.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .h. Before moving from a contaminated body site to a clean body site during resident care.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents. The facility failed to provide Resident #1, who had dementia, with adequate supervision to prevent her from eloping from the facility on 11/03/25. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 11/03/25 and ended on 11/03/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of harm, severe injury, and possible death. Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 09/04/25, reflected she was an [AGE] year-old female who was admitted on [DATE]. She had a BIMS score of 08, indicating moderate cognitive impairment. Her MDS did not indicate she had any wandering behaviors. Her active diagnoses included Non-Alzheimer's Dementia (loss of cognitive functioning that interferes with daily life and activities) and Schizophrenia (a serious mental health condition that affects how people think, feel, and behave). Record review of Resident #1's Care Plan, revised on 11/04/25, reflected the following: Focus: Resident has Episodes of Unwanted Behaviors As Evidenced By: [sic] Walked away from the Facility [sic] without telling anyone.Interventions: Encourage to attend social activities of preference.Focus: Risk for Wandering/Elopement Identified.Interventions: Engage Resident in purposeful activity, Schedule time for regular walks/appropriate activity. Record review of Resident #1's Wandering Risk Assessment, dated 07/03/24, reflected she scored a 5 which was at moderate risk for wandering. Record review of Resident #1's Elopement Evaluation, dated 11/04/25, reflected the following: she had a history of elopement, had a history of elopement or attempted to leave the facility without informing staff, and she wandered. It also noted she went out of the facility today, ambulated with a walker. State; she was going to the store [sic]. Record review of Resident #1's Progress Notes reflected the following:- 11/03/25 at 5:06 PM, the SW wrote: Social Worker was notified that resident was observed outside of facility boundaries walking down the street after her routine time sitting outside for fresh air. This is the first known incident of wandering for this resident. Upon approach, resident reported that she was 'going down the street to the hospital for an injection.' Resident was calm and cooperative as staff escorted her safely back into the facility. Social Worker completed a Brief Interview for Mental Status (BIMS) assessment;resident [sic] scored 10/15, indicating moderate cognitive impairment. While being escorted back inside, resident stated, 'Please don't send me to live somewhere else because of this,' suggesting that she has some awareness and insight regardingthe [sic] incident and potential consequences. Social Worker provided re-education to resident on the importance of notifying staff when desiring to go for a walk or leave the facility area so that staff can provide appropriate supervision and support to ensure her safety. Resident verbalized understanding and agreement with this plan. Attempted to contact [Resident #1's RP] to inform of incident; no answer, voicemail message left requesting return call. No adverse psychosocial or physical effects noted as a result of this incident. Social Services will continue to monitor and provide support as needed. - 11/03/25 at 9:30 PM, LVN A wrote: Resident tries to leave the facility when she was let out by staff to sit outside for a bit as per resident's request. Resident was brought back to the facility without any concern noted or voice. [sic] This writer asked resident where she was going, resident states ' I [sic] was going to get something from the store' This [sic] writer called RP. no [sic] response. Resident is sitting at the nursing station at this time. Will continue to monitor. - 11/04/25 at 6:06 AM, LVN B wrote: Resident monitored this shift q 15min continues slept most of the shift no any concerns voiced wctm [sic] - 11/04/25 at 12:52 PM, the SW wrote: SW met with resident to follow up regarding the wandering incident noted on 11/3/25. Resident was observed to be doing well, pleasant, and cooperative during the visit. No adverse psychosocial issues or changes in behavior were noted or reported at this time. Resident denied feelings of anxiety or distress. SW will continue to monitor and provide support as needed.- 11/05/25 at 2:59 PM, the SW wrote: SW completed a second follow-up visit with resident to provide ongoing support and assess for any arising needs related to the prior wandering incident. Resident remained calm, oriented, and engaged appropriately during the interaction. No new behavioral concerns or psychosocial issues were identified. Resident reported feeling comfortable and well-adjusted in the current environment. SW offered continued emotional support and reminded resident to seek staff assistance if feeling restless or disoriented. SW will continue routine monitoring and support. Record review of a Provider Investigation Report, dated 11/04/25, reflected the following: Description of the Allegation: Resident #1 was found walking with her walker on the sidewalk away from the Facility. She was brought back by Facility staff. No adverse incident or injuries noted on the resident. States: 'she [sic] was walking towards the hospital and the store. Resident alert and oriented at that time. [sic].Provider Response: Resident is alert/oriented with bouts of confusion. Is able to relate the incident on how she walked with a walker on the sidewalk. She usually stays at the front of the entrance door and does not attempt to walk away. At that time, she decided to walk through the sidewalk attempting to go to the hospital and the store which was close by. She said she would never cross the street, so she decided to walk back.Investigation Summary: Alert/ oriented [sic] resident with a diagnosis of unspecified dementia, walked through the sidewalk with her walker away from the Facility premises without notifying anyone. Resident was last seen 15 minutes before she was reported seen by the sidewalk close to the [local pharmacy]. Resident is able to relate the circumstances that led her to reach where she was. She is independently ambulatory with a walker and she knows what she wants and where to go. She wanted to go to the store to get something. Asked [sic] what she wanted from the store, and she said she needed some stuff. Investigation Findings: Confirmed. Provider Action Taken Post-Investigation: Resident was assessed for any injuries. none noted. Resident was instructed not to leave the Facility [sic] unless someone is with her. Resident was supervised closely by the staff for any further attempt to leave. Staff was educated on Elopement [sic] risk and making sure residents are supervised closely. MD and family were notified. Left a message to [Resident #1's RP]. Awaiting call back. Referral to Psych initiated. Resident on the caseload for Psych Services. Record review of a witness statement, dated 11/04/25, and signed by the ADON reflected the following: [The previous admission Director] called the facility to report that [Resident #1] was observed walking on the sidewalk toward [a road nearby the facility]. The Director of Rehab and I, the ADON, went to meet the resident and the [previous admission Director] in front of [local pharmacy]. The resident stated that she was going to the hospital and the store. We safely returned to the facility with the resident without incident. The Director of Nursing (D.O.N.) was made aware. The nurse on duty attempted to notify the family; no one answered, and a voicemail message was left. Observation and interview on 11/20/25 at 11:55 AM with Resident #1 revealed she was sitting in the dining room at one of the tables. Resident #1 was dressed and had her walker to the side of her. Resident #1 appeared to be upset because she was fidgeting and had a scowl on her face. Resident #1 said she was doing okay on the outside but not on the inside. Resident #1 said she remembered leaving the facility a few weeks ago because she had tried to find her son, then she said she had actually tried to find her house. Resident #1 seemed confused and kept going in and out of the two stories of why she left the facility. Resident #1 ultimately said she was upset and did not want to be at the facility. Interview on 11/20/25 at 12:06 PM, Resident #1's RP stated she was told Resident #1 usually sat in the front area of the facility and while the staff were not looking, she wandered off and went to the local pharmacy down the street on 11/03/25. Resident #1's RP said Resident #1 told her she had tried to buy some make up but she did not have enough money so she went back to the facility to get some more. Resident #1's RP said Resident #1 was no longer allowed to sit outside in the front area anymore, but she had never tried to leave the facility before this incident. Resident #1's RP said she feared something like this would happen to Resident #1 but the staff assured her that Resident #1 was always watched by them while she was outside in the front area. Resident #1's RP said her main concern was that Resident #1 had mental illness and what she thought was not reality and she could have been hurt leaving the facility. Resident #1's RP said thankfully Resident #1 was not injured from the 11/03/25 incident. Interview on 11/20/25 at 12:26 PM, RA B stated Resident #1 wanted freedom to come and go from the facility as she wished. RA B said Resident #1 periodically sat outside in the front of the building. RA B said since the elopement on 11/03/25, Resident #1 was not allowed in the front by herself, staff have to be with her at all times now. RA B said Resident #1 never talked about leaving the facility or attempted to leave the facility through the exit doors prior to the elopement on 11/03/25. RA B said there was always a receptionist at the front who kept an eye on Resident #1 while she sat outside in the front area. RA B said she was in-serviced and knew the facility's policy and procedures for elopements and wandering residents. RA B said she knew to look for the residents both inside and outside the facility if they were noted to be missing. RA B said she knew to call the Administrator and DON to report the missing resident immediately. RA B said she knew to report to the nurse when a resident wandered around or was exit seeking. RA B said she knew to redirect a resident if they were wandering or exit seeking and to keep a close eye on them to make sure they did not leave. Interview on 11/20/25 at 12:36 PM, LVN C stated she was in-serviced and knew the facility's policy and procedures for elopements and wandering residents. LVN C said she knew to look for the residents both inside and outside the facility if they were noted missing. LVN C said she knew to call the Administrator and DON to report the missing resident immediately. LVN C said she knew to redirect a resident if they were wandering or exit seeking and to keep a close eye on them to make sure they did not leave and possibly place on 1:1 monitoring too. LVN C said while she did not care for Resident #1, she knew she was an elopement risk. Interview on 11/20/25 at 12:52 PM, LVN D stated she cared for Resident #1 and knew she was an elopement risk. LVN D said she had to monitor Resident #1 after the elopement incident on 11/03/25. LVN D said Resident #1 never talked about wanting to leave the facility or attempted to exit seek that she was aware of. LVN D said Resident #1 was not allowed to go outside by herself in the front, she had to have a staff member with her at all times. LVN D said she was in-serviced and knew the facility's policy and procedures for elopements and wandering residents. LVN D said she knew to look for the residents both inside and outside the facility if they were noted missing. LVN D said she knew to call the Administrator and DON to report the missing resident immediately. LVN D said she knew to redirect a resident if they were wandering or exit seeking and to keep a close eye on them to make sure they did not leave and possibly place on 1:1 monitoring too. Interview on 11/20/25 at 12:56 PM, CNA E stated Resident #1 was an elopement risk. CNA E said she was in-serviced and knew the facility's policy and procedures for elopements and wandering residents. CNA E said she knew to look for the residents both inside and outside the facility if they were noted missing. CNA E said she knew to call the Administrator and DON to report the missing resident immediately. CNA E said she knew to report to the nurse when a resident began to wander around or was exit seeking. CNA E said she knew to redirect a resident if they were wandering or exit seeking and to keep a close eye on them to make sure they did not leave. Interview on 11/20/25 at 1:09 PM, the DOR stated she walked to the front of the building and the ADON said Resident #1 was down the street by the crosswalk. The DOR said she had a wheelchair available so she grabbed it and a gait belt and walked down the street with the ADON to Resident #1. The DOR said Resident #1 was able to walk back using her own walker until about three quarters of the way when she accepted being wheeled back by staff. The DOR said when Resident #1 was brought back into the facility, the nursing department evaluated her and then took her to eat dinner in the dining room. The DOR said she could not see any injuries to Resident #1. Interview on 11/20/25 at 1:11 PM, the ADON stated the previous Admissions Director called to tell her Resident #1 was on the sidewalk down the street from the facility around 4:30/5:00 PM on 11/03/25. The ADON said she ran from her office and told a few other people what happened, including the DOR, who grabbed a wheelchair and went with her. The ADON said they found Resident #1 down the street and she was uninjured. Interview on 11/20/25 at 1:34 PM, CNA F stated she did not care for Resident #1 but knew she was an elopement risk. CNA F said she was in-serviced and knew the facility's policy and procedures for elopements and wandering residents. CNA F said she knew to look for the residents both inside and outside the facility if they were noted to be missing. CNA F said she knew to call the Administrator and DON to report the missing resident immediately. CNA F said she knew to report to the nurse when a resident began to wander around or was exit seeking. CNA F said she knew to redirect a resident if they were wandering or exit seeking and to keep a close eye on them to make sure they did not leave. Interview on 11/20/25 at 2:08 PM, the previous Admissions Director stated he left the facility for the day and was driving down the street on 11/03/25 when he saw Resident #1 walking down the sidewalk away from the building. The previous Admissions Director said he pulled into the local pharmacy's parking lot and got out of his vehicle to talk to Resident #1 and asked her to wait with him. The previous Admissions Director said he called the ADON to let her know about Resident #1's location and after a few minutes both the ADON and the DOR met with them. The previous Admissions Director said the ADON and the DOR brought a wheelchair with them and took Resident #1 back to the building. The previous Admissions Director said he did not see any injuries on Resident #1. The previous Admissions Director said he asked Resident #1 why she left the facility and he was told two different stories: one was that she wanted to go buy a house by the hospital and the other was about wanting to go to the hospital for a procedure. Interview on 11/20/25 at 1:42 PM, the Receptionist stated she was at the facility the morning of 11/03/25 when Resident #1 eloped. The Receptionist said she left around 12:30 PM and asked Resident #1 to come inside since no one was going to be able to watch. The Receptionist said typically, Resident #1 sat in the front of the building outside and she could see her from where she sat inside. The Receptionist said before 11/03/25 Resident #1 had never tried to leave the building. The Receptionist said since 11/03/25, Resident #1 was no longer allowed to sit outside the building and had to have a staff member with her if that was what she wanted to do. Follow-up interview on 11/20/25 at 1:53 PM, the ADON stated since Resident #1 had never eloped before 11/03/25, she was not considered an elopement risk. The ADON said Resident #1 would make a comment saying she was waiting for her family member to pick her up but she would never act or say she wanted to leave. The ADON said it was normal for Resident #1 to sit in the front of the building outside because she enjoyed the sunshine. The ADON said the Receptionist would keep an eye on Resident #1 while she was outside to make sure she was safe. The ADON said Resident #1 was confused at times. The ADON said Resident #1 was no longer allowed to be outside without a staff member present with her after the elopement on 11/03/25. The ADON said, after the incident, staff were in-serviced regarding the facility's policy and procedures for elopements and wandering residents. The ADON said staff knew to look for the residents both inside and outside the facility if they were noted to be missing. The ADON said staff knew to call the Administrator and DON to report the missing resident immediately. The ADON said staff knew to redirect a resident if they were wandering or exit seeking and to keep a close eye on them to make sure they did not leave and possibly put them on 1:1 monitoring too. The ADON said staff had been informed that Resident #1 was an elopement risk now and to redirect her if she attempted to go outside without staff. Interview on 11/20/25 at 2:25 PM, LVN A stated she did not know Resident #1 was an elopement risk because the 11/03/25 elopement was her first time eloping. LVN A said she saw Resident #1 sit in front of the building often because she liked the sun. LVN A said Resident #1 never talked about wanting to leave or attempted to leave the facility. LVN A said Resident #1 was no longer allowed to go outside the facility without staff with her after she eloped on 11/03/25. LVN A said she was in-serviced and knew the facility's policy and procedures for elopements and wandering residents. LVN A said she knew to look for the residents both inside and outside the facility if they were noted to be missing. LVN A said she knew to call the Administrator and DON to report the missing resident immediately. LVN A said she knew to redirect a resident if they were wandering or exit seeking and to keep a close eye on them to make sure they did not leave and possibly put them on 1:1 monitoring too. Interview on 11/20/25 at 2:37 PM, the DON stated Resident #1 usually sat in the front of the building by herself. The DON said on 11/03/25 the ADON got a call from the previous Admissions Director who said Resident #1 was on the sidewalk down the street from the facility. The DON said she saw the DOR and ADON brought Resident #1 back to the building and she was not injured. The DON said the Receptionist was supposed to be watching her but she had left for the day. The DON said Resident #1 normally did not leave the area she sat at in the front of the building, but sometimes the resident was alert and sometimes she was not. The DON said afterwards, she asked Resident #1 why she left and she told her she just went walking. The DON said staff were in-serviced regarding the facility's policy on elopements and Resident #1 was monitored every 15 minutes for the next three days to make sure she was in the building and safe. The DON said Resident #1 could no longer go outside to the front area without staff with her at all times. The DON said staff redirect Resident #1 away from the front doors when they see her going near them. The DON said the purpose of making sure residents do not elope was to prevent injury or accidents. The DON said if a resident eloped from the facility they could go missing or have injuries from an accident. The DON said all staff were responsible for making sure residents did not elope from the facility. The DON said all staff had been trained and understood the expectation to keep all residents within eyesight and to check their whereabouts often. The DON said Resident #1 was the only resident in the facility who had been identified as an elopement risk and no other residents had eloped prior to or after the incident on 11/03/25. Record review of the facility's policy titled Elopement In-service reflected: Purpose: To educate staff on the prevention, identification, and appropriate response to resident elopement to ensure resident safety and compliance with facility policies. Definition of Elopement: Elopement occurs when a resident leaves the facility or a safe area without authorization and without necessary supervision, potentially placing themselves at risk for harm. Key Points: Conduct elopement risk assessments upon admission and as needed. Monitor exit doors and alarms for proper function. Observe residents who exhibit wandering, restlessness, or confusion. The facility implemented the following corrective actions following the incident: Record review of Resident #1's 15 Minute Monitoring Sheets, dated 11/03/25 to 11/05/25, reflected the resident was monitored every 15 minutes by staff to ensure she was safe and in the building. Record review of the Incident/Accident report from the last three months reflected Resident #1 was the only resident to elope from the facility. Record review of an in-service, dated 11/03/25 and 11/04/25, reflected staff were provided with in-service training regarding the facility's policy and procedures regarding elopements.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of five residents (Resident #49) reviewed for pressure ulcers.The facility staff failed to notify the Wound Care Physician of Resident #49's Stage 2 pressure ulcer on his coccyx upon admission. Resident #49 was not provided with wound care treatment from 06/02/25 - 06/25/25 which resulted in resident's pressure ulcer worsening from a Stage 2 to a Stage 4. An IJ was identified on 07/02/25. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems.These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, decreased quality of life, and hospitalization.Findings included: Record review of Resident #49's admission MDS assessment, dated 06/09/25 and signed off as completed by the DON on 06/15/25, reflected the resident was a [AGE] year-old male, who admitted to the facility from the hospital on [DATE]. The resident's active diagnoses included malnutrition, pneumonia, respiratory failure, anxiety disorder, essential hypertension (high blood pressure), and generalized muscle weakness. Resident #49 had moderate cognitive impairment with a BIMS score of 11. The resident required supervision or touching assistance with eating, and he had an admission weight of 128 pounds. The resident required substantial/maximal assistance with toileting hygiene, and he was frequently incontinent of bowel and bladder. The MDS further reflected the resident admitted to the facility with one Stage 2 pressure ulcer, and he was supposed to have pressure ulcer/injury care and a pressure reducing device for bed. Record review of Resident #49's Clinical Admission Initial Assessment, dated 06/02/25, completed by RN L reflected Resident #49 admitted to the facility with a Stage 2 pressure ulcer that measured 3.0 cm x 5.0 cm x 0.0 cm. Record review of Resident #49's Progress Notes written by LVN K, dated 06/02/25 at 9:50 PM, reflected the following: Skin: Skin warm & dry, skin color WNL and turgor (skin's elasticity) is normal. Skin Issue: #001: New skin Issue. Location: Coccyx (the final segment of the vertebral column). Laterality / Orientation: Medial (closer to the midline of the body). Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Painful: No. Staged by: In-house nursing. Length (cm): 3 Width (cm): 5 Depth (cm): 0. Record review of Resident #49's Progress notes from 06/02/25 through 06/24/25 by LVN K, RN L, LVN M, RN Z, and LVN AA reflected they all used the same note in all their entries regarding Resident #49's pressure ulcer: Skin: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Staged by: In-house nursing.There was no documentation in Resident #49's Progress Notes reflecting the Physician, Nurse Practitioner, or the Wound Care Physician had been made aware of Resident #49's pressure ulcer. There was also no documentation in the Progress Notes reflecting Resident #49 was receiving wound care nor was there documentation reflecting the resident was on a low air loss mattress. Record review of Resident #49's Nurse Practitioner Visit Notes dated 06/05/25 reflected the resident had a diagnosis of protein calorie malnutrition prior to his admission the facility in the hospital on [DATE]. Regarding the resident's skin, the Nurse Practitioner documented: .Physical Examination.Skin: No visible skin lesions or rashes noted in exposed BUE or BLE. There was no documentation in the Nurse Practitioner's notes reflecting the resident's pressure ulcer was observed nor was there an order for care/treatment of the pressure ulcer.Record review of Resident #49's Care Plan, initiated on 06/09/25, reflected Resident #49 was at risk for weight loss as evidenced by being a new admission and consuming less than 25% of meals with a poor appetite. Care Plans, initiated on 06/21/25, reflected: Resident #49 was at risk for skin breakdown; the resident had ADL deficits to include bed mobility, transfers, eating, toilet use, dressing, personal hygiene, and bathing; and the resident was incontinent of bowel and bladder. Record review of Resident #49's Initial Wound Evaluation & Management Summary dated 06/25/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Record review of Resident #49's Physician's Orders dated 06/25/25 reflected the following orders were initiated to treat Resident #49's pressure ulcer as follows: Zinc Oral Tablet 50 MG (Zinc) Give 1 tablet by mouth in the evening for wound care for 2 Weeks until wound heals - Start date 06/25/25 Wound treatment plan to the sacrum: clean with NS or wound cleanser, pat dry, apply sodium hypochlorite gel (anasept), collagen powder, cover with gauze island w/bdr once daily, every day shift for wound care. - Start Date 06/26/2025 Beneprotein Oral Powder (Protein) Give 7 gram by mouth two times a day for wound care for 90 Days - Start date 06/26/2025. Resident #49 had no medication or treatment orders for his wound from 06/02/25 - 06/25/25. Record review of Resident #49's June 2025 MAR/TAR reflected wound care medication started on 06/25/25 and wound care treatment started on 06/26/25. There was no documentation of wound care treatment provided to Resident #49 from 06/02/25 - 06/25/25. The June 2025 TAR also reflected the resident was placed on a low air loss mattress starting on 06/27/25 to address wound healing for the pressure ulcer. Record review of Resident #49's care plan, revised on 06/27/25, reflected: Focus: Resident has current Skin Concerns: Pressure Ulcer on sacral area. Goal: Areas will heal without complications over the next 90 days. Interventions: Assess skin weekly and record findings in clinical record. Perform treatments per order, if no improvement x 2 weeks-report to MD. Provide pressure relieving and positioning devices as needed. Care Plan revised on 07/01/25, reflected: Focus: Resident has a Pressure Area: Stage: 4 (characterized by full-thickness tissue loss, exposing muscle, tendon, or bone) Location: SACRUM (large, triangular bone at the base of the spine that forms the back wall of the pelvis.) TX: Sodium hypochlorite gel (anasept) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Goal: Resident will have improved skin integrity as evidenced by a decrease in size and depth of pressure area during the next 90 days. Interventions: Keep family/responsible party and MD informed of resident's progress. Monitor labs and report abnormals to MD. Record review of Resident #49's Wound Evaluation & Management Summary dated 07/02/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Observation and interview on 07/02/25 at 8:51 AM revealed Resident #49 in bed and awake. Observed Resident #49 to be on a pressure relieving mattress. Resident #49 stated he had been at facility for about 2-3 weeks. Resident #49 stated he had a pressure sore on his bottom. He stated he was not sure if he admitted with the wound or if it developed at the facility. Resident #49 stated he had been seen by the wound care doctor twice since being admitted . Resident #49 stated he was seen by the wound care doctor last week unknown of exact date and today (07/02/25). He stated prior to being seen by the wound care doctor he was not receiving any treatment for his wound. Resident #49 stated he never refused any treatment. Resident #49 stated he had pain but was getting pain medication. Interview by phone on 07/02/25 at 10:51 AM, LVN K revealed Resident #49 admitted to her hall. She stated when Resident #49 admitted to the facility she completed a skin assessment and noted a wound on his bottom. She stated the facility's process of when a resident admitted to the facility was the admitting nurse was responsible for completing the skin assessment and if the resident admitted with a wound the admitting nurse must notify the ADON and the ADON would notify the Wound Care Physician. LVN K stated the Wound Care Physician visits=ed twice a week, and Resident #49 had been seen by the Wound Care Physician, unknown date. She stated she was not sure if Resident #49's treatment was completed during the morning shift or afternoon shift. She stated she could not recall if she provided any treatments during her shift. She stated she could not recall if treatment orders were obtained for his wound upon admission or if the physician was notified. Interview by phone on 07/02/25 at 10:57 AM, RN L revealed she only worked at the facility during the weekends. RN L stated she could not recall admitting Resident #49 and could not recall any wounds or what wound care Resident #49 required. Interview on 07/02/25 at 11:01 AM ADON A/Wound Care Coordinator revealed the process of when a resident admitted to the facility, the admitting nurse must complete a head-to-toe assessment. If wounds were present upon admission, the admitting nurse must complete a communication form, put it in her box and she was responsible for contacting the Wound Care Physician. ADON A stated the nurses were responsible for completing wound care treatments for residents. She stated she was responsible for contacting the Wound Care Physician and completing rounds when the Wound Care Physician visited every Wednesday. She stated every Wednesday before the Wound Care Physician visited, she completed rounds and would ask all the nurses if they had any admitting residents with wounds. She stated Resident #49 admitted to the facility with a wound on his sacrum. ADON A reviewed Resident #49's clinical records and stated Resident #49 was first seen by the Wound Care Physician on 06/25/25 and received treatment orders the same day. ADON A stated based on documentation it did not seem Resident #49 received any wound care treatment. ADON A stated there was a gap from the time Resident #49 admitted until he was seen on 06/25/25 by the Wound Care Physician. ADON A stated Resident #49 admitted to the facility on [DATE] which was a Monday, and the Wound Care Physician would have visited Wednesday, and the reason Resident #49 was not seen was because Resident #49 did not show up in the Wound Care Physician's computer system, and the nurses were told to continue standing treatment orders. ADON A stated if nurses were not able to obtain attending physician's orders for wound care the facility had in-house standing treatment order dry dressing and should be uploaded in the resident's chart. ADON A reviewed Resident #49's discontinued orders and stated in-house standing treatment orders were not put in the system. ADON A stated she was not sure if Resident #49 received any treatment prior to being seen by the Wound Care Physician. She stated she visited Resident #49, but did not document her visit. She stated she would monitor her nurses when the nurses would ask her for wound care supplies, then she would complete a supply count and the count wound be accurate. ADON A stated when nurses would ask her for wound care supply, she would not question the nurses who the supplies were used for. ADON A stated she never obtained a communication form from the admitting nurse who admitted Resident #49, and she did not follow up because she was not aware of the wound. ADON A stated nurses should not measure the wounds and should not stage the wounds because the measurements could be wrong. ADON A stated she was not aware RN L staged and measured Resident #49's pressure wound. She stated the Wound Care Physician was notified of Resident #49's pressure wound. However, she could not recall the exact date, but it was a day or two before Resident #49 was seen by the Wound Care Physician on 06/25/25. Interview on 07/02/25 at 12:35 PM, LVN M revealed she was on leave when Resident #49 admitted to the facility, and she had returned to work on 06/09/25 morning shift. She stated she could not recall the exact date, but it was the week when Resident #49 was seen by the Wound Care Physician on 06/25/25 when she was notified of the pressure wound. She stated CNA J notified her of the wound on Resident #49's sacrum area. When CNA J was providing Resident #49 incontinent care, Resident #49 dressing came off and CNA J needed her to put a new dressing on. She stated she was not aware of the pressure wound. She stated she cleaned it and put a new dressing on. She stated when she cleaned the wound it did not appeared infected, no drainage was noted and had no odor to it. She stated she immediately went and notified ADON A. She stated there should had been orders in the system but there were no treatment orders in the resident's clinical chart when she reviewed it. She stated the facility had standing treatment orders, but she could not recall if any orders were put in the system. LVN M stated she did not put any orders in the system when she cleaned the wound. She stated if it was not documented it did not happen and it was her mistake for not putting the standing treatment orders in the system. She stated the process of when a new resident admitted to the facility the admitting nurse should complete skin assessment, notify the ADON A, obtain orders and put them in the system. LVN M stated prior to CNA J notifying her of the wound, she was never told or received any report from any staff regarding the wound. She stated she never provided any wound care to Resident #49 during her shift until the day CNA J asked her to put a new dressing on. She stated she completed a skin check on Resident #49 and had not noticed the wound; however, Resident #49 would refuse to be checked. She stated it was her mistake for not documenting the refusal. She stated the potential risk of not providing wound care treatment would be infections. She stated it was not good quality of care. Interview on 07/02/25 at 1:27 PM, CNA J revealed she could not recall the exact date, but she was providing Resident #49 incontinent care when his wound dressing had come off. She stated prior to proving the incontinent care Resident #49 had the dressing on his sacrum. She stated when the dressing came off, she notified LVN M and LVN M cleaned the wound and put a new dressing on him. She stated that was the first time she was assigned to Resident #49. She stated she was not aware of the wound until she provided incontinent care. Interview on 07/02/25 at 1:39 PM, ADON B revealed she was working when Resident #49 admitted to the facility. She stated Resident #49 admitted to the facility with a wound on his sacrum and nursing staff were using the standing orders to clean and cover the wound until he was seen by the Wound Care Physician. ADON B stated the admitting nurse was responsible for putting in standing orders in the system and completing a communication form to request wound care for residents to the ADON A. She stated the admitting nurse failed to communicate to ADON A to put Resident #49 on the list to be seen by the Wound Care Physician. ADON B stated LVN M had just resumed her job duty from being on leave and was completing skin assessments on residents when she noticed Resident #49's wound. She stated LVN Y was the nurse assigned to Resident #49 before LVN M returned to work. She stated LVN Y was providing wound care treatment to Resident #49, but it was unknown if it was documented. She stated if the ADON A was not notified of Resident #49's pressure wound then the Wound Care Physician was not notified. She stated the potential risk of not providing any wound care treatment would be infection. Interview on 07/02/25 at 2:00 PM, the DON revealed her expectation for when a resident admitted to the facility was the admitting nurse should complete a skin assessment. If a resident admitted with a wound, the admitting nurse should obtain treatment orders either form the doctor, hospital records or the in-house standing orders and should be put in the system. She stated the nurses should also complete a communication form and provide it to ADON A, and ADON A would place the resident's name on the list to be seen by the Wound Care Physician. The DON stated when Resident #49 was being provided with incontinent care, the resident had a dressing on the sacrum, and it fell off. She stated the nurse put a new dressing on and reported the wound to ADON A. The DON stated the admitting nurse for Resident #49 had not communicated Resident #49 had a wound. She stated she was not aware Resident #49's wound was staged and measured upon admission. She stated wound care treatment was provided to Resident #49; the nurses were using the standing orders, but the standing orders were not put in the system. She stated she was not aware there was no documentation in Resident #49's clinical chart. The DON stated she expected her nurses to put physician orders in the resident clinical chart/system. The DON stated Resident #49's wound was getting better and had no signs of infection. She stated her staff failed to put treatment orders in the system and failed to communicate to ADON A. She stated the Wound Care Physician was not notified until the ADON A was notified of the wound. She stated the potential risk would be infection. Interview on 07/02/25 at 2:06 PM with CNA N revealed she was the CNA assigned to Resident #49 when he was on the 100 Hall. She stated every time she would provide incontinent care to Resident #49, he had a dressing on his bottom. She stated Resident #49 admitted to the facility with a wound. CNA N stated during the morning shift, LVN M would change the wound dressing on Resident #49. She stated Resident #49 always had a dressing on his wound. She stated the nursing staff were aware of Resident #49's sacrum wound. An attempt was made on 07//02/25 at 2:33 PM to interview LVN Y by phone but was unsuccessful. Interview by phone on 07/02/25 at 3:00 PM, the Wound Care Physician stated if a resident admitted with a wound, he expected the Attending Physician or Nurse Practitioner to see the resident and write initial wound care orders, and to add him as an attending. If the resident had hospital orders that included wound orders, staff could follow those orders. ADON A would text him with a new resident's information prior to his next visit. He did not give any standing orders for wound care due to the liability, but he would allow ADON A to start treatment because he had worked with her for many years. He stated he was not aware of Resident #49's wound until he saw him on 6/25/25. He stated all wounds were considered colonized with a bacterium of some form, but that did not mean it was infected. If the wound was not healing, then it would be considered infected. Resident #49's wound was healing so he did not consider it to be infected. Interview on 07/02/25 at 3:13 PM, the Nurse Practitioner revealed she was not made aware of Resident #49's pressure wound when she visited the resident on 06/10/25. She stated she visited Resident #49 and completed an assessment, but she did not inspect the resident's back because she was not aware of the wound. She stated since she was not made aware of the wound no treatment orders were provided. She stated she could not recall the exact date, but she was notified by the DON that Resident #49's wound had worsened and that the Wound Care Physician had been notified and provided treatment orders. She stated when a resident admits to the facility with a wound her expectations were to be notified and for nurses to obtain orders. She stated if a resident had not been seen by the Wound Care Physician or the nurses were not able to get ahold of the Wound Care Physician, the ADON normally would notify her, and she would provide treatment orders. Interview on 07/02/25 at 3:51 PM, the Administrator revealed wound care questions were more of a clinical nursing aspect, but his expectations were for the nurses to assess the wound and notify the Wound Care Physician. The Administrator expected nursing staff to follow treatment orders and to document any care that the resident was being provided with. Record review of facility policy Significant Change in Resident's Status undated reflected the following: It is the policy of this organization that this facility immediate inform the resident, consult with the resident physician, and if knows notifies the resident's legal representative or an interested family when there is: . C. Need to alter treatment significantly (this is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. 4. Deterioration in a resident's health status, where this change: places the resident's life in danger. is associated with a serious clinical complication, e.g., initial development of stage III or stage IV pressure ulcer. When any of the above occurs the attending physician, the resident and/or responsible party and/or legal representative and/or interested family member is notified. Document is made in the Nurses Notes and the Resident Assessment Instrument, and the Comprehensive Care Plan is updated to reflect the changes This was determined to be an Immediate Jeopardy (IJ) on 07/02/25 at 4:02 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 07/02/25 at 4:10 PM. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/02/25 at 6:32 PM and reflected the following: Date of IJ Determination: 07/02/2025 Immediate Corrective Actions Taken Physician Notification for Identified Resident As of 07/02/2025, the resident identified in the IJ was immediately assessed by the Director of Nursing. The resident's attending physician and the Wound care Physician were immediately consulted, and updated treatment orders were obtained to address the resident's wound and overall plan of care. Chart Review for Timely Physician Notification A comprehensive audit of all admissions and current residents with significant changes in physical status was completed on 07/02/2025 to ensure physician notification occurred as required. Any instances lacking documented physician notification were immediately corrected by contacting the respective physician and updating the medical records. Immediate Staff Education On 07/02/2025, all licensed nurses received in-service training on: - Recognizing and defining significant changes in resident condition. - The requirements for immediate physician consultation upon identification of significant changes. - Accurate and timely documentation of physician notifications and resulting orders. Staff sign-in sheets and education materials are maintained for verification. Process Changes A Physician Notification Protocol has been implemented requiring nurses to notify the physician within 1 hour of identifying a significant change in a resident's condition, including the development or worsening of pressure ulcers. A physician notification from was created to document: -The date and time change identification. -The date and time of physician notification. -Physician response and orders. admission protocols were updated to require physician notification within 24 hours for all residents admitted with pressure ulcers or other significant health conditions. Ongoing Monitoring The Director of Nursing or designee will conduct daily audits of residents with significant changes in condition to confirm timely physician notification and documentation. Weekly audits of 10% of resident charts will be performed for 3 months to ensure compliance with the physician notification protocol. Quality Assurance and Oversight Physician notification compliance will be a standing agenda item at the facility monthly Quality Assurance Performance Improvement (QAPI) meeting for at least 3 months. Audit results and corrective actions will be reviewed by the Administrator and Medical Director. How the Plan Removes the Immediate Jeopardy Immediate assessment and physician consultation for the identified resident ensures appropriate and timely medical oversight, mitigating current risk. Staff education and protocol changes ensure future prompt physician notification for any significant changes, reducing the risk of delayed treatment. Ongoing audits and oversight confirm sustained complaint, preventing recurrence of the issue and ensuring resident rights are protected. Date IJ was Corrected: We believed the Immediate Jeopardy was removed on 07/02/2025, the date corrective actions were implemented. Ensuring Staff Not Present Received Training All nursing staff who are not present on 07/02/2025 for the in-services training will receive a make-up in-service by the Staff Development Nurse within 5 calendar days of returning to work, and before providing direct resident care. Completing will be tracked on a staff education log. Implementation Date for Physician Notification Protocol: The updated Physician Notification Protocol was implemented on 07/02/2025, the same day as the initial corrective actions. Title of Staff Conducting Audit and In-Service: The Director of Nursing (DON) conducted the comprehensive char audit for physician notifications. The Staff Development Nurse (SDN) provided the in-service training on physician notification requirements. Electronic In-Service Distribution and Acknowledgement: Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. In-Service: Recognizing Significant Changes & Physician Notification Objective: Train nursing staff to recognize significant changes in resident condition, promptly notify the physician, and properly document the process to ensure timely treatment and protect resident rights. Agenda: Defining Significant Change - Examples: new/worsening wounds, sudden mental status changes, falls with injury, acute infections, uncontrolled pain. Timeframes for Physician Notification - Immediate vs. urgent vs. routine notification standards - Facility policy on notifying the physician within 1 hour of significant changes. Documentation of Notification - How to complete the physician notification form. - Documenting date/time of change, date/time of call, physician response. Communication Best Practices - SBAR (Situation, Background, Assessment, Recommendation) approach when calling providers. - Tips for effective and concise communication Policy & Procedure Review - Physician notification protocol - Review of facility admission protocols requiring physician notification. Q&A Session Materials: Physician notification form Updated physician notification policy Competency Validation: Staff sign-in sheet Charting exercise: completing a sample physician notification form Electronic In-Service Distribution and Acknowledgement: Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. Monitoring of the facility's Plan of Removal included the following: Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Skin Issues on Admission. Protocol: Do a thorough assessment. 1) Document. Initially nurses are not to measure unless you're a wound care certified nurse. 2) Make sure there is a treatment ordered. (Hospital order, standing order or MD/NP order) Fill up a communication form and submit it to the Wound Care Nurse (ADON) for Dr. (Name) (Wound MD) to look at on his next visit. Document everything! Do Skin assessments every week! Notification of MD for worsening wounds if it's not documented it's not done!! Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Accurate and timely wound assessment and documentation. The requirement for immediate physician notification for wounds at admission or with signs of worsening. Proper initiation for treatment orders for wounds. Staff sign-in sheets and education materials are maintained for verification. Record review of the facility QAPI meeting revealed the facility medical director was notified by the director of nurses of the immediate jeopardy via phone while in attendance with the facility administrator on 07/02/25. Record review of the facility admission Wound Assessment Checklist form reflected on 07/02/2025 the form included the name of the resident, date of admission, wound treatment, MD Notified, notes. Record review of the facility Weekly Audit tool blank form revealed it included the date, resident, treatment, and documentation in PCC. Record review of the facility Communication Form revealed it must include information pertaining the resident, new admission/readmission, indicate which department it applied to and to include message/comments. Record review of the facility Physician notification Form undated, reflected staff should provide the date and time change identification, the date and time of physician notification and Physician response and orders. Record review of the Facility SBAR (Situation, Background, Assessment, Recommendation) reflected staff should document when a change of condition occurred and when the provider was notified. Record review of Resident #49's progress noted dated 07/02/25 by the DON reflected Pressure wound on sacrum assess with wound MD. Stage 4 full thickness. Wound size (LxWxD) 4.0x3.5x0.8 cm Surface area = 14, exudate - Moderate serous (clear fluid drainage from a wound). Wound has improved since last visit as evidence by decrease surface area. No signs of infection noted. Treatment review with physician. No changes made at this time. Resident remains on air mattress. No c/o pain but instructed to call the nurse if he has pain. PRN pain medication ordered. Dietician made aware of the nutritional consult for the resident. Staff instructed to turn and reposition resident Q 2 hours. Call light within reach. Record review of Skin Assessments revealed they were completed on 07/02/25 for all 73 residents. The assessments indicated any skin concerns and the location of the skin concerns. Record review of a facility in-service training report for facility nurses across all shifts dated 07/03/25 reflected the following: On wound assessment on admission, the Admitting Nurse is required to document the following: 1. Wound measurements. 2) Notification of the physician w/in 24 Hrs. of identification. 3) Initiation of wound treatment per

Based on observation, interview, and record review, the facility failed to ensure there were physician orders for a resident's immediate care at the time the resident was admitted for 1 of 5 (Resident #49) reviewed for admission orders.The facility failed to obtain physician orders for Resident #49's immediate care when he admitted to the facility on [DATE] with a Stage 2 pressure ulcer on his coccyx, which resulted in the resident not receiving physician-ordered wound treatment from 06/02/25-06/24/25 and the Stage 2 pressure ulcer worsening to a Stage 4. An IJ was identified on 07/02/25. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems.The failure placed residents at risk for medical complications, wound deterioration, infection, and death. Record review of Resident #49's admission MDS assessment, dated 06/09/25 and signed off as completed by the DON on 06/15/25, reflected the resident was a [AGE] year-old male, who admitted to the facility from the hospital on [DATE]. The resident's active diagnoses included malnutrition, pneumonia, respiratory failure, anxiety disorder, essential hypertension (high blood pressure), and generalized muscle weakness. Resident #49 had moderate cognitive impairment with a BIMS score of 11. The resident required supervision or touching assistance with eating, and he had an admission weight of 128 pounds. The resident required substantial/maximal assistance with toileting hygiene, and he was frequently incontinent of bowel and bladder. The MDS further reflected the resident admitted to the facility with one Stage 2 pressure ulcer, and he was supposed to have pressure ulcer/injury care and a pressure reducing device for bed.Record review of Resident #49's Clinical Admission Initial Assessment, dated 06/02/25, completed by RN L reflected the following questions were answered: .24. Skin Issue - Pressure ulcer/Injury27. Pressure ulcer staging - Stage 2 Pressure Ulcer/Injury: Partial thickness skin loss with exposed dermis[BR5] [LO6] (the skin)35. Acquired - Present on admission36. Onset - Unknown46. Presence of wound pain - No53. Staged by: In-house nursing59. Length (cm) - 360. Width (cm) - 561. Depth (cm) - 0 Record review of Resident #49's Progress notes on 06/02/25 21:50 by LVN K reflected the following Skin: Skin warm & dry, skin color WNL and turgor (skin's elasticity) is normal. Skin Issue: #001: New skin Issue. Location: Coccyx (the final segment of the vertebral column). Laterality / Orientation: Medial (closer to the midline of the body). Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Painful: No. Staged by: In-house nursing. Length (cm): 3 Width (cm): 5 Depth (cm): 0#002: New skin Issue. Location: Left antecubital space (the triangular area on the inner side of the left elbow). Additional location information: Bruises Issue type: Bruising (contusion). Wound was present on admission. It is unknown how long the wound has been present.#003: New skin Issue. Location: Right anterior (nearer the front) elbow. Laterality / Orientation: Right. Additional location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. Record review of Resident #49's Progress notes from 06/02/25 through 06/24/25 by LVN K, RN L, LVN M, RN Z, and LVN AA reflected the following notes: Skin: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Staged by: In-house nursing. #002: Skin issue has not been evaluated. Location: Left antecubital space. Additional location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. #003: Skin issue has not been evaluated. Location: Right anterior elbow. Laterality / Orientation: Right. Additional location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. There was no documentation of Wound Care Physician, Nurse Practitioners were made aware of Resident #49's pressure wound. No documentation of any wound care provided to Resident #49.Record review of Resident #49's Nurse Practitioner Visit Notes dated 06/10/25 reflected: Chief complaint - Skilled care visit - Nurse reports abnormal lab results and request to review lab.Review of systems: Skin - neg for rash Objective: Physical Examination: Skin: Warm and Dry. There was no documentation in the Nurse Practitioner's notes reflecting the resident's pressure ulcer was observed. Record review of Resident #49's Initial Wound Evaluation & Management Summary dated 06/25/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Record review of Resident #49's Physician's orders dated 06/25/25 reflected the following orders: Zinc Oral Tablet 50 MG (Zinc) Give 1 tablet by mouth in the evening for wound care for 2 Weeks until wound heals - Start date 06/25/25Wound treatment plan to the sacrum: clean with NS or wound cleanser, pat dry, apply sodium hypochlorite gel (anasept), collagen powder, cover with gauze island w/bdr once daily, every day shift for wound care. - Start Date 06/26/2025Beneprotein Oral Powder (Protein) Give 7 gram by mouth two times a day for WOUND CARE for 90 Days - Start date 06/26/2025. Resident #49 had no medication or treatment orders for his wound from 06/02/25 - 06/25/25. Record review of Resident #49's June 2025 MAR/TAR reflected wound care medication started on 06/25/25 and wound care treatment started on 06/26/25. There was no documentation of wound care treatment provided to Resident #49 from 06/02/25 - 06/25/25.Record review of Resident #49's care plan, revised on 06/27/25, reflected Focus: Resident has current Skin Concerns: Pressure Ulcer on sacral area. Goal: Areas will heal without complications over the next 90 days. Interventions: Assess skin weekly and record findings in clinical record. Perform treatments per order, if no improvement x 2 weeks-report to MD. Provide pressure relieving and positioning devices as needed. Care Plan revised on 07/01/25, reflected: Focus: Resident has a Pressure Area: Stage: 4 (characterized by full-thickness tissue loss, exposing muscle, tendon, or bone) Location: SACRUM (large, triangular bone at the base of the spine that forms the back wall of the pelvis.) TX: Sodium hypochlorite gel (anasept) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Goal: Resident will have improved skin integrity as evidenced by a decrease in size and depth of pressure area during the next 90 days. Interventions: Keep family/responsible party and MD informed of resident's progress. Monitor labs and report abnormals to MD. Record review of Resident #49's Wound Evaluation & Management Summary dated 07/02/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Observation and interview on 07/02/25 at 8:51 AM revealed Resident #49 in bed and awake. Observed Resident #49 to be on a pressure relieving mattress. Resident #49 stated he had been at facility for about 2-3 weeks. Resident #49 stated he had a pressure sore on his bottom. He stated he was not sure if he admitted with the wound or if it developed at the facility. Resident #49 stated he had been seen by the wound care doctor twice since being admitted . Resident #49 stated he was seen by the wound care doctor last week unknown of exact date and today (07/02/25). He stated prior to being seen by the wound care doctor he was not receiving any treatment for his wound. Resident #49 stated he never refused any treatment. Resident #49 stated he had pain but was getting pain medication. Interview by phone on 07/02/25 at 10:51 AM, LVN K revealed Resident #49 admitted to her hall. She stated when Resident #49 admitted to the facility she completed a skin assessment and noted a wound on his bottom. She stated the facility's process of when a resident admitted to the facility was the admitting nurse was responsible for completing the skin assessment and if the resident admitted with a wound the admitting nurse must notify the ADON and the ADON would notify the Wound Care Physician. LVN K stated the Wound Care Physician visits=ed twice a week, and Resident #49 had been seen by the Wound Care Physician, unknown date. She stated she was not sure if Resident #49's treatment was completed during the morning shift or afternoon shift. She stated she could not recall if she provided any treatments during her shift. She stated she could not recall if treatment orders were obtained for his wound upon admission or if the physician was notified. Interview by phone on 07/02/25 at 10:57 AM, RN L revealed she only worked at the facility during the weekends. RN L stated she could not recall admitting Resident #49 and could not recall any wounds or what wound care Resident #49 required. Interview on 07/02/25 at 11:01 AM ADON A/Wound Care Coordinator revealed the process of when a resident admitted to the facility, the admitting nurse must complete a head-to-toe assessment. If wounds were present upon admission, the admitting nurse must complete a communication form, put it in her box and she was responsible for contacting the Wound Care Physician. ADON A stated the nurses were responsible for completing wound care treatments for residents. She stated she was responsible for contacting the Wound Care Physician and completing rounds when the Wound Care Physician visited every Wednesday. She stated every Wednesday before the Wound Care Physician visited, she completed rounds and would ask all the nurses if they had any admitting residents with wounds. She stated Resident #49 admitted to the facility with a wound on his sacrum. ADON A reviewed Resident #49's clinical records and stated Resident #49 was first seen by the Wound Care Physician on 06/25/25 and received treatment orders the same day. ADON A stated based on documentation it did not seem Resident #49 received any wound care treatment. ADON A stated there was a gap from the time Resident #49 admitted until he was seen on 06/25/25 by the Wound Care Physician. ADON A stated Resident #49 admitted to the facility on [DATE] which was a Monday, and the Wound Care Physician would have visited Wednesday, and the reason Resident #49 was not seen was because Resident #49 did not show up in the Wound Care Physician's computer system, and the nurses were told to continue standing treatment orders. ADON A stated if nurses were not able to obtain attending physician's orders for wound care the facility had in-house standing treatment order dry dressing and should be uploaded in the resident's chart. ADON A reviewed Resident #49's discontinued orders and stated in-house standing treatment orders were not put in the system. ADON A stated she was not sure if Resident #49 received any treatment prior to being seen by the Wound Care Physician. She stated she visited Resident #49, but did not document her visit. She stated she would monitor her nurses when the nurses would ask her for wound care supplies, then she would complete a supply count and the count wound be accurate. ADON A stated when nurses would ask her for wound care supply, she would not question the nurses who the supplies were used for. ADON A stated she never obtained a communication form from the admitting nurse who admitted Resident #49, and she did not follow up because she was not aware of the wound. ADON A stated nurses should not measure the wounds and should not stage the wounds because the measurements could be wrong. ADON A stated she was not aware RN L staged and measured Resident #49's pressure wound. She stated the Wound Care Physician was notified of Resident #49's pressure wound. However, she could not recall the exact date, but it was a day or two before Resident #49 was seen by the Wound Care Physician on 06/25/25.Interview on 07/02/25 at 12:35 PM, LVN M revealed she was on leave when Resident #49 admitted to the facility, and she had returned to work on 06/09/25 morning shift. She stated she could not recall the exact date, but it was the week when Resident #49 was seen by the Wound Care Physician on 06/25/25 when she was notified of the pressure wound. She stated CNA J notified her of the wound on Resident #49's sacrum area. When CNA J was providing Resident #49 incontinent care, Resident #49 dressing came off and CNA J needed her to put a new dressing on. She stated she was not aware of the pressure wound. She stated she cleaned it and put a new dressing on. She stated when she cleaned the wound it did not appeared infected, no drainage was noted and had no odor to it. She stated she immediately went and notified ADON A. She stated there should had been orders in the system but there were no treatment orders in the resident's clinical chart when she reviewed it. She stated the facility had standing treatment orders, but she could not recall if any orders were put in the system. LVN M stated she did not put any orders in the system when she cleaned the wound. She stated if it was not documented it did not happen and it was her mistake for not putting the standing treatment orders in the system. She stated the process of when a new resident admitted to the facility the admitting nurse should complete skin assessment, notify the ADON A, obtain orders and put them in the system. LVN M stated prior to CNA J notifying her of the wound, she was never told or received any report from any staff regarding the wound. She stated she never provided any wound care to Resident #49 during her shift until the day CNA J asked her to put a new dressing on. She stated she completed a skin check on Resident #49 and had not noticed the wound; however, Resident #49 would refuse to be checked. She stated it was her mistake for not documenting the refusal. She stated the potential risk of not providing wound care treatment would be infections. She stated it was not good quality of care. Interview on 07/02/25 at 1:27 PM, CNA J revealed she could not recall the exact date, but she was providing Resident #49 incontinent care when his wound dressing had come off. She stated prior to proving the incontinent care Resident #49 had the dressing on his sacrum. She stated when the dressing came off, she notified LVN M and LVN M cleaned the wound and put a new dressing on him. She stated that was the first time she was assigned to Resident #49. She stated she was not aware of the wound until she provided incontinent care. Interview on 07/02/25 at 1:39 PM, ADON B revealed she was working when Resident #49 admitted to the facility. She stated Resident #49 admitted to the facility with a wound on his sacrum and nursing staff were using the standing orders to clean and cover the wound until he was seen by the Wound Care Physician. ADON B stated the admitting nurse was responsible for putting in standing orders in the system and completing a communication form to request wound care for residents to the ADON A. She stated the admitting nurse failed to communicate to ADON A to put Resident #49 on the list to be seen by the Wound Care Physician. ADON B stated LVN M had just resumed her job duty from being on leave and was completing skin assessments on residents when she noticed Resident #49's wound. She stated LVN Y was the nurse assigned to Resident #49 before LVN M returned to work. She stated LVN Y was providing wound care treatment to Resident #49, but it was unknown if it was documented. She stated if the ADON A was not notified of Resident #49's pressure wound then the Wound Care Physician was not notified. She stated the potential risk of not providing any wound care treatment would be infection. Interview on 07/02/25 at 2:00 PM, the DON revealed her expectation for when a resident admitted to the facility was the admitting nurse should complete a skin assessment. If a resident admitted with a wound, the admitting nurse should obtain treatment orders either form the doctor, hospital records or the in-house standing orders and should be put in the system. She stated the nurses should also complete a communication form and provide it to ADON A, and ADON A would place the resident's name on the list to be seen by the Wound Care Physician. The DON stated when Resident #49 was being provided with incontinent care, the resident had a dressing on the sacrum, and it fell off. She stated the nurse put a new dressing on and reported the wound to ADON A. The DON stated the admitting nurse for Resident #49 had not communicated Resident #49 had a wound. She stated she was not aware Resident #49's wound was staged and measured upon admission. She stated wound care treatment was provided to Resident #49; the nurses were using the standing orders, but the standing orders were not put in the system. She stated she was not aware there was no documentation in Resident #49's clinical chart. The DON stated she expected her nurses to put physician orders in the resident clinical chart/system. The DON stated Resident #49's wound was getting better and had no signs of infection. She stated her staff failed to put treatment orders in the system and failed to communicate to ADON A. She stated the Wound Care Physician was not notified until the ADON A was notified of the wound. She stated the potential risk would be infection. Interview on 07/02/25 at 2:06 PM with CNA N revealed she was the CNA assigned to Resident #49 when he was on the 100 Hall. She stated every time she would provide incontinent care to Resident #49, he had a dressing on his bottom. She stated Resident #49 admitted to the facility with a wound. CNA N stated during the morning shift, LVN M would change the wound dressing on Resident #49. She stated Resident #49 always had a dressing on his wound. She stated the nursing staff were aware of Resident #49's sacrum wound. An attempt was made on 07//02/25 at 2:33 PM to interview LVN Y by phone but was unsuccessful. Interview by phone on 07/02/25 at 3:00 PM, the Wound Care Physician stated if a resident admitted with a wound, he expected the Attending Physician or Nurse Practitioner to see the resident and write initial wound care orders, and to add him as an attending. If the resident had hospital orders that included wound orders, staff could follow those orders. ADON A would text him with a new resident's information prior to his next visit. He did not give any standing orders for wound care due to the liability, but he would allow ADON A to start treatment because he had worked with her for many years. He stated he was not aware of Resident #49's wound until he saw him on 6/25/25. He stated all wounds were considered colonized with a bacterium of some form, but that did not mean it was infected. If the wound was not healing, then it would be considered infected. Resident #49's wound was healing so he did not consider it to be infected. Interview on 07/02/25 at 3:13 PM, the Nurse Practitioner revealed she was not made aware of Resident #49's pressure wound when she visited the resident on 06/10/25. She stated she visited Resident #49 and completed an assessment, but she did not inspect the resident's back because she was not aware of the wound. She stated since she was not made aware of the wound no treatment orders were provided. She stated she could not recall the exact date, but she was notified by the DON that Resident #49's wound had worsened and that the Wound Care Physician had been notified and provided treatment orders. She stated when a resident admits to the facility with a wound her expectations were to be notified and for nurses to obtain orders. She stated if a resident had not been seen by the Wound Care Physician or the nurses were not able to get ahold of the Wound Care Physician, the ADON normally would notify her, and she would provide treatment orders. Interview on 07/02/25 at 3:51 PM, the Administrator revealed wound care questions were more of a clinical nursing aspect, but his expectations were for the nurses to assess the wound and notify the Wound Care Physician. The Administrator expected nursing staff to follow treatment orders and to document any care that the resident was being provided with. Record review of facility policy Significant Change in Resident's Status undated reflected the following: It is the policy of this organization that this facility immediate inform the resident, consult with the resident physician, and if knows notifies the resident's legal representative or an interested family when there is: .C. Need to alter treatment significantly (this is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.4. Deterioration in a resident's health status, where this change: places the resident's life in danger. is associated with a serious clinical complication, e.g., initial development of stage III or stage IV pressure ulcer.When any of the above occurs the attending physician, the resident and/or responsible party and/or legal representative and/or interested family member is notified. Document is made in the Nurses Notes and the Resident Assessment Instrument, and the Comprehensive Care Plan is updated to reflect the changes This was determined to be an Immediate Threat (IT) on 07/02/25 at 4:02 PM. The Administrator and DON were notified. The Administrator was provided with the IT template on 07/02/25 at 4:10 PM. The Facility's Plan of Removal for Immediate Threat was accepted on 07/02/25 at 6:32 PM and reflected the following: Date of IJ Determination: 07/02/2025 Immediate Corrective Actions Taken Physician Notification for Identified ResidentAs of 07/02/2025, the resident identified in the IJ was immediately assessed by the Director of Nursing. The resident's attending physician and the Wound care Physician were immediately consulted, and updated treatment orders were obtained to address the resident's wound and overall plan of care. Chart Review for Timely Physician NotificationA comprehensive audit of all admissions and current residents with significant changes in physical status was completed on 07/02/2025 to ensure physician notification occurred as required. Any instances lacking documented physician notification were immediately corrected by contacting the respective physician and updating the medical records.Immediate Staff EducationOn 07/02/2025, all licensed nurses received in-service training on:- Recognizing and defining significant changes in resident condition.- The requirements for immediate physician consultation upon identification of significant changes.- Accurate and timely documentation of physician notifications and resulting orders.Staff sign-in sheets and education materials are maintained for verification. Process ChangesA Physician Notification Protocol has been implemented requiring nurses to notify the physician within 1 hour of identifying a significant change in a resident's condition, including the development or worsening of pressure ulcers.A physician notification from was created to document:-The date and time change identification.-The date and time of physician notification.-Physician response and orders.admission protocols were updated to require physician notification within 24 hours for all residents admitted with pressure ulcers or other significant health conditions. Ongoing MonitoringThe Director of Nursing or designee will conduct daily audits of residents with significant changes in condition to confirm timely physician notification and documentation.Weekly audits of 10% of resident charts will be performed for 3 months to ensure compliance with the physician notification protocol. Quality Assurance and OversightPhysician notification compliance will be a standing agenda item at the facility monthly Quality Assurance Performance Improvement (QAPI) meeting for at least 3 months. Audit results and corrective actions will be reviewed by the Administrator and Medical Director. How the Plan Removes the Immediate JeopardyImmediate assessment and physician consultation for the identified resident ensures appropriate and timely medical oversight, mitigating current risk. Staff education and protocol changes ensure future prompt physician notification for any significant changes, reducing the risk of delayed treatment. Ongoing audits and oversight confirm sustained complaint, preventing recurrence of the issue and ensuring resident rights are protected. Date IJ was Corrected:We believed the Immediate Jeopardy was removed on 07/02/2025, the date corrective actions were implemented. Ensuring Staff Not Present Received TrainingAll nursing staff who are not present on 07/02/2025 for the in-services training will receive a make-up in-service by the Staff Development Nurse within 5 calendar days of returning to work, and before providing direct resident care. Completing will be tracked on a staff education log. Implementation Date for Physician Notification Protocol:The updated Physician Notification Protocol was implemented on 07/02/2025, the same day as the initial corrective actions. Title of Staff Conducting Audit and In-Service:The Director of Nursing (DON) conducted the comprehensive char audit for physician notifications.The Staff Development Nurse (SDN) provided the in-service training on physician notification requirements. Electronic In-Service Distribution and Acknowledgement:Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. In-Service: Recognizing Significant Changes & Physician NotificationObjective: Train nursing staff to recognize significant changes in resident condition, promptly notify the physician, and properly document the process to ensure timely treatment and protect resident rights. Agenda: Defining Significant Change - Examples: new/worsening wounds, sudden mental status changes, falls with injury, acute infections, uncontrolled pain. Timeframes for Physician Notification - Immediate vs. urgent vs. routine notification standards - Facility policy on notifying the physician within 1 hour of significant changes. Documentation of Notification - How to complete the physician notification form. - Documenting date/time of change, date/time of call, physician response. Communication Best Practices - SBAR (Situation, Background, Assessment, Recommendation) approach when calling providers. - Tips for effective and concise communication Policy & Procedure Review- Physician notification protocol - Review of facility admission protocols requiring physician notification. Q&A Session Materials: Physician notification form Updated physician notification policyCompetency Validation: Staff sign-in sheet Charting exercise: completing a sample physician notification form Electronic In-Service Distribution and Acknowledgement:Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. Monitoring of the facility's Plan of Removal included the following: Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Skin Issues on Admission. Protocol: Do a thorough assessment. 1) Document. Initially nurses are not to measure unless you're a wound care certified nurse. 2) Make sure there is a treatment ordered. (Hospital order, standing order or MD/NP order) Fill up a communication form and submit it to the Wound Care Nurse (ADON) for Dr. (Name) (Wound MD) to look at on his next visit. Document everything! Do Skin assessments every week! Notification of MD for worsening wounds if it's not documented it's not done!! Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Accurate and timely wound assessment and documentation. The requirement for immediate physician notification for wounds at admission or with signs of worsening. Proper initiation for treatment orders for wounds. Staff sign-in sheets and education materials are maintained for verification. Record review of the facility QAPI meeting revealed the facility medical director was notified by the director of nurses of the immediate jeopardy via phone while in attendance with the facility administrator on 07/02/25. Record review of the facility admission Wound Assessment Checklist form reflected on 07/02/2025 the form included the name of the resident, date of admission, wound treatment, MD Notified, notes. Record review of the facility Weekly Audit tool blank form revealed it included the date, resident, treatment, and documentation in PCC. Record review of the facility Communication Form revealed it must include information pertaining the resident, new admission/readmission, indicate which department it applied to and to include message/comments. Record review of the facility Physician notification Form undated, reflected staff should provide the date and time change identification, the date and time of physician notification and Physician response and orders. Record review of the Facility SBAR (Situation, Background, Assessment, Recommendation) reflected staff should document when a change of condition occurred and when the provider was notified. Record review of Resident #49's progress noted dated 07/02/25 by the DON reflected Pressure wound on sacrum assess with wound MD. Stage 4 full thickness. Wound size (LxWxD) 4.0x3.5x0.8 cm Surface area = 14, exudate - Moderate serous (clear fluid drainage from a wound). Wound has improved since last visit as evidence by decrease surface area. No signs of infection noted. Treatment review with physician. No changes made at this time. Resident remains on air mattress. No c/o pain but instructed to call the nurse if he has pain. PRN pain medication ordered. Dietician made aware of the nutritional consult for the resident. Staff instructed to turn and reposition resident Q 2 hours. Call light within reach. Record review of Skin Assessments revealed they were completed on 07/02/25 for all 73 residents. The assessments indicated any skin concerns and the location of the skin concerns. Record review of a facility in-service training report for facility nurses across all shifts dated 07/03/25 reflected the following: On wound assessment on admission, the Admitting Nurse is required to document the following: 1. Wound measurements. 2) Notification of the physician w/in 24 Hrs. of identification. 3) Initiation of wound treatment per protocol or physician order. 4) A standing protocol has been established requiring automatic wound consult for any Stage 2

Based on observations, interviews and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #50) of 7 residents observed for infection control. Staff failed to use the appropriate PPE when providing care for Resident #50 who was on EBP. This failure could place resident at risk of being infected with germs from another resident. Record review of Resident #50's undated admission Record reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the leg with surgical repair, dementia, and kidney failure. Record review of Resident #50's admission MDS, dated [DATE], reflected a BIMS score of 12, indicating she had moderate cognitive impairment. Her Functional Status assessment reflected she required some assistance with her ADLs. Record review of Resident #50's care plan, dated 6/17/25, reflected she was planned for right leg fracture, decreased ADL function, and isolation precautions related to surgical wound. Record review of the facility's Infection Control/Antibiotic Stewardship log revealed the facility had 14 residents on isolation for wounds, catheters, gastric tubes, and IV access. Resident #50 was on EBP because she had wounds as well as a urinary catheter. Observation on 7/01/25 beginning at 9:10 AM of the 100 and 200 Halls revealed seven residents with signage outside their rooms indicating they were on EBP. Observation on 7/01/25 at 9:15 AM revealed Resident #50 had signage on her door indicating she was on EBP. PPE was located in an alcove near her room. Observation on 7/02/25 at 11:21 the COTA transferred Resident #50 from her wheelchair to her bed using a slide board. The COTA was not wearing any PPE. Observation on 7/03/25 at 12:30 PM CNA-D and CNA-E transferred Resident #50 from her bed to her wheelchair, without wearing any PPE, using the mechanical lift. In an interview on 7/3/25 at 1:25 PM CNA-D stated she knew which residents were on isolation by the signage outside their room. The sign advised her what level of PPE was required to be worn when providing care to the resident. She stated she did not wear PPE while transferring Resident #50 because she did not normally work on the floor, and she was unfamiliar with the residents of that hall and she just forgot. She stated the risk of not wearing PPE was spreading infection from one resident to the other. In an interview on 7/3/25 at 1:45 PM CNA-E stated she did not notice the sign outside Resident #50's room, so she did not use any PPE. She stated she was called to that hall from where she normally works, and she was not familiar with the residents of that hall. She knew residents with the sign at the door meant she had to wear a gown and gloves. In an interview on 7/3/25 at 2:15 PM the COTA stated she did not know what it meant when a resident was on EBP. She stated she was aware of the signs on the resident rooms showing the wearing of gowns and gloves. She stated she just did not wear it as the resident was in a hurry to get back to bed. She stated the risk of not wearing the PPE was possibly spreading infections. In an interview on 7/3/25 at 2:20 PM CNA- F stated she did not know what EBP was, but she knew to wear a gown and gloves with residents who had the sign outside their room. She did not know the risk of not wearing the proper PPE. In an interview on 7/3/25 at 2:28 PM CNA-G stated EBP signs were placed outside the rooms of residents they were supposed to wear a gown and gloves when they were providing care to them. In an interview on 7/3/25 at 2:35 PM CNA-H stated she knew which residents were on EBP because the nurse would tell them, plus there was a sign outside their room. EBP required a gown and gloves to be worn. In an interview on 7/3/25 at 5:15 PM the DON stated EBP were put in place for any resident with a wound, IV, or any tube that was inserted. She stated signs were placed outside the room of those residents, and PPE was kept in an alcove on the hall. She stated the risk of not wearing the appropriate PPE was giving the resident an infection from another resident. The DON stated she or the Infection Preventionist perform in-services for staff on infection control and PPE usage. She stated there was no monitoring of staff to ensure PPE was being used. Record review of the facility's undated policy Infection Control reflected: Contact Precautions Use personal protective equipment (PPE) appropriately, including gown and gloves. Wear gown and gloves for all interactions that may involve contact with the resident or the resident's environment.

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 the facility's only kitchen. 1. The facility failed to ensure the refrigerator was maintained in a sanitary manner free from dark substances. 2. The facility failed to ensure food items stored in the freezer were properly discarded. This failure could place all residents at risk for food contamination and food borne illness. Findings included: Observation and interview on 07/01/25 at 9:01 AM with the Dietary Manager revealed a dark substance on the floor of the walk-in cooler. The dark substance was approximately 12 inches by 4 inches on the non-porous floor. The Dietary Manager stated that the substance had built up over the years and would not come off the floor. Therefore, nothing had been attempted in the past to clean the substance off the floor. The Dietary Manager said that the substance on the floor would not affect the residents' health because it was not touching anything. The Dietary Manager also revealed it was his responsibility to ensure the kitchen was clean and sanitary. Observation and interview on 07/01/25 at 9:06 AM with the Dietary Manager revealed a clear unlabeled and undated sealed plastic bag in the freezer was previously defrosted ground beef and re-frozen. The clear bag had a puddle of frozen blood from being previously thawed and re-frozen. The Dietary Manager stated that the previously defrosted ground beef should not have been in the freezer and should not have been re-frozen. The Dietary Manager said that if the ground beef was cooked and served, residents were at risk of food borne illnesses. The Dietary Manager revealed this meat had been put in the freezer by a new cook who was not aware this could be harmful to the residents. The Dietary Manager stated the new cook, who would not work the remainder of the week, had placed the thawed meat back into the freezer on the previous Sunday when he had not worked. Attempts were made to interview the staff member that placed the re-frozen meat in the freezer, but she did not work that week. The Dietary Manager stated he had not seen the meat in the freezer. The Dietary Manager stated that he in-serviced staff every Wednesday at 1:00 PM, and he would in-service his staff that afternoon regarding the issues found. The Dietary Manager said that he expected his cooks to know how to store, label, and date and regularly made rounds to ensure that items were not stored incorrectly. The Dietary Manager removed the previously defrosted ground beef from the freezer and disposed of it. Review of the facility's undated Receiving and Storage policy, reflected: Storage: All foods will be properly stored to preserve flavor, nutritive value, and appearance and to protect against foodborne illness 1. b. Do not refreeze a thawed product - cook and or use immediately . 7. Refrigeration units should be kept clean with spillage wiped up immediately and a thorough cleaning at least weekly

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one (Residents #5) of three residents reviewed for dental services. The facility failed to follow up and schedule an appointment for resident to be seen by dentist so that she could receive dentures. This failure could affect residents by placing them at risk for oral complications, dental pain, and diminished quality of life. Findings included: Review of Resident #5's Quarterly MDS, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (longstanding disease of the kidneys leasing to renal failure), non-Alzheimer's dementia (a group of neurodegenerative disease that cause cognitive decline, but are distinct from Alzheimer's disease, diabetes mellitus (a group of diseases that result in too much sugar in the blood), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review also reflected a BIMS score of 7, indicating severe cognitive impairment. Resident #5's functional status indicated she required supervision or touching assistance in her ADLs. Her Oral/Dental Status did not indicate broken or loose-fitting dentures and no pain with chewing. Review of Resident #5's care plan, dated 7/15/24, reflected resident had a mechanical soft, low concentrated sweets diet. Review of Resident #5's care plan dated 05/06/25 also reflected: Focus-Resident has dental problems AEB: Edentulous (meaning no teeth)Goal-Resident will have no adverse effects from dental problems through the next review periodInterventions-Staff will assess oral status on admission, staff will provide oral care daily, staff will refer any dental problems to social services for follow up. Review of Resident #5's Progress Notes by the Social Worker, dated 05/21/25 at 1:07 PM, reflected SW reached out JPS and left voicemail to return call for dental referral. Review of Resident #5's weights revealed that resident had no weight loss since admission. Interview and observation on 07/02/2025 at 4:26 PM with Resident #5 revealed the resident had no lower teeth or upper teeth. Resident #5 stated that she had no dentures nor teeth. Resident #5 said that it bothered her having no teeth because she had to eat chopped meats and did not like eating it that way. Resident #5 stated that she desperately wanted dentures. The resident did not say how long she had been without teeth. Interview on 07/02/25 at 3:17 PM with the Social Services Director revealed that it was her responsibility to schedule dental appointments for residents. The Social Services Director stated Resident #5 was referred to a dental company by her hospital due to her income status. The Social Services Director stated she had not gotten around to calling the referred dental company and asking what documents needed to be sent over so that the appointment could be scheduled. The Social Services Director said that it was on her to do list. The Social Services Director stated that she was aware the resident and knew the resident had no teeth and was on a mechanical soft diet due to having no upper or lower teeth. The Social Services Director revealed that when she assisted residents who need dentures, she would check financing, check resourcing, then call the referred dental company. The Social Services Director stated that in this case, she had not had time to call the referred dental company in the past five weeks. The Social Services Director stated that having no teeth didn't affect Resident #5 because she has seen Resident #5 eat what she wants to eat. Interview on 07/03/25 at 12:05 PM with the Administrator revealed that it was the Social Services Director's responsibility to follow up on dental referrals. The Administrator stated if the Social Services Director did not follow up on referrals, it was ultimately his responsibility to follow up on the referral but did not reveal this process. The Administrator said that the importance of residents' dental appointments was so residents could enjoy their food and eating. Interview on 7/3/25 at 12:35 PM with LVN C revealed if a resident needed to see a dentist the nurses would communicate it to the Social Services Director. LVN C then stated that the Social Services Director would then put the resident's name on the dentist's list so they could be seen by the dentist the next time they came to the facility. LVN C also revealed that he would inform the doctor. And if the resident is in pain, LVN C would request pain medication. Record Review of Timeliness of Referral to Outside Vendors policy, dated 7/3/25, reflected:The designated staff member (e.g., Social Worker, DON, or Referral Coordinator) must contact the vendor within 3 business days of referral initiation. If the service is urgent, contact must be made within 24 hours, and documentation must reflect the urgency. Residents with no source of income, may require extended processing of referrals.

Based on record review and interviews the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment for 1 resident (Resident #50) of 6 residents reviewed for informed consents. The facility failed to ensure Resident #50 was informed of the risks and benefits prior to being administered antipsychotic medications. This failure could place the residents at risk of receiving medications with side effects they do not wish. Findings include: Record review of Resident #50's undated admission Record reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of her neck, and psychotic disturbance. Record review of Resident #50's admission MDS dated [DATE], reflected a BIMS score of 12 which indicated she had moderate cognitive impairment. Her Functional Assessment indicated she used a walker or wheelchair and required minimal assistance with her ADLs Record review of Resident #50's care plan, dated 6/05/25, reflected she had depression, Alzheimer's Disease, and was taking psychotropic medications. Record review of Resident #50's physician's orders reflected orders, dated 6/04/25, for Olanzapine Oral Tablet 5 MG (Olanzapine). Give 1 tablet by mouth at bedtime for mood. and Aripiprazole Oral Tablet 10 MG (Aripiprazole). Give 1 tablet by mouth one time a day for Depression Record review of Resident #50's June 2025 medication administration record reflected she began receiving Olanzapine Oral Tablet 5 MG and Aripiprazole Oral Tablet 10 MG on 6/05/25. Record review on Resident #50's consents reflected a consent for Aripiprazole Oral Tablet 10 MG for psychotic disturbance was signed by her responsible party on 6/28/25. There was no indication of the responsible party giving verbal consent. Record review of Resident #50's consents reflected a consent for Olanzapine Oral Tablet 5 MG for psychotic disturbance was signed by her responsible party on 6/28/25. There was no indication of the responsible party giving verbal consent. In an interview on 7/3/25 at 5:15 PM the DON stated the ADONs were responsible for ensuring consents for antipsychotic medications were signed prior to the medication being administered. She stated the risk of the resident receiving antipsychotic medications without being informed of the risks, benefits, and side-effects of the medication could be the resident having unexpected outcomes from the medication. In an interview on 7/3/25 at 5:30 PM the ADON stated consents for antipsychotic medications needed to be signed prior to the resident receiving the first dose. She stated she did not recall when Resident #50's consents were signed, but often times they got consent over the phone from the responsible party and then had them sign the paperwork on their next visit. She stated the consent should be dated the date a verbal consent was given. In a phone interview on 7/3/25 at 5:38 PM Resident #50's Responsible Party stated they did not recall signing the consent for antipsychotic medications or talking about it over the phone with anyone. They stated there was so much paperwork signed and so many phone calls he may have given consent and not remembered it. He had no concerns about the resident taking the medications because she had taken them before being admitted to the facility. On 7/3/25 at 5:50 PM the Administrator was unable to supply a policy on Consents prior to exit. He stated he did not think there was a policy addressing consents specifically.

Based on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 1 of 21 residents (Residents #48) reviewed for environment. The facility failed to ensure Residents #48's bed curtain was free from a dried brown substance. This failure could affect any resident and place them at risk for not having a sanitary homelike environment. Findings included: Record Review of Resident #48's Quarterly MDS, dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #48's MDS also reflected diagnoses of non-Alzheimer's dementia (a range of neurodegenerative and other disorders that cause cognitive decline, distinct from Alzheimer's disease), anxiety, and chronic kidney disease stage 2 (signifies a mild decrease in kidney function alongside evidence of kidney damage). Resident #48's MDS also reflected a BIMS of 6 (meaning severe cognitive impairment). Resident #48's MDS also reflected Resident #48 required supervision for ADL's. Observation and interview on 07/01/25 at 10:37 AM with CNA H of Resident #48's room revealed the privacy curtain had a dried brown substance on it. The substance area was approximately .5 cm x 1 cm. CNA H stated that it was her responsibility to tell maintenance when a resident's privacy curtain became dirty. CNA H said that when aides reported dirty privacy curtains to maintenance, maintenance would remove the dirty privacy curtains and take them to the laundry. CNA H revealed it was important to keep residents' privacy curtains clean to help prevent infections. CNA H stated that the facility policy was to keep privacy curtains clean and when resident's privacy curtains became dirty, staff were to report it to the maintenance director. Observation on 07/02/25 at 04:03 PM of Resident #48's room revealed the privacy curtain had a dried brown substance on it. The substance area was approximately 0.5 cm x 1 cm. Interview on 07/02/25 at 04:14 PM with LVN I revealed that dirty privacy curtains should be reported to the maintenance department who would take the curtain down and send it to the laundry. LVN I stated the importance of clean privacy curtains was to prevent infection and ensure residents' dignity. LVN I said it was all staff's responsibility to report dirty privacy curtains. Interview on 07/03/25 at 9:28 AM with the facility Director of Maintenance/Housekeeping revealed soiled privacy curtains should be reported to him. The Director of Maintenance/Housekeeping stated that when dirty privacy curtains were reported to him, he would ensure that they were removed, washed, and hung back up the same day. The Director of Maintenance/Housekeeper said that it was everyone's responsibility to report soiled curtains. He also said that if the curtains are not reported, the resident would have to continue to view the dirty curtains. The Director of Maintenance/Housekeeper revealed that no one had reported the dirty curtains to him. Interview on 07/03/25 at 9:46 AM with CNA J revealed that staff should report to their nurse if they saw a dirty privacy curtain. CNA J stated that the importance of clean curtains was for good health and avoid the spread of germs. CNA J said that when the maintenance department got the request, they should remove dirty privacy curtains, wash them, and hang them back up. CNA J stated that if the nurse would not report the dirty curtains to the maintenance department, she would notify her ADON. Interview on 07/03/25 at 10:41 AM with the Housekeeper revealed that if she saw a dirty privacy curtain, she would report it to her supervisor. Interview on 07/03/25 at 12:43 PM with Resident #48 revealed that the dirty privacy curtain did not interrupt her daily life. Resident #48 stated that she didn't see well, so she could not see the brown substance on her privacy curtain. Record Review of the facility's Use of Privacy Curtains in Resident Rooms policy, undated, reflected: .Procedures .5. Infection Control-Curtains must be laundered or replaced according to infection control guidelines or immediately if soiled

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #61) reviewed for enteral nutrition. The facility failed to follow Resident #61's physician's orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health. Findings included:Record review of Resident #61's Quarterly MDS, dated [DATE], reflected a [AGE] year-old female with an initial admit date of 01/30/25 and re-admit date of 06/10/25. Resident #61 had diagnoses of nontraumatic intracerebral hemorrhage in hemisphere, subcortical (a type of stroke where bleeding occurs within the brain's white matter, specifically in the area beneath the cortex of the cerebral hemispheres), gastrostomy status (refers to the presence of a gastrostomy tube, an artificial opening in the stomach for feeding or medication administration), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and dysphagia following cerebral infarction (a common and serious swallowing difficulty complication following a cerebral infarction(stroke)). Record review also reflected Resident #61 could rarely or never be understood so a BIMS score could not be attained. Record review also reflected that Resident #61 also received nutrition via a feeding tube. Record review of Resident #61's care plan revised dated 06/10/25 reflected:Focus: Resident at nutrition and dehydration risk related to receiving feeding via G-tube secondary to Dysphagia. Formula: Glycerna, may use Osmolite. Goal: Resident will have adequate nutrition and fluid over the next 90 days. Interventions: Administer Tube Feeding as order by the MD. Check for residual q shift or as the physician orders. Check for tube placement q shift or as ordered by physician. Flush g-tube before and after meds as ordered by physician. H2O as ordered by the physician. Record review of Resident #61's physician order dated 06/11/25 revealed every shift for g-tube every shift Glucerna 1.5 via g-tube @50 ml[BR7] [LO8] /hr, (may use Osmolite 1.5) x 22 hours (off between 12PM and 2 PM) with water flushes 100 ml every 6 hours and every shift flush g-tube with 60 ml of H2O before and after medication administration. Observation on 07/02/25 at 11:01 AM revealed Resident #61 lying in bed watching television. Observation also revealed Resident #61's feeding pump was running at a rate of 60 ml/hr. Interview on 07/02/25 at 11:08 AM with LVN C revealed Resident #61's physician's order reflected the enteral feeding pump should be set at 50 ml/hr. LVN C stated that the pump was running incorrectly at 60 ml/hr. LVN C said that the enteral feeding pump rate should match the physician's order. LVN C then revealed the incorrect rate could create a risk of fluid overload which could then lead to aspiration, (which is the inadvertent inhalation of substances like food, liquid, or other materials into the lungs), instead of being swallowed properly. LVN C stated that it was his responsibility to verify residents' enteral feeding pump rates were the same as the physician's orders when making rounds. LVN C said he should report it to the ADON if he found a resident's enteral feeding pump was running at an incorrect rate. LVN C corrected the enteral feeding pump and notified ADON A. Interview on 07/02/25 at 05:05 PM with ADON A revealed she expected nurses to review the physician's order prior to entering the rate on the resident's enteral feeding pump. ADON A stated that the nightshift nurse started the enteral feeding pumps, but she expected the dayshift and evening shift to verify the orders when making rounds. ADON A said that the facility policy stated that the enteral feeding pump rate should match the physician's orders. ADON A revealed that the risk to the resident when the rate entered was more than the rate ordered was the resident's stomach getting too full, weight gain, etc. ADON A stated that a nurse should follow the chain of command and notify their ADON if they found an order entered wrong on an enteral feeding pump. ADON A stated that she was notified previously of the incorrect rate on Resident #61's enteral feeding pump. Interview on 07/02/25 at 06:14 PM with the DON revealed that she expected nurses to follow physician's orders when they set residents' enteral feeding pumps. The DON stated that it was the responsibility of all nurses to ensure their residents' orders were entered correctly on the enteral feeding pump and were checked by nurses when they made rounds. The DON said that the if a nurse found an enteral feeding pump set incorrectly, the nurse should notify their ADON. The DON revealed that residents risked fluid overload and excess calories when their enteral feeding pumps were set too at a faster rate than their physician's orders. Record review of the facility's Enteral Tube Feeding via Continuous Pump policy, revised March 2015, reflected: .General Guidelines .3. Check the enteral nutrition label against the order before administration. Check the following information: .g. Rate of administration (mL/hour) )

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection for 1 resident (Resident #1) of 3 observed for infection control. RN A failed to perform hand hygiene and change gloves during wound care for Resident #1. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old admitted to the facility on [DATE] with a primary admitting diagnosis of Traumatic Subdural Hemorrhage Without Loss of Consciousness (an abnormal collection of blood under the covering of the brain caused by trauma). Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed a BIMS score of 03, indicating severe impairment in cognitive functioning. The Comprehensive MDS reflected Resident #1 required substantial/maximal assistance with eating, toileting hygiene, bathing, dressing, and repositioning. In an observation on 08/14/24 at 1:45 PM, wound care of Resident #1's coccyx revealed RN A washed her hands and put on gloves prior to the beginning of wound care. She removed the old dressing and cleaned the wound. She did not change her gloves, wash her hands, or use hand hygiene prior to applying the new dressing. After applying the new dressing and completing other tasks, she removed her gloves and washed her hands. In a review of records on 08/14/24 at 2:05 PM, a review of employee records for RN A reflected an infection control quiz signed by the employee and dated 07/22/24. In a phone interview with RN A on 08/14/24 at 3:07 PM, she reported that handwashing should be completed before and after providing wound care to a resident. She reported that during today's (08/14/24) wound care for Resident #1 she washed her hands both before and after wound care. When asked if she washed her hands after removing the bandage and cleaning the wound (dirty), but before applying medication/new dressing (clean) she stated she did not. She stated it is understandable that this should be done and that once she finished clean activities, she should have removed her gloves and performed hand hygiene. She stated this helped prevent the reintroduction of the bacteria to the wound. In an interview with LVN B on 08/14/24 at 03:26 PM, he reported that he has worked at this facility about two years, first on double weekends, and more recently on the evening shift. He reported that staff should perform hand hygiene when they come into the residents' room and when they leave. In-between, he reported that the gloves would need to be changed and hands washed in-between when providing wound care and incontinence care. He reported that he had received infection control and handwashing in-service since being hired. He reported that failing to change gloves between clean and soiled parts of wound care could result in infection spreading. In an interview with CNA C on 08/14/24 at 03:50 PM, she reported that she had worked at this facility about seven years on both the evening and day shifts. She reported that when she entered a room to provide personal care, she washed her hands and put on gloves. She reported she removed her gloves after providing care and washed her hands. She reported that she changed her gloves and washed her hands during care when the gloves become soiled or when finishing cleaning the resident before starting clean activities. She stated she did this to prevent the spread of infection. She reported she had received infection prevention and handwashing teaching this past year. In an interview on 08/14/24 at 04:00 PM with ADON, she reported that she was the facility wound care nurse and had worked at the facility about 2.5 years. She reported that she expected staff to change their gloves and wash their hands as soon as they entered the room, after they completed their task, and if possible, in between. She stated they would need to sanitize their hands in-between care if for any reason they needed to change gloves before putting on another pair. She reported that during wound care staff were supposed to wash their hands, put on gloves, take off the old bandage, and change gloves and wash their hands before putting on the new bandage. She stated that infection could be a result of not doing this. She reported that staff had received handwashing and infection control prevention teaching at the beginning of this year (2024). In an interview on 08/14/24 at 04:27 PM, the DON reported that she was also the facility Infection Preventionist. She reported that staff should wash their hands before, after, and in between care. She stated that if their gloves were soiled, they should change them. For wound care, she reported that the hands should be washed before, after, and in-between before putting on a clean dressing. She reported all staff had received training for handwashing and infection control within the last month or so. She reported that staff who fail to wash their hands when going from dirty to clean activities could cause cross contamination and that this could cause the patient to get an infection. She reported that she, as the Infection Preventionist and the DON, was responsible for making sure that these things were being done. She reported she provided the staff with regular in-service training, that the staff had annual competencies, and that she watched staff to monitor for compliance with hand hygiene and infection control practices. In an interview on 08/14/24 at 05:00 PM, Administrator reported she had worked as the Interim Administrator since January (2024). She reported that she expected the employees to follow the facility's policies. She stated that when providing wound care, staff should not go from clean to dirty without hand hygiene and changing gloves. She stated that failing to do this could open the door for infection to occur. She reported the DON was responsible for ensuring the policy was being followed and providing in-services for the staff. Review of the facility policy titled, Handwashing/Hand Hygiene noted dated 2001 and revised August 2015, was reviewed. Number two of the policy states, All personnel shall follow the handwashing/hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. This policy states that an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water will be used before handling clean or soiled dressings, gauze pads, etc.; and before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, and after handling used dressings, contaminated equipment, etc., after removing gloves.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, mental, and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 5 residents (Residents #27, #39, and #52) reviewed for care plans. 1. The facility failed to create a care plan addressing Resident #27's Apixaban Oral Tablet 2.5 mg. 2. The facility failed to create a care plan addressing Resident #39's Foley catheter. 3. The facility failed to create a care plan addressing Resident #52's Mirtazapine Oral Tablet 15 mg, Donepezil Hydrochloride Oral Tablet 10 mg, and Seroquel Oral Tablet 25 mg (Quetiapine Fumarate). These failures could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: 1. Record Review of Resident #27's admission record dated 06/19/24, reflected the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record Review of Resident #27's quarterly MDS, dated [DATE], reflected she had a BIMS score of 10, indicating moderate cognitive impairment. Further review revealed she had active diagnoses of unspecified dementia (memory loss) unspecified fracture of shaft of right tibia (fracture of the right leg), malignant neoplasm of the neck, face, and head (cancer), hyperlipidemia (high levels of fat particles in the blood), and hypertension (force of blood against the artery walls is too high). Record review or Resident #27's orders dated 06/20/24 reflected it did not address her Apixaban Oral Tablet 2.5 mg order which was prescribed to prevent and treat blood clots and strokes due to her diagnosis of hyperlipidemia. Record Review of Resident #27's care plan dated 06/19/24 reflected it did not address her Apixaban Oral Tablet 2.5 mg order which was prescribed to prevent and treat blood clots and strokes due to her diagnosis of hyperlipidemia. 2. Review of Resident #39's admission record, dated 06/19/24, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. Review of Resident #39's quarterly MDS assessment, dated 05/09/24, reflected he had a BIMS score of 0, indicating severe cognitive impairment. Further review revealed he had active diagnoses of obstructive uropathy ( a condition in which the flow of urine is blocked), aphasia ( a brain disorder where a person has trouble speaking or understanding other people speaking), retention of urine, and he had an indwelling catheter. Review of Resident #39's care plan dated 02/04/24 reflected it did not address his Foley catheter. Review of Resident #39's physician's orders dated 05/28/24 revealed change (Size) French Foley catheter every night shift starting on the 28th and ending on the 28th every month for patency and as needed for leakage or malfunction. There was no size for the Foley catheter. 3. Record review of Resident #52's admission record, dated 06/19/24, reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE]. Record review of Resident #52's quarterly MDS, dated [DATE], reflected the resident could not be understood so she was not able to have a BIMS test, or score recorded. Further review revealed the resident had progressive neurological conditions, coronary artery disease (buildup of plaque in the heart's major blood vessels), hypertension (force of blood against the artery walls is too high), Alzheimer's disease (disease that destroys memory and other important mental functions), and depression (lowering of a person's mood). Record review of Resident #52's care plan dated 06/19/24 reflected the care plan did not address the resident's current medication orders of Mirtazapine Oral Tablet 15 mg for apatite stimulant, Donepezil Hydrochloride Oral Tablet 10 mg for Alzheimer's disease and Seroquel Oral Tablet 25 mg (Quetiapine Fumarate ) for vascular dementia to be taken daily. Observation and attempted interview on 06/18/24 at 1:25 PM with Resident #39 revealed he could hear but was unable to speak or answer questions. Resident #39 was observed in the emergency unit at the hospital, and he did not have a Foley catheter. Interview via telephone on 06/20/24 at 4:01 PM with the MDS Coordinator revealed she was responsible for completing care plans by reviewing the residents' orders. The MDS Coordinator also stated that the admission nurse is responsible for inputting the orders for the resident upon admission. The MDS Coordinator said the purpose of the care plan was to ensure all staff knew how to care for each resident at the facility. She stated the it could affect the continuity of care for residents if the care plans were not updated and complete. The MDS Coordinator said the facility DON was ultimately responsible for updating the care plans. Interview on 06/20/24 at 5:46 PM with the DON revealed the MDS Coordinator was not at the facility during the survey period. The DON stated it was the responsibility of the MDS Coordinator, the interdisciplinary team, and herself to update the care plans. The DON said the IDT was responsible for initiating care plans according to their disciplines. The DON stated she and the MDS followed up to ensure the care plans were updated. The DON said the purpose of the care plan was for the continuity of care. The DON said the entire IDT team was responsible for care plans and the MDS Coordinator had done trainings. The DON was asked for the in-service training records, but they were not provided. Review of the facility's Care Planning - Interdisciplinary Team policy, revised September 2013, reflected: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized. .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/ Interdisciplinary Team which includes, [NAME] is not necessarily limited to the following personnel: a. The resident's Attending Physician. b. The Registered Nurse who has responsibility for the resident. c. The Dietary Manager/Dietitian. d. The Social Services Worker responsible for the resident. e. The Activity Director/Coordinator. f. Therapists (speech, occupational, recreational, etc.), as applicable. g. Consultants (as appropriate). h. The Director of Nursing (as applicable). i. The Charge Nurse responsible for resident care. j. Nursing assistants responsible for the resident's care and k. Others as appropriate or necessary to meet the needs of the resident 48236

Based on interview and record review, the facility failed to ensure there were physician orders for 2 of 15 residents (Residents #39 and #57) reviewed for physician orders. 1. The facility failed to obtain physician orders for Resident #57 gastrostomy tube flushes between medications. 2. The facility failed to obtain physician orders for Resident #39's urinary catheter, to include the size of the catheter to be used. These failures could place residents at risk of not receiving the appropriate care as ordered by the physician. Findings included: Record review of Resident #57's entry MDS assessment, dated 05/30/23, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was severely impaired with a BIMS score of 0. The resident had diagnoses which included gastronomy status and she had a feeding tube. Review of Resident #57's June 2024 Physician Orders reflected there was no orders for flushing gastrostomy tube with 5-10 ml of free water between each medication administration but reflected an order dated 05/29/24 to every shift Flush G-tube with 60ml of water before and after medication administration. Review of Resident #57's care plan dated 05/24/24 reflected: Flush g-tube before and after meds as ordered by physician. Interview with LVN A on 06/19/24 at 1:11 PM revealed he was aware of flushing the gastrostomy tube with water before, between, and after medication administration through gastrostomy tube for Resident #57 but he did not, because he did not have orders. He stated it was his responsibility and best nursing standard of practice to check the orders before administration of any medication, but he has been flushing at the beginning and at the end of administration. LVN A stated failure to flush between medication administration could lead to gastrostomy tube blockage and medication interactions. Interview with the DON on 06/19/24 at 4:34 PM revealed her expectation was for the nurses to flush the gastrostomy tube before, between, and after each medication administration as per the doctor's orders and follow the facility policy. She stated failure to check orders to flush the gastrostomy tube may lead to gastrostomy tube being clogged and medication interaction. The DON stated he had trained the nurses on medication administration via gastrostomy tubes, and she had done competency for skills on all staff., No documentation was provided as requested. She stated it was the ADON's responsibility to follow-up on nurses to ensure they have orders in the MAR. Interview with ADON H on 06/20/24 at 10:37 AM revealed she was notified by LVN A he did not flush with 5-10 ml water between the medications through the gastronomy.She stated she educated LVN A, checked on physician orders, and they were missing orders to flush between the medications.She stated she called the doctor, and she has updated the orders. ADON H stated it was her responsibility to audit the charts weekly. She stated she audited the charts on other orders but on gastronomy orders. She stated failure would cause gastronomy tube clogging. 2. Review of Resident #39's admission record dated, 06/19/24, revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. Review of Resident #39's MDS assessment, dated 05/09/24, reflected he had a BIMS score of 0, indicating severe cognitive impairment. Further review revealed he had active diagnoses of obstructive uropathy (is a condition in which the flow of urine is blocked), aphasia (is a brain disorder where a person has trouble speaking or understanding other people speaking), retention of urine, and he had an indwelling catheter. Review of Resident #39's care plan dated 02/04/24 reflected it did not address his Foley catheter. Review of Resident #39's physician's orders dated 05/28/24 revealed change (size) French Foley catheter every night shift starting on the 28th and ending on the 28th every month for patency and as needed for leakage or malfunction. There was no size for the Foley catheter. Review of Resident #39's nursing progress notes reflected the facility was using Foley catheter French size 18. Interview with LVN D on 06/20/24 at 10:06 AM revealed she had not seen the size for the Foley catheter, but she has been inserting a French size 18. She stated the size was left open on the Foley catheter orders, and she had not consulted with the doctor because she thought the size was left out intentionally. She stated she was supposed to confirm the size. She stated the risk of not confirming the size was that if they inserted a bigger size it could harm the resident or if they inserted a smaller size it might cause urine to leak. She stated she had done training on physician orders. Interview with ADON on 06/20/24 at 10:20 AM revealed it was her responsibility to follow-up on admissions and ensure the orders were correct and also when there was a new order. She stated she checked and found out there were orders for a Foley catheter but no specific orders for the size. The risk of not having a physician order for catheter size was that it could lead to leakage or blocking the urine passage. Interview with the DON on 06/20/24 at 10:50 AM revealed her expectation was that the nurses would ensure they had Foley catheter sizes before they inserted a catheter into a resident. She stated the nurses failed to follow-up with the primary physician to get the size from admission. She stated failure to have sizes could cause trauma if they used big sizes or cause leakage if they used small sizes. Interview with the Physician K on 06/20/24 at 11:33 AM revealed he gave verbal orders to staff in the facility, and his expectation was they were supposed to update the size orders. For gastronomy flushing, Physician K stated those were standard orders that should be documented on any resident receiving medications through gastronomy tube. He stated he could not remember when he gave the verbal orders. He stated failure to use the right size catheter might cause trauma or leakage. Review of the facility's Medication and Treatment Orders policy, revised July 2016, reflected: Verbal orders must be recorded immediately in the resident chart by the person receiving the order and must be include prescriber's last name, credentials, the date, and the time of the order.

Based on observation, intervies, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure sanitary practices were maintained in the kitchen as the dish machine was not performing at the optimal sanitation rate due to having no chlorine and the test strips being used were both expired and the wrong type. These failures could place resident who ate from the kitchen at risk for cross-contamination and food-borne illnesses. Findings included: Observation on [DATE] at 9:30 AM revealed the dishwashing machine had a data plate that read Required: 50 ppm chlorine and Washer Rinse Temperature 120 degrees Minimum. Observation and interview on [DATE] at 9:35 AM of the kitchen revealed Dietary Aide E attempted to run the dish machine. Dietary Aide E then with assistance of Dietary Aide F used testing strips, which they stated they had regularly been utilizing, to test the dish machine's chlorine level. The test revealed a slight change in color only. Both Dietary Aide E and Dietary Aide F observed the chlorine container was empty. Dietary Aide F contacted maintenance to change the large container of chlorine because she stated she could not lift the container by herself. Dietary Aide F stated the procedure was to report to maintenance when the chlorine was out and needed to be changed because the staff could not lift the heavy containers of chlorine. Observation and interview on [DATE] at 11:30 AM with Dietary Aide F revealed when the chlorine was tested again after the new chlorine was changed and added, the test strip continued to have an only slight change in color. When Dietary Aide F was asked to turn the chlorine testing strips over to view the expiration date after viewing the ppm of the chlorine testing strips, the test strips expiration date was [DATE] and the ppm range first increment was 100 million. The dish machine ppm requirement was 50. When asked who Dietary Aide F should notify that the testing strips were expired, she stated her manager. Dietary Aide F also stated she had never looked at the expiration date before and had no knowledge or been trained to check testing strips expiration dates. Dietary Aide F stated using expired test strips meant that the ppm of chlorine was possibly incorrect. Dietary Aide F said this could lead to the dishes being improperly sanitized which could lead to residents becoming sick. Observation and interview on [DATE] at 11:47 PM with Dietary Manager revealed at that time, Dietary Aide F notified the Dietary Manager the chlorine test strips were expired, and the Dietary Manager attempted to locate another package of test strips. When the Dietary Manager was asked how dishware was sanitized, the Dietary Manager answered, I have no clue. The Dietary Manager located another package of chlorine testing strips, but it was expired with an expiration date of [DATE]. Also, it too was the type of chlorine strip that was to be used in the dish sink, not the dish machine. The dish machine's chlorine test strip's first test increment was 50 ppm. The expired test strip brought out by the Dietary Manager first chlorine test increment was 100 ppm. Again, the Dietary Manager voiced that she did not know what the correct chlorine ppm test strip was supposed to be used and what the correct ppm was suggested on the placard of the dish machine. The Dietary Manager stated she did not know that the testing strips had expiration dates, and that they were supposed to be checked. The Dietary Manager stated the chemical supply company supplied the chlorine testing strips. The Dietary Manager stated it was her responsibility to request new testing strips from the company when they deliver the kitchen's chemicals. Lunch was served using disposables because testing strips that were expired and the correct ppm could not be located before the residents' lunch time. Interview on [DATE] at 1:27 PM with Dietary Aide F revealed Dietary Aide F had worked at the facility for about 6 months. She stated the previous Dishwasher gave her that specific pack of testing strips and told her the color should be somewhere between ,d+[DATE] ppm when she was trained in [DATE]. She said she looked for that color when she tested for chlorine in the mornings before she washed the first load of dishes. Dietary Aide F confirmed it was her responsibility to tell the Dietary Manager the test strips were out of date. When asked what ppm were required per the dish machine specifications, she stated she was unsure. When asked when she should tell her manager that her test strips were expired, the wrong type, or she was out of chlorine, she stated she should tell the Dietary Manager immediately. Dietary Aide F said that residents could get sick if there was not enough chlorine in the machine. Interview on [DATE] at 1:56 PM with [NAME] J revealed she had worked at the facility for more than [AGE] years. She stated whoever used the dish machine was supposed to test for chlorine level before they ran the dishes through it. [NAME] J also stated if there was no chlorine, the test strips were expired, or the test strips were the wrong type. She stated the Dietary Manager was supposed to be notified because that was who was ultimately responsible. She stated she did not use the dish machine because she was the Cook. She also stated the risk to the resident was that the residents could get stomach illnesses, stomach infections, and stomach poisoning, et cetera. Interview on [DATE] at 2:10 PM with Dietary Aide E revealed she had worked at the facility for about six months. Dietary Aide E revealed it was the Dishwasher's responsibility to check for chlorine, type of test strip, and expiration date before starting the first load of dishes. She stated it was their responsibility to inform the Dietary Manager if they ran out of chlorine or chlorine testing strips during their shift. Dietary Aide E stated she was unable to tell if the dish machine was using 50 ppm because the testing strips that were currently being used start at 100 ppm on the testing strips, and they were expired. Dietary Aide E stated she did not report the expired or wrong type of testing strip to the Dietary Manager. Dietary Aide E stated the only training she received was by the previous Dishwasher who trained her on those test strips. Dietary Aide E also added that she was unsure the dish machine had been out of chlorine. Dietary Aide E revealed residents could get sick if the dish machine had no chlorine, the test strips were expired, or it was the wrong type of chlorine testing strips. Interview on [DATE] at 2:33 PM with Dietary Manager revealed she started dietary manager training in [DATE] with online with a university. She also stated it was the Dishwasher's responsibility to check for chlorine before beginning the dishwasher and to test the dish machine for chlorine. The Dietary Manager revealed it was her responsibility to ensure the facility had the correct type of test strips and that the test strips were not expired. The Dietary Manager was unsure how long the expired and wrong type of chlorine strips had been used in the facility and because of this that the dish machine log was probably inaccurate. When she was asked how long she thought the dish machine was without chlorine, the Dietary Manager said that it was about a day. Then Dietary Manager stated residents could get a stomach virus and get sick. Interview on [DATE] at 6:28 PM with the Administrator revealed the Dishwasher should use the proper test strips. The Administrator stated they should run a few cycles after changing and adding chlorine and test it after each meal to ensure that it was running properly. The Dietary Manager was responsible for insuring this was done. The Dietary Manager should tell the Administrator if there was a problem. Improper sanitation was a risk to the resident because it could cause an upset stomach. Record review of the facility's Infection Control/Procedure Departmental Dietary Services policy, dated [DATE], reflected: .The dishwasher should be kept between 140 degrees and 200 degrees F, if using chemical sanitizer, rinse temperature can be 120 degrees F Machine should be maintained and run according to manufacturer's instructions. Review of the U.S. Public Health Service, Food Code (2017) section S,d+[DATE].113(A) reflected: .(B) A WAREWASHING machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operation specifications including the: Temperatures required for washing, rinsing, and SANITIZING; Pressure required for the [NAME] SANITIZING rinse unless the machine is designed to use only a pumped SANITIZING rinse.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable when applicable for 1 of 3 medication carts (Hall C medication cart) and failed to ensured all drugs and biologicals were stored securely for 1 of 5 residents (Resident #2) observed for medication storage. 1. The facility failed to ensure the medication cart for Hall C did not have the following expired medication: 1 bottle Naloxone tablets (used to rapidly reverses an opioid overdose), Sodium chloride ophthalmic solution (used to reduce swelling of the surface of the eye), Aspirin 81 mg (used to prevent heart attack or stroke), Zinc sulfate 220 mg capsules (used to treat or prevent low levels of zinc), Debrox ear drops (for wax removal) and Lispro insulin (used for diabetes). 2. Resident #2 had 1 bottle of eye drops stored at the resident's bedside table not locked in a lock box or secured in the medication cart or medication room. Findings included: Observation on 06/19/24 at 08:50 AM revealed the medication cart for Hall C had the following: - 1 bottle Naloxone tablets with expiry date of 03/05/24, - Sodium chloride ophthalmic solution with expiry date of 03/24, - Aspirin 81 mg expiry 05/24, - Zinc sulfate 220 mg capsules with expiry date of 12/23, - Debrox ear drops with expiry date 04/24 and - Lispro insulin with open date 04/01/24. Interview on 06/19/24 at 9:20 AM LVN B stated it was all nurses' responsibility to ensure expired medications are removed from the cart and put on destruction boxes. She stated she was expected to check the cart each shift, but she did not check. LVN B started the insulin vial was supposed to be discarded after 28 days or when it was discontinued. LVN B stated the outcome for administering expired medications would be that the medication would not be as effective. Interview on 06/19/24 at 2:05 PM with the ADON revealed it was her responsibility to follow behind the nurses and check the carts for expired medications. She stated her expectation was nurses to check their carts ecah shift for expired medications. She stated the risk of administering expired medications would be that the medication will not be effective. Interview on 06/19/24 at 4:42 PM with the DON revealed her expectation was for all nurses to check the medication carts every shift for labelling and removal of the expired medications. She stated the risk of administering expired medications would be that the medication would not be potent. She stated the ADONs were responsible of checking carts after the nurses. She stated she had done training regarding expired medication removal and cleaning of the carts on 01/08/24. 2. Observation on 06/18/24 at 3:44 PM revealed a bottle of eye drops sitting on Resident #2's bedside table Record review of Resident #2's Face Sheet dated 06/19/24, reflected the resident was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Record review of Resident #2's quarterly MDS dated [DATE], reflected Resident #2 had a BIMS score of 14, indicating cognition was intact. The assessment indicated Resident #2 required supervision or touching assistance with eating, oral hygiene, toileting, shower/bath, upper and lower dressing, putting on/taking off footwear, and personal hygiene. Active diagnoses included Anemia (blood has reduced ability to carry oxygen), Coronary Artery Disease (reduction of blood flow to heart muscle), Heart Failure (heart's ability to fill with and pump blood), Hypertension (high blood pressure), Diabetes Mellitus (sustained high blood sugar levels), Malnutrition (too few or too many nutrients), Depression (mental state of low mood), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems). Resident #2's MDS indicated use of corrective lenses, with adequate ability to see in adequate light. Record review of Resident #2's care plan, reflected Resident #2 had impaired visual function related to Diabetes. Goal included to show no decline in visual function and ensure appropriate visual aids - Glasses are available to support resident's participation in activities. Interventions included regular visits by mobile vision care, monitor/document/report sudden visual loss, pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, blurred or hazy vision. Record review of Resident #2's physician order summary report, dated 06/18/24 reflected: Refresh Liquigel Ophthalmic Gel 1 % (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes every 8 hours as needed for analgesics Active 7/17/2023 3:15PM start 7/17/2023 Record review of Resident #2's Medication Administration Record dated 05/01/24-06/18/24 reflected Resident #2's order was as needed, and had not been administered any eyedrops. Interview on 06/18/24 at 4:34 PM with the ADON revealed she entered Resident #2's room to remove the eyedrops, but Resident #2 refused. According to the ADON, Resident #2 once had orders to allow eyedrops at her bedside. Upon her return from the hospital, it appeared the order was no longer there. The ADON stated she would contact the physician for an appropriate order. The ADON stated upon returning from the hospital physician orders were to be entered by the admitting nurse. The ADON stated she was responsible for ensuring all orders were entered, not doing so would place residents at risk with their care. The ADON stated having medications at the bedside placed residents at risk for over medicating, improper administration, and other residents having access to the medication. Interview on 06/18/24 at 4:37 PM with LVN G revealed she was not aware of the eye drops at Resident #2's bedside table. LVN G stated Resident #2 had an order for eyedrops on the nurse cart to be administered. LVN G stated Resident #2's family had personal items and believed that was where the eyedrops came from. According to LVN G, this failure placed residents at risk of using more than prescribed. LVN G stated all nursing staff were responsible for ensuring all medications were properly stored. Interview on 04/20/24 at 4:20 PM with the DON revealed she was not aware Resident #2 was storing eyedrops at her bedside without an order. The DON stated she expected nursing staff to have appropriate orders for each resident. The DON stated in this case, not having proper order would indicate she did not have eyedrops at her bedside, which could cause over dosing. The DON stated nursing staff are to be observant of resident items and secure anything that could present potential harm. Record review of the facility's Discontinued Medications policy, dated January 2023, reflected the following: ''1. if prescriber discontinue a medication, the medication container is removed from the medication cart according to state federal regulations in a timely manner . 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. .8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 44937

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 on two of four medication carts (Hall C) and (Hall D) and 2 of 6 (Resident #46 and #47) reviewed for pharmacy services. The facility failed to ensure the Hall C and Hall D nurses medication carts contained accurate narcotic logs for Residents #46 and #47. LVN B and LVN C failed to document the administration of narcotic medications in a correct and timely manner. These failures could place residents at risk for medication error, drug diversion, and delay in medication administration. Findings included: Review of Resident# 46's Quarterly MDS assessment, dated 06/16/24, reflected the resident was [AGE] year-old female admitted to the facility on [DATE] and a re-admission of 06/10/24, with diagnoses that included hip and knee replacement. Resident #46's had intact cognition with a BIMS score of 13. She was also getting pain medication as needed. Review of Resident #46's physician's orders dated 06/11/24 reflected Tylenol with Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine). Give 1 tablet by mouth every 6 hours as needed for Pain. Review of Resident # 46's Medication Administration Record reflected last administration was on 06/19/24 at 6:30 AM. Review of Resident# 47's Quarterly MDS assessment, dated 04/09/24, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included hip and knee replacement. Resident #46 had intact cognition with a BIMS score of 15. He was also getting scheduled pain medications. Review of Resident #47's physician's orders dated 07/18/23 reflected Tramadol HCl (hydrochloride) Oral Tablet 50 MG . Give 1 tablet by mouth four times daily routinely for Pain. Review of Resident # 47's Medication Administration Record reflected the last administration was on 6/19/24 at 11:00AM. Observation on 06/19/24 at 08:50 AM of the nurses' medication cart for hall C and the Narcotic Administration Record, with LVN B, reflected the following information: Resident #46's Narcotic Administration Record sheet for Acetaminophen-codeine #3 was last signed off on 06/16/24 for a one-tablet dose given at 09:30 PM, for a total of 97 pills remaining while the blister pack count was 96 pills. Interview with LVN B on 06/19/24 at 09:20 AM, revealed at first she admitted having administered the pain pill and later stated it was administered by the night shift nurse. LVN B stated it was nurses' responsibility to log narcotics after administering. She stated the risk of not logging narcotics after administration could lead to drug diversion, overdose, and discrepancy. LVN B stated she had done in-service on medication administration and narcotic log. Observation on 06/19/24 at 01:31 PM of the nurses' medication cart for Hall D and the Narcotic Administration Record, with LVN C, reflected the following information: Resident #47's Narcotic Administration Record sheet for Tramadol 50mgs was last signed off on 06/16/24 for a one-tablet dose given at 8:00AM, for a total of 38 pills remaining while the blister pack count was 37 pills. Interview with LVN C on 06/19/24 at 1:42 PM revealed she administered Tramadol 50 mg 1 tablet to Resident #47 and had not signed off on the NAR. She stated she gave the resident the medication, but she forgot to sign off on the narcotic administration log. She stated she knew she was to sign-out on the narcotic count sheet after administration, but she did not because she got busy. She said she was not sure what would happen if the narcotics were not being logged off immediately after administration. Interview with the ADON on 06/19/24 at 1:48 PM revealed her expectation was for nurses to log narcotics as soon as possible after administration. She stated after the nurse reported to her, she checked and found out that both the night and the morning shift nurses did not count the narcotics during shift change. She stated Resident #46 was administered pain medication on 6/19/24 at night. She stated her expectation was that nurses should count during shift change and report any discrepancies to her. She stated it was her responsibility to check the cart and ensure the nurses were documenting narcotic administration, but she could not recall the last time she checked the carts. She stated she had done in-services with staff on medication administration, counting of narcotics, and logging off on 01/08/24, 03/10/24, and 03/11/24. Interview with LVN B on 06/19/24 at 2:38 PM revealed she did not count the narcotics with the outgoing nurse. She stated she knew she was supposed to count before she took the key from the night shift, but she did not because after report the night shift nurse was busy on the floor giving report to another nurse. LVN B stated the risk of not counting between the shifts could lead to medication diversion. She stated she had done training on counting before handing over the key. Interview on 06/19/24 at 4:42 PM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the Medication Administration Record and to sign on the narcotic log. The DON stated she talked to both nurses and they revealed they did not count during shift change. She stated the DONs were supposed to be checking on the nurse's carts. She stated she had done an in-service regarding key handling and the nurses were aware they cannot leave the facility before counting. Interview with LVN D on 06/20/24 at 2:23 PM revealed she did not count with day shift nurse because she had a family member that was sick. She stated she knew she was supposed to count before handing over the key. She stated she administered the pain medication, and she knew she was supposed to log the medication off after administering, but she got distracted. LVN D stated she knew she was supposed to count to ensure the count was right and failure to count could lead to narcotics missing and diversion. She stated she had done training on counting before handing over the key. Review of the facility's Medication-Controlled Substances policy revised on December 2012 reflected: .9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make sure they count together. They must document and report any discrepancies to the DON .

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #2) reviewed for oxygen. 1. The facility failed to have physician orders for Resident #2's oxygen use. 2. The facility failed to ensure Resident #2's humidifier and nasal cannula was changed out on a weekly basis. This failure could place residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection. Findings included: Record review of Resident #2's face sheet dated 06/19/24, reflected the resident was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Record review of Resident #2's MDS dated [DATE], reflected the resident had a BIMS score of 14, indicating cognition was intact. The assessment indicated Resident #2 required supervision or touching assistance with eating, oral hygiene, toileting, shower/bath, upper and lower dressing, putting on/taking off footwear, and personal hygiene. Active diagnoses included anemia (blood has reduced ability to carry oxygen), coronary artery disease (reduction of blood flow to heart muscle), heart failure (heart's ability to fill with and pump blood), hypertension (high blood pressure), diabetes mellitus (sustained high blood sugar levels), malnutrition (too few or too many nutrients), depression (mental state of low mood), and chronic obstructive pulmonary disease (airflow blockage and breathing-related problems). Resident #2's MDS did not indicate required use of oxygen therapy. Record review of Resident #2's care plan reflected Resident #2 was at risk of shortness of breath, edema, chest pain, elevated blood pressure, related to chronic obstructive pulmonary disease. Goals included: Resident will be free of complications of shortness of breath and increased edema. Interventions included: oxygen as ordered. Record review of Resident #2's physician order summary report, dated 06/18/24, reflected there was not an active physician's order for oxygen use. Record review of Resident #2's progress notes dated 06/06/24 at 9:25 PM written by LVN reflected: progress notes: Resident had an episode of syncope in the beauty shop when the hairstylist was doing her hair. This writer went their resident was rush to her room transferred safely back to bed. Resident vital signs were stable except 02 sat noted at 89. Residents open her eyes and was responding 02 sat went up to 95% on 3 liters per minute via nasal cannula. Resident is stable no s/s of discomfort or respiratory distress noted, denied any discomfort. Daughter notified. Observation and interview on 06/18/24 at 3:44 PM revealed an oxygen humidifier bottle with tape, but the date was not legible. Observation of the nasal canula revealed it was not dated and appeared discolored. Oxygen level indicated Resident #2 was provided with 3 liters. Interview with Resident #2 revealed she had been on continuous use of oxygen for some time now. Resident #2 stated a nurse entered her room today to add water to humidifier bottle, but it had been a long while since she had her nasal canula changed. Resident #2 stated it had been over several weeks since she received a cannula replacement. Resident #2 stated she required the use of oxygen at all times, especially while she was up out of bed. Observation and interview on 06/19/24 at 2:21 PM with LVN C revealed Resident #2 had been with oxygen use continuous for a long while now. LVN C stated she was not aware there was no order for Resident #2's oxygen use. LVN C stated it was the admitting nurse's responsibility to ensure all orders were entered to care properly for residents. LVN C stated Resident #2's humidifier and nasal canula should be changed out every Sunday on the 10:00 PM-6:00 AM shift by the charge nurse. LVN C stated Resident #2 had not told her that the canula had not been changed. LVN C stated she was not aware the date was not provided on the oxygen nasal cannula or clear writing on the humidifier bottle. LVN C stated dates were provided to indicate when the task was last done. LVN C stated not providing fresh water or new nasal cannula would cause Resident #2 to be at risk for infection or respiratory concerns. Observation and interview on 06/19/24 at 3:25 PM with the ADON revealed Resident #2 went to the hospital about two months ago and at that time all her orders were discontinued. The ADON stated once Resident #2 returned the admitting nurse should have entered new orders. The ADON stated she was then responsible for reviewing the orders to ensure they were all entered and correct. The ADON stated the oxygen nasal cannula was to be changed out on Sundays, on the overnight shift, by the nurse. The ADON stated she was not aware her chord had not been changed or that there was not a physician order. The ADON stated she expected for nursing staff to ensure they were following physician orders when administering care and treatments. If there was no order, nurses should contact the doctor to get an order. The ADON stated she expected nursing staff to ensure they were changing the nasal cannula and humidifier bottle weekly to prevent risk of the cannula clogging, preventing the proper amount of oxygen flow. The ADON revealed Resident #2 should be on 2 liters of oxygen; however, observation revealed Resident #2 was receiving 3 liters. Interview on 04/20/24 at 4:20 PM with the DON revealed she was not aware there were no orders regarding Resident #2's oxygen use. The DON stated admitting nurses have authority to contact the physician or their Nurse Practitioners to get an order for oxygen. The DON stated not contacting the physician for an order placed the resident at risk of care not being completed properly, staff will not know what to do. The DON stated the humidifier and nasal cannula should be changed out every Sunday once a week by the 10:00 PM-6:00 AM nursing staff, not doing so would increase respiratory illness and infection. A policy on oxygen/respiratory treatment was requested on 06/20/24 at 11:17 AM; however, the policy was not provided prior to exit. The facility also failed to provide a policy on following physician orders.

Based on interviews and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 2 of 20 residents (Residents #2 and #27) reviewed for advanced directives. The facility failed to ensure Resident #2's and Resident #27's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored. Findings included: Record review of the face sheet dated 06/19/24, reflected Resident #2 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Record review of Resident #2's quarterly MDS, dated [DATE], refleced Resident #2 had a BIMS score of 14, indicating cognition was intact. The assessment indicated Resident #2 required supervision or touching assistance with eating, oral hygiene, toileting, shower/bath, upper and lower dressing, putting on/taking off footwear, and personal hygiene. Active diagnoses included anemia (blood has reduced ability to carry oxygen), coronary artery disease (reduction of blood flow to heart muscle), heart failure (heart's ability to fill with and pump blood), hypertension (high blood pressure), diabetes mellitus (sustained high blood sugar levels), malnutrition (too few or too many nutrients), depression (mental state of low mood), and chronic obstructive pulmonary disease (airflow blockage and breathing-related problems). Record review of Resident #2's undated care plan, revised on 02/18/24, reflected Resident #2 had code status as full code. Goal included to maintain status over the next 90 days. Interventions included code status indicated by green for full code, inform staff of code status, make sure code status was signed by the resident or responsible party, monitor for decrease in change of condition, and report to the physician and the responsible party. Record review of Resident #2's physician order summary report, dated 06/18/24, reflected it did not have an active physician's order for code status: Full Code Status or any other order to support her advanced directive. Record review of the face sheet dated 06/19/24, reflected Resident #27 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Record review of Resident #27's quarterly MDS dated [DATE], reflected Resident #27 had a BIMS score of 10, indicating cognition was intact. The assessment indicated Resident #27 required supervision or touching assistance with eating and oral hygiene, partial/moderate assistance with toileting, shower/bath, upper and lower dressing, putting on/taking off footwear, and personal hygiene. Active diagnoses included cancer, hypertension (high blood pressure), diabetes mellitus (sustained high blood sugar levels), malnutrition (too few or too many nutrients), depression (mental state of low mood), and immunodeficiency (failure of the immune system to protect the body adequately form infection). Record review of Resident #27's care plan reflected Resident #27 had code status as Do Not Resuscitate. Goal included to maintain status over the next 90 days. Interventions included code status indicated by red for DNR, inform staff of code status, make sure code status was signed by the resident or responsible party, monitor for decrease in change of condition, and report to the physician and the responsible party. Record review of Resident #27's physician order summary report, dated 06/18/24, did not indicate an active physician's order for code status. During an interview 06/19/24 at 3:14 PM, the Social Worker stated both Resident #2 and Resident #27 readmitted prior to her employment. The Social Worker revealed she had been assisting where she could with medical records. The Social Worker stated she reviewed the advance directive at admission with the resident or the responsible party. The Social Worker stated not having an advance directive placed residents at risk of not having their wishes honored. During an interview of 06/19/24 at 3:17 PM, LVN G stated she was not aware Resident #2's electronic health record did not include an advance directive order. LVN G revealed inside Resident #2's clinical chart at the nursing station indicated Resident #2 was full code. LVN G stated if there was a situation, she would go by the paper chart, and follow the facility protocol based on her paper documentation. LVN G stated advanced directives were discussed and signed at admission. LVN G stated the ADON would review the advance directive and ensure the order was entered. LVN G stated, Resident's electronic health record should match their paper chart so that we could honor resident wishes. During an interview on 06/19/24 at 3:25 PM, the ADON stated when residents admit to the facility, the resident or responsible party provided the advance directive. The ADON stated nursing staff were to keep up with resident advanced directives throughout their facility stay. The ADON stated advance directives were kept in resident charts at the nursing station and in the electric health records. The ADON stated she was not aware there were no orders in place for Resident #2 and Resident #27's advance directive. The ADON stated although all residents were full code unless a do not resuscitate order was in place, there should have been an order to match the paper clinical records. The ADON stated not having an order in place placed residents at risk of not having their life saving measures in place. She stated staff would not know what to do to honor their request. During an interview on 06/20/24 at 4:20 PM, the DON stated she expected advance directive orders to be in place at admission to the facility. The DON stated she and the ADON's were responsible for ensuring orders were in place by reviewing orders after admission. The DON stated the admission nurses enter the orders which would include the resident's advance directives. She stated the ADON reviewed them, and the DON went in to ensure the triggers were activated. The DON stated she guessed the orders were missed upon their last re-admission to the facility. The DON stated not having an order can compromise staff honoring resident lifesaving wishes. Record review of the facility undated admission packet reflected: Policy Statement Regarding Self Determination and Advance Directives. The facility will provide all residents and or their responsible party, at the time of admission, with information relating to the resident's right to accept or refuse medical treatment, and the right to formulate advance directives. The facility will follow physician's orders reflecting such rights Record review of facility policy titled Advance Directive revised December 2016 reflected: .Advance Directives will be respected will be respected in accordance with state law and facility policy. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, or family, or legal representative, about the existence of any written advance directive. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Nursing staff will document in the medical record the offer to assist and the president's decision to accept or decline assistance. The attending physician will provide information to the resident and legal representative regarding the president's health status, treatment options, and expected outcomes during the development of the initial comprehensive assessment and care plan

Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for one of three staff (LVN A) which resulted in an 8.57% medication error rate after 35 opportunities with 3 errors for 1 of 3 residents (Resident #57) reviewed for medications. LVN A failed to flush Resident #57's gastrostomy tube with prescribed amount of water before, between, and after medications, when he administered medication. These failures could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response and put residents who received medications via gastrostomy tube at risk for gastronomy tube blockage and medication interaction. Findings included: Record review of Resident #57's entry MDS assessment, dated 05/30/23, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was severely impaired with a BIMS score of 0. The resident had diagnoses which included gastronomy status and she had a feeding tube. Review of Resident #57's June 2024 Physician Orders reflected there was no orders for flushing gastrostomy tube with 5-10 ml of free water between each medication administration but reflected an order dated 5/29/24 to every shift Flush G-tube with 60ml of water before and after medication administration. Observation on 06/19/24 at 1:00 PM revealed LVN A prepared Carbidopa 25-100 1 tablet (treats Parkinson), Liothyronine 5 mcg 1 tablet (treat hypothyroidism, a condition wherein the thyroid gland does not produce enough thyroid hormone), and Metoclopramide 5 mg 1 tablet (for ulcers), and put the medication in different cups. LVN A crushed the medication, put it in separate cups, and went to Resident #57's room. LVN A washed hands and put on gloves and he positioned Resident #57 in an upright position. LVN A checked for the gastrostomy tube placement and failed to check for residual. He flushed the gastrostomy tube with 30 ml of water, administered medication one at a time, but he did not flush the gastrostomy tube with water between medications. LVN A flushed the gastrostomy tube with 60 ml of water after medications and the administered the 200 ml water as scheduled. Interview with LVN A on 06/19/24 at 1:11 PM revealed he was aware of flushing the gastrostomy tube with water before, between, and after medication administration through the gastrostomy tube for Resident #57. He stated he did not flush because he did not have orders. He stated it was his responsibility and best nursing standard of practice to check the orders before administration of any medication, but he had been flushing at the beginning and at the end of administration. LVN A stated failure to flush between medication administration could lead to the gastrostomy tube having blockage and medication interactions. He stated he had received training on medication administration via gastrostomy tube. He stated he did not contact the doctor because there was an order to flush before and after with 60 ml. Interview with the DON on 06/19/24 at 4:34 PM revealed her expectation was for the nurses to flush the gastrostomy tube before, between, and after each medication administration as per the doctor's orders and follow the facility policy. She stated failure to check orders to flush the gastrostomy tube may lead to gastrostomy tube being clogged and medication interaction. The DON stated he had trained the nurses on medication administration via gastrostomy tubes, she had done competency for skills on all staff, but no documentation was provided. She stated it was the ADON's responsibility to follow up on nurses to ensure they have orders in the MAR. Interview with ADON H on 06/20/24 at 10:37 AM revealed she was notified by LVN A he did not flush with 5-10 ml of water between the medications through the gastronomy. She stated she educated LVN A, checked on physician orders, and they were missing orders to flush between the medications. She stated she called the doctor and she has updated the orders. ADON H stated it was her responsibility to audit the charts weekly. She stated she audited the charts but not on gastronomy orders. ADON H stated her expectation was the staff should follow the physician orders and flushing was the best practice with or not having orders. She stated failure to check orders to flush the gastrostomy tube may lead to gastrostomy tube being clogged and medication interaction. Record review of the facility's current Administering Medication through an enteral tube policy revised March 2015, reflected the following: .1 .verify there is a physician order for the procedure. 20 .Check gastric residual volume to assess for tolerance of enteral feeding. .26 .If administering more than one medication flush with 15mls (or prescribed amount) warm sterile purified water between medications.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain proper incontinent care for 1 of 5 residents (Resident #26) for activities of daily living care. The facility failed to provide proper incontinence care to Residents #26 without using multiple briefs every 2 hours and as needed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Review of Resident #26's face sheet, dated 04/21/24, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #26's MDS Quarterly Assessment, dated 05/28/24, reflected a BIMS score of 0, which indicated severe cognitive impairment. Further review reflected Resident #2 required total dependence on staff regarding activities of daily living. Review of Resident #26's diagnosis reflected urinary tract infection (an infection in any part of the urinary system), pressure ulcer of the sacral area (localized damage tothe skin and underlying soft tissue at the base of the spine), sepsis (the body's extreme and life-threatening response to an infection), benign prostatic hyperplasia with lower urinary tract symptoms (enlargemet in the size of the prostate gland), neuromuscular disfunction of bladder (when the relationship between the nervous system and bladder function is disrupted by disease or injury). Review of Resident #26's care plan reflected the following: Resident incontinent of the bladder and bowel with the use of briefs, Goal: Resident will not have any skin breakdown over the next 90 days .Intervention: monitor for incontinent care every two hours and as needed, change promptly - cleanse and apply barrier cream .Resident activity of daily living included toileting with 1-2 person assist. Goal: will maintain a sense of dignity by being clean, dry, odor free, and well groomed. Interventions: assist with toileting and peri care. Observation and interview on 06/20/24 at 1:40 PM with LVN C revealed Resident #26 had on two incontinence briefs. Interview with LVN C revealed aides were responsible for incontinence care for Resident #26 every two hours. LVN C stated she assisted if needed. LVN C stated she was aware Resident #2 required an extra brief because of the amount of urine he produced. LVN C stated it was not protocol to use more than one brief; however, exceptions were made for Resident #26. LVN C stated having more than one brief could cause skin breakdown and irritation. Interview on 06/20/24 at 1:57 PM with CNA I revealed she was aware Resident #26 had more than one brief on. According to CNA I, Resident #26 heavily urinated and with the position of his penis, the urine would travel upward, and soak at his sacrum. CNA I stated she had been questioned about his incontinence care several times because it would appear as if she never changed him. CNA I stated it was her idea to put two briefs on the resident, so that it would give extra padding to prevent urine from traveling down around his pressure wound. CNA I stated the ADON and the DON was aware of the method she was using and had not instructed her to discontinue. CNA I stated since they had started putting two briefs on Resident #26, there had not been any more complaints of the resident appearing wet or soiled. CNA stated double briefing could cause skin breakdown. Interview on 06/20/24 at 02:42 PM with the ADON revealed she was aware staff was using more than one brief while completing incontinence care with Resident #26. The ADON stated she had been notified Resident #26 was often wet with shift change, so she went to observe him. The ADON stated she questioned staff after seeing the double briefs. She stated the staff explained urine would travel up, so that was why they were putting two briefs on the resident. The ADON stated everything would be wet around the resident's waist, so this would protect urine from coming up on him and settling around his wound. The ADON stated interventions in place were more frequent rounds. The ADON stated she knew applying multiple briefs were not facility protocol, and it would place residents at risk of skin breakdown and infection. Interview on 06/20/24 at 5:54 PM with the DON revealed aides, nursing, and anyone doing direct care on the residents were responsible to provide adequate incontinence care for residents. The DON stated Resident #26 had a wound on his sacrum. The DON stated she was made aware of Resident #26's double brief which should be in the front area to prevent urine from settling down near his wound. According to the DON, aides revealed the reason for the double briefing was due to the resident's clothing getting wet all the time. The DON stated the thought process included preventing skin breakdown or pressure sores. She stated if it was done with good intentions, it would be a benefit. The DON stated Resident #26 had an air mattress and was being turned every two hours with frequent incontinence care checks. The DON stated it was usually not okay to use this method. She stated if the family found another means of keeping moisture off the resident's private areas, they would be open to trying the suggestion. The DON stated this method placed Resident #26 at risk of having dignity concerns and the collection of urine could cause more skin breakdown. The DON provided several policies but did not provide a policy specific to pericare, briefing procedures, or care with incontinent residents.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. On 07/23/22 CNA A failed to comply with the facility's no cell phone use policy and conversed on her personal cell phone while preparing Resident #1 for an assisted transfer using a mechanical lift. Resident #1 fell from the lift resulting in a laceration to the right forehead that required 5 sutures to close, a fractured right upper arm and subarachnoid hemorrhage (bleeding within the subarachnoid space located between the brain and the tissue covering the brain). It was determined a past non-compliance Immediate Jeopardy existed from 07/23/22 to 07/27/22. The Immediate Jeopardy was determined to have been removed on 07/28/22 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's undated Admission Record revealed the resident was an [AGE] year old female admitted to the facility 10/30/17 with diagnoses to include Alzheimer's disease (a gradually progressive brain disorder that causes problems with memory, thinking and behavior), muscle contractures (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with daily life and activities). Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed the resident was rarely/never understood and cognitive skills for daily decision making were severely impaired. The resident was always incontinent of bowel/bladder, required extensive physical assistance of two or more staff for bed mobility, totally dependent on two or more staff for transfers and totally dependent on one staff for dressing, eating and hygiene. Record review of Resident #1's care plan revised 05/21/22 revealed the resident's activities of daily living were addressed and a Hoyer lift (brand of mechanical lift) and two persons were to be used for all transfers. Interview with the Administrator and DON on 07/28/22 at 9:02 a.m. revealed CNA A and CNA B had been suspended as a result of Resident #1's fall from the mechanical lift when the sling became unhooked from the lift on the right lower side. Just before Resident #1's fall on 07/23/22, CNA A had answered a call on her personal cell phone and was talking while attaching the resident's transfer sling to the mechanical lift. The Administrator and DON stated the facility had a strict no cell phone use policy. They further stated CNA A told them that she may have been distracted from attaching the lift properly while using her cell phone. The lift was inspected and found to be functioning properly. The resident's personal sling was inspected and was found to be in good condition and practically new. The DON stated it was important for facility staff to follow the facility's no cell phone use policy because staff could become distracted causing an accident and/or resident injury. She stated both CNAs remained on suspension. Resident #1's incident report dated 07/23/22 reflected the resident was being transferred in the mechanical lift when the resident accidently slid to the floor from the sling. The nurse was informed and observed the resident on the floor laying on the right side with blood noted to the right side of the head. The resident was assessed by the nurse and left immobilized on the floor with an ice pack until paramedics arrived. Staff have been and are currently being retrained to include return demonstrations on the use of the mechanical lift, in-service training included the facility's no cell phone use policy, abuse, and neglect. They further stated no staff would be allowed to work until they had received the retraining and in-service. Review of Resident #1's hospital records revealed the resident presented to theER on [DATE] after a fall from a mechanical lift. The resident sustained a fracture of the right humerus (largest bone of the upper arm), facial lacerations and subarachnoid hemorrhage and was subsequently admitted to the ICU. A 4 cm facial laceration was closed with 5 sutures. Orthopedic notes dated 07/24/22 reflected no surgical intervention was provided as the risks outweighed the benefits given the resident's advanced dementia and significantly poor functional status. Interview with the physician on 07/28/22 at 10:28 a.m. he identified himself as Resident #1's primary hospital and primary facility physician. He stated the resident arrived at the ER with a fractured humerus and a small stable brain bleed that had been assessed by the Neurologist as requiring no further intervention. Resident #1 was observed in the hospital on 07/28/22 at 10:44 a.m. asleep in bed with a sling to the right arm, a bandage to the forehead and she was utilizing a BPAP machine. (Bilevel positive airway pressure-a form of non-invasive ventilation therapy used to facilitate breathing). The resident's family member was at the bedside and stated facility staff had often transferred the resident using the mechanical lift and she felt the facility took really good care of Resident #1 until now. She stated she had been informed by the facility's administrative staff that CNA A was distracted and should have told her (the daughter) she was busy and could not talk so that she (CNA A) could pay more attention to what she was doing. She further stated there was a camera in the resident's room, and she had provided video of the entire incident to the facility's administrative staff per their request. Interview with CNA B on 07/28/22 at 12:16 p.m. revealed she assisted CNA A with transferring Resident #1 on 07/23/22 for a shower. She stated she managed the controls and the handlebars of the mechanical lift and attached the left side of the sling to the lift. She recalled CNA A receiving a phone call and was talking on the phone while attaching the right side of the sling to the lift. She stated she just stood and waited for CNA A to complete the call and did not notice if the sling on the right side was attached properly by CNA A. She stated they were close to Resident #1's bathroom door when the resident fell from the lift to the floor. She further stated the transfer was going well and she did not know how the resident fell . After the resident fell the right lower half of the sling was noted detached from the lift. She further stated she was aware of the facility's no cell phone usage policy. Interview with CNA A on 07/28/22 at 2:02 p.m. revealed she recalled transferring Resident #1 from the bed on 07/23/22 for a shower. She initially stated the sling was not in place or attached to the lift when she received a call on her personal phone. She stated she and CNA B placed the sling and attached it to the lift after she had completed the phone call. She further stated as she and CNA B approached the bathroom door with the resident in the lift, the resident fell on to the floor. She stated after the resident's fall she noticed the sling was not attached on the right lower side. She further stated she was aware of the facility's no cell phone usage policy and should not have answered the phone. Interview with CNA A on 07/28/22 at 2:49 p.m. she stated she wanted to add additional information and had been rethinking the incident. She stated she did recall the sling being in place under Resident #1 at the time she received the phone call. She stated she answered the phone and was speaking on the phone while she connected the right side of the sling to the lift. She further stated she may have been distracted and may not have connected the sling to the lift properly. She further stated she did not know how the right lower side of the sling became detached from the lift. Observation of the Resident #1's electronic monitoring video with the Administrator on 07/28/22 at 3:28 p.m. revealed CNA A and CNA B were in the Resident #1's room attaching the sling to the mechanical lift. CNA A answered her cell phone and remained on the phone talking while attaching the sling to the right side of the lift. After she ended the call, the lift was raised, and the CNAs proceeded to push the lift with the resident towards the bathroom. As they approached the bathroom Resident #1 fell forward out of the lift onto the floor. Review of personnel files for CNA A and CNA B revealed mechanical lift training had been provided. CNA A was hired on 03/09/11 and was provided safe resident handling training that included the use of the mechanical lift on 9/21/20, 09/01/21 and 07/25/22. CNA B was hired on 06/20/22 and was provided mechanical lift training on and on 07/25/22. The personnel files of both CNAs included signed acknowledgements of the facility's no cell phone use policy. The signed acknowledgement for CNA A was dated signed 03/09/11 and the acknowledgment for CNA B was dated signed 06/20/22. Review of education material, training and in-service records revealed the DON and ADON had provided training and in-services related to how to use a Hoyer lift, using a mechanical lift, abuse/neglect, fall prevention and cell phone use. The records revealed a plan of action had been initiated to include monitoring prior to entry on 07/28/22. Review, of the following reflected the facility was in compliance on 07/28/22. The facility implemented the following interventions: Mechanical lift training with return demonstration was provided to all nursing staff to included licensed nurses. Implementation of a two-step process requiring staff to verbally state to one another that the loops were secure upon immediate placement to the lift and again when the lift is raised to support the weight of the resident. DON/ADON/Designee will develop a list of residents requiring mechanical lift transfers. This list will be utilized to monitor random observations of transfers as follows: (a) Twice a day for one week (b) Three days for one week (c) Two days for one week (d) Random monitoring will be continued and reported to QAPI committee for recommendation. Interviews were conducted with 12 CNAs on 07/28/22 from 12:16 p.m. to 4:30 p.m. and 4 CNAs and 6 nurses on 07/29/22 from 1:33 p.m. to 3:23 p.m. The nursing staff were able to accurately summarize the mechanical lift training they received and the facility's no cell phone use policy. Review of the facility's policy entitled Personal Use of Cellular and Town Hall Phones dated April 2021 revealed in part: Employees are to keep personal cellular phones on silent while on duty and may ask (sic) to limit use to personal cellular phones during break or lunch periods. Cellular phones may not be used while operating company vehicles or other equipment or machinery.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, based on the comprehensive person-centered care plan, and the residents' choices for one of five residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 did not suffer injury and extreme back pain during her physical therapy treatment on 09-02-21. Following the physical therapy treatment, the resident was unable to continue physical therapy for the remainder of her stay at the facility due to back pain. The resident had a CT scan ordered for continued back pain and was diagnosed with a compression fracture of the T12 (Compression fracture of the spine) on 09/17/21. This failure could place residents at risk for injuries that could cause harm, hospitalization , and a decreased quality of life. Findings include: Record review of Resident #1's admission MDS (minimum data set) assessment, dated 09/15/21, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She did not have impaired cognitive skills. She received pain medication as needed and was almost constantly in pain which limited her day to day activities. The resident received physical therapy that started on 08/27/21. The resident was totally dependent on staff for bed mobility. Record review of Resident #1's Care Plan, dated 09/15/21, reflected the following problems and interventions: Resident admitted with impaired upper extremity strength, impaired activity tolerance, impaired trunk control, impaired sitting balance and impaired functional mobility. Intervention: Bed mobility - Resident is totally dependent on 1 staff for repositioning and turning in bed. Record review of Resident #1's Physician Orders, dated 08/27/21, reflected: Physical Therapy to evaluate and treat as indicated. Record review of Resident #1's Daily Physical Therapy/Occupational Therapy notes, dated 08/27/21 - 09/21/21, reflected the following: 08/27/21 Physical Therapist: Training in lower extremity exercises to improve strength and circulation and to prevent blood clots while in bed. High complexity evaluation performed with indication of personal factors and/or comorbidities: chronic back pain and multiple back surgeries. Resident activity limitations and/or participation restrictions include bed mobility, transfers, sitting and standing balance, coordination deficit, pain on low back, activity tolerance deficit, and deficit in strength. Pain Rating Scale = 9/10 for back pain. Resident training included proper posture in bed, scooting up in bed to improve posture. Resident felt better in a flexed posture (leaning forward position instead of sitting straight up) due to moderate to severe central canal stenosis (central canal stenosis is the medical term for the narrowing of the spinal canal.) 08/30/21 Physical Therapy Assistant: Resident's friend present at beginning of treatment. Friend reports that resident does not tolerate much and has high back pain often. Trained resident on bed rolling side to side with log rolling technique. 09/01/21 Physical Therapy Assistant: Educated resident on working past the point of pain to allow the body to acclimate with exercises and tasks and improve functional mobility. Therapy will work around resident's pain medications to allow optimal pain tolerance with therapy .Resident reports 10/10 pain in today's treatment, even with pain medicine provided. 09/02/21 Physical Therapy Assistant: Resident in bed with head of bed elevated approximately 75-degrees, resident eating lunch, and being assisted by friend. Attempted to reposition the resident to a 90-degree angle for upright posture when eating to promote proper digestion and facilitate engaging core muscles. Positioned resident to approximately 90-degree angle for approximately 25 (seconds) to allow pain if any to subside with change of posture. Resident complained of pain 10/10 in her lower back. Pain medicine for mid-day has not been provided yet. Repositioned resident to comfort with HOB at approximately 35-degrees. Resident pain remains 10/10 and resident is limited to perform any tasks due to pain. Hall nurse notified to provide pain medicine when appropriate. Hall nurse reports resident is angry due to increase in pain with repositioning. 09/02/21 Certified Occupational Therapy Assistant: Co-treatment with Physical Therapy Assistant. Resident found in bed eating lunch requiring maximum assistance from caregiver. Resident repositioned in bed requiring maximum assistance of 2 staff. Education provided regarding raising head of bed when eating to reduce aspirating and for better digestion. Resident agreeable with head of bead raised to approximately 90 degrees for 25 seconds. Stopped due to complaint of unbearable pain. Resident visually upset about the occurrence. 09/03/21 Physical Therapy Assistant: Family request to withhold physical therapy until further notice. Record review of Resident #1's Physical Therapist Progress & Discharge Summary, dated 09/21/21, reflected: Discharge analysis of progress: Resident did not achieve established long-term goals. Negative response to physical therapy episode of care influenced by patient unable to try tasks due to complaint of severe back pain; therapy put on hold for more than a week due to complaint of severe back pain; unable to try bracing for back due to unable to tolerate any activity or task for bed mobility due to severe back pain. -Physical Therapist Record review of Resident #1's Physician Orders, dated 09/03/21, reflected: Hold Physical Therapy until cleared. Record review of Resident #1's Progress Notes, reflected: 09/02/21 at 9:24 AM Medication Administration Note: [MEDICATION(S)] Tablet 7.5-325 milligrams (pain medicine). Give 1 tablet by mouth every 4 hours as needed for pain. 09/02/21 at 3:49 PM Medication Administration Note: [MEDICATION(S)] Tablet 7.5-325 milligrams (pain medicine). Give 1 tablet by mouth every 4 hours as needed for pain. Record review of Resident #1's Nursing Home Visits, reflected: 09/03/21 Chief complaint: Granddaughter states patient complains Rehab staff came to room yesterday and raised her head of bed too fast that resulted in causing her to have increased back pain, patient requests X-rays of the back due to increased pain . Physical Examination: Patient appears in moderate distress . oriented X 3 . patient complains of increased tenderness to palpation mid thoracic and lower back with pain at 8, on the scale of 1-10. Assessment: Increased pain mid thoracic and lower back, severe osteopenia, pain right hip, pain left hip, [CONDITION(S)] joint disease of the spine. Thoracic spine X-ray: Impression: Prominent [CONDITION(S)] changes consistent with patient age; this requires correlation with CT scan. Plan: Discussed with attending nurse, the patient, and Administrator that patient's present X-rays don't show any acute fracture . - FNP 09/15/21 Chief Complaint: Team conference regarding patient staying on bedrest and not getting any therapy . Assessment: Discussed with nursing home team and the patient, in her room with Physical Therapy Director, Administrator, DON .also called patient's daughter on the phone. Patient has been in the bed on bedrest per family request due to allegations of patient's back being hurt and per family they believe patient definitely has a fracture even though the X-rays show no acute fracture .Discussed with daughter to get CT scan done of the spine since she continues to say that she does not trust the X-rays and the reports and wants second opinion . Will hopefully get CT scan done within next 48-72 hours and start the therapy again gradually. - Physician Record review of Resident #1's CT scan of the thoracic spine, dated 09/17/21, reflected: There is an acute appearing compression fracture involving the .T12 (thoracic) vertebrate (bone in the spine) . Record review of Resident #1's Progress Notes reflected the following: 09/09/21 at 4:34 PM Communication with Family: (Late Entry for 09-06-21) Received request to call family regarding resident's activity level and pain management. Family voiced concerns regarding frequency of pain medication and resident not being able to get adequate relief. Family requested results of X-rays completed on 09-03-21. Informed her the results were negative for acute injury. 09/14/21 at 7:47 PM Informed by resident that she has not been able to sleep at nights, going on one week now. The resident said the pain medicine she gets at night does not help in aiding her to sleep and that is why she is asking for sleep medicine. 09/15/21 at 3:03 PM Care Meeting was held this afternoon; Physician stated the resident told him she would like to slowly begin therapy. The resident's request was to sit up in her recliner for 30 minutes/day. The Physician said he wanted to get a CT scan set up first, for the resident's back, and if all was clear, then they could proceed with the therapy. Family will let facility know when to schedule the CT scan, because the family wants to be with the resident at the time of the test. The family was concerned that if the resident went to the emergency room for the CT scan that the facility would not take her back. Family reassured that facility would not deny the resident's return. 09/17/21 at 10:57 AM Orders received at 10:15 AM to transfer resident to the emergency room for further evaluation for acute, low back pain. 09/21/21 at 6:23 PM Resident preparing to go to assisted living facility. Resident sent to new facility by non-emergent ambulance transport due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Facility Investigation Report for Resident #1's incident on 09/02/21 reflected: Resident #1 said the incident was abuse on 09/09/21. The Administrator documented no injury at that time and the Physical Therapist Assistant was suspended pending investigation. The Facility investigation report indicated the Physical Therapist Assistant followed protocol and appropriate treatment was provided to the resident. Witness Statement of Resident #1's Physical Therapist Assistant: Resident #1 stated she would not tolerate well the task requested by the Physical Therapy Assistant but said she would try. Resident #1's head of bed was positioned to a 90-degree angle for a few seconds to allow pain if any to subside with change in posture. Resident #1 complained of pain 10/10, said, it hurts, no, no, no, pain unbearable. Patient nauseas with loss of appetite due to pain. The Physical Therapy Assistant apologized to Resident #1. The Physical Therapist Assistant told the resident that therapy might cause pain with certain activities due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Witness Statement of Resident #1's Certified Occupational Therapy Assistant: The Physical Therapist Assistant said she wanted to see if Resident #1 was able to tolerate an upright posture with support. Witness Statement of Resident #1's Physical Therapist: The first day of treatment was on 08/28/21. The resident's back pain was 9/10 and the resident was unable to sit on the side of bed. Before 09/02/21, the Physical Therapist recommended that the Physical Therapist Assistant do leg exercises and pelvic exercises to manage the resident's back pain. The Physical Therapist also told the Physical Therapy Assistant she could train the resident in rolling side to side if tolerated. An interview on 12/27/21 at 10:45 AM with the family of Resident #1 (Resident #1 was not available for interview) revealed the resident was no longer in the facility. The family member said the resident was admitted to the facility for therapy and on 09/02/21 the facility's Physical Therapist Assistant came into the resident's room, grabbed the resident's bed control and elevated the resident. The Physical Therapist then moved the resident's head towards her knees. The resident yelled out twice asking the Physical Therapist Assistant to stop because of the pain. The Physical Therapist Assistant said she wanted to see how far the resident could go without pain. The family said the resident was not able to sit above a 50-degree angle in bed. The family member said the facility did X-rays after the incident and there were no injuries. The Physical Therapist Assistant was not allowed back in the resident's room after the incident. The family member said the resident had to stop all physical therapy. An interview on 12/27/21 at 12:35 PM with a friend of Resident #1 who witnessed the incident on 09/02/21, revealed the Physical Therapist Assistant came into the resident's room at lunch time and was angry. The Physical Therapist Assistant said, We are going to see what she (resident) can't do. The friend said the Physical Therapist Assistant raised the head of the bed to a 90-degree angle. She said Resident #1 kept telling the Physical Therapist Assistant to stop, but she did not stop until she had the resident in bed elevated to a 90-degree angle. She said the physical therapist lowered the head of the bed after Resident #1 had yelled for her to, Stop the third time. The friend said the Physical Therapist lowered the head of the bed back down and that was painful for the resident too. The friend said she notified the nurse to give Resident #1 pain medication and it took an hour for her to receive pain medicine. The friend said she thought the incident resulted in the resident having a back fracture. An interview was attempted on 12/27/21 at 1:58 PM with the Physical Therapist Assistant for Resident #1. The Physical Therapist Assistant did not return the call of the State Surveyor. An interview on 12/27/21 at 4:20 PM with the OTR, Regional Vice President for Resident #1 revealed she reviewed the incident (09/02/21) that occurred with the Physical Therapist Assistant. She said she was not aware of any other reported incidents regarding the Physical Therapy Assistant and could not think of anything the Physical Therapist Assistant should have done differently. She said she did not know what caused the resident's fracture and could not say what the Physical Therapist Assistant should have done when Resident #1 complained of pain because therapy for chronic back pain was a slow progression and she was not there at the time of the incident. She said she did not know how many days Resident #1 was unable to receive therapy following the incident. An interview with LVN A on 12/27/21 at 1:25 PM revealed Resident #1 preferred to be pre-medicated before physical therapy, but on 09/02/21 at the time of her therapy session, it was too soon for her to be medicated for pain. LVN A said X-rays were completed after the therapy session and they were negative for fracture. An interview with the DON on 12/27/21 at 1:00 PM and 4:00 PM revealed she was not hired until October 2021 and was not the DON at the time of Resident #1's incident on 09/02/21. The DON said a resident should be premedicated before therapy and a nurse would stop a treatment at the level of pain. She said physical therapy was a grey area for pain because some residents would fight against the therapy. The DON said premedicating residents for therapy was helpful. The DON was not able to provide a phone number for the previous DON. The DON was asked to provide a phone number for the Physical Therapist. The DON said she tried to contact the Physical Therapist three times with no answer. An interview was attempted on 12/27/21 at 1:55 PM and 2:25 PM with the Physical Therapy Director. The Physical Therapy Director did not return the call of the State Surveyor. An interview on 12/27/21 at 3:00 PM with the Administrator revealed following Resident #1's physical therapy treatment on 09/02/21 the Physical Therapist Assistant was suspended during investigation. She said the Physical Therapist Assistant resigned. The Administrator said the previous DON and the OTR, Regional Vice President were involved in the investigation. She said the OTR, Regional Vice President determined the Physical Therapist Assistant followed the resident's plan of care protocol. The Administrator said she did not know when Resident #1's fracture occurred and thought maybe it had occurred prior to admission. The Administrator said the resident had back pain prior to admission to the facility. Record review of the facility policy, Standards of Practice for Physical Therapy, dated 08/12/20, reflected: Intervention The physical therapist provides or directs and supervises intervention consistent with results of the examination, evaluation, diagnosis, prognosis, and plan of care. Intervention is focused on meeting the goals of the plan of care and optimizing functional performance, emphasizes patient or client education, and promotes proactive, wellness-oriented lifestyles . The intervention: Is provided at a level that is consistent with best available evidence and current physical therapist practice; is in direct alignment with the patient's or client's desired outcomes and goals; is altered in accordance with changes in response or status; and is provided in such a way that directed and supervised responsibilities are commensurate with the qualifications and legal limitations of the physical therapist assistant .