Every finding on record at Willowbend Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #1) reviewed for infection control. The facility failed to ensure Housekeeper A followed protocol to prevent spread of infection when cleaning a Resident #1's room that had signage to use contact precautions. This failure could place residents and staff at risk of infection and cross contamination.Findings Included:A record review of Resident #1's Quarterly MDS assessment, dated 05//30/25, reflected Resident #46 was a [AGE] year-old female admitted to the facility on [DATE], diagnoses included urinary tract infection (an infection in any part of the urinary system), extended spectrum beta lactamase (enzymes produced by certain bacteria that make them resistant to many common antibiotics), and chronic diastolic heart failure (a long-term condition where the heart muscle becomes stiff and cannot relax normally to fill with blood between beats). Resident #1 had a BIMS score of 11 which indicated moderate cognition impairment.An observation on 08/28/26 at 11:26 AM revealed a sign on Resident #1's door which reflected, Contact Precautions, everyone must clean their hands before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Housekeeper A entered Resident #1's room for cleaning. He did not put on PPE; he was in the room wiping and moping around the resident talking to her while she sat in her chair. He stated he worked with housekeeping. He stated the sign on the door meant that the patient was in isolation. He stated the resident was no longer on the isolation, and he did not know why the sign was still on the door. He stated the risk whatever the resident had could be spread to the other residents, if exposed to resident. In an interview on 08/28/26 at 11:26 AM, Housekeeper A stated he worked in housekeeping for the facility. He stated he did see the sign on Resident #1's door for Contact precautions. He stated the sign on the door meant that Resident #1 was in isolation. He stated he believed she was no longer in isolation and did not know why the sign was still on the door, and that was the reason he did not use PPE. He stated they received a list every morning of residents who were taken off of isolation. He stated he believed Resident #1 had been on the list on 08/28/26. He stated he did not have a current list. He stated the nurses would be responsible for removing the contact precautions sign from the residents' doors. He stated if he entered a room that was on contact precautions he would put other residents at risk of an infection if he did not follow precautions. He stated taking a resident, on isolation, to an area with other residents could also place the residents at risk of infection. He stated he had received an in-service on infection control, and he knew that he should put on the PPE located outside the room prior to entering the room and to take it off and wash hands prior to exiting the room.In an interview on 08/28/26 at 11:40 AM Licensed Vocational Nurse (LVN) B stated Resident #1 was still on contact isolation with protective precautions. She stated they had completed in-services with staff to ensure the staff knew which residents were on contact precautions. She stated the nurses were responsible for ensuring all staff and visitors knew which residents were on contact precautions. She stated residents on contact precautions had a bin located outside the door with PPE and if a person did not know they should contact the nurse prior to entering the room. She stated if a person entered the room without PPE, they would place other residents and staff at risk of infection.In an interview on 08/28/26 at 12:57 PM the Housekeeping Supervisor stated the housekeepers were trained by either him or the lead housekeeper (Housekeeper-C) prior to being on their own on the floor. He stated Housekeeper-A was trained by Housekeeper-C. He stated the signs on the door have instructions on what the staff needed to wear in order to enter the rooms and what to put on prior to entering. He stated the risk to all was cross contamination. He stated the staff were trained on the difference in the signs. He stated they received a daily report with who was still on isolation and Resident #1 was not on the list on 08/28/26. He stated after he received information from admissions whose room had the different contacts he sent out a text message to the housekeepers with updates and that would continue throughout the day. In an interview on 08/28/26 at 1:09 PM., Lead Housekeeper-C stated she was the person who trained Housekeeper-A. She stated during the training she went over the signs and why the bins were outside the room with the PPE for them to use. She stated she instructed the staff to use hand sanitizer prior to putting on the PPE and prior to coming out of the rooms. She said they should put everything in a bag, wash and sanitize their hands after they exit. She stated she always instructed them to ask someone if they did not know if they should put on the PPE. She stated if a person went into a room and needed to put on PPE and did not the residents and staff would be put at risk of getting sick.Record review of facility's in-service dated 08/28/26 reflected, Isolation sign on the door, staff should pay attention to signs on the door when entering resident rooms, if there is a sign for contact isolation on the door, you are required to clean your hands and put on your PPE prior to entering the room, ensure that you clean your hands prior to leaving the room.Record review of facility's infection prevention and control program policy updated 4/2025 reflected, there is on-going monitoring for infection among residents and personnel and subsequent documentation of infections that occur. Surveillance tools are used to recognize the occurrence of infections,

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 10 of 20 resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10) observed for cleanliness. The facility failed to ensure Resident Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 01/20/26 at 10:57 AM of room [ROOM NUMBER], reflected the windowsill had dirt and dead gnats. The shower floor had a rust like substance near a shower wall, and black and white substances around the center of the shower floor. The bathroom floor had white substances under the sink and near the toilet. had grayish dirt stains on the floor under the sink and grayish and brownish stains around the toilet area. The paper towel dispenser had dust and white substances all over the outer shell. An observation on 01/20/26 at 11:10 AM of room [ROOM NUMBER], reflected the windowsill had dirt and dead gnats. The air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The shower floor had black substances near the shower walls and around the center of the shower floor. The bathroom floor had white substances under the sink and around the toilet. An observation on 01/20/26 at 11:15 AM of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. An observation on 01/20/26 at 11:18 AM of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The shower floor had black and substances near the shower walls and around the center of the shower floor. The bathroom floor had white substances under the sink and around the toilet. An observation on 01/20/26 at 11:21 AM of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The windowsill had a reddish spill stain on the windowsill and going down the wall under the windowsill. An observation on 01/20/26 at 11:24 AM of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor had white substances under the sink and around the toilet. The shower floor had black and substances near the shower walls and around the center of the shower floor. An observation on 01/20/26 at 11:30 AM of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. An observation on 01/20/26 at 11:33 AM, of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor had white substances under the sink and around the toilet. An observation on 01/20/26 at 11:35 AM of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The windowsill had black stains along the windowsill. The bathroom floor had black stains under the sink and around the toilet. The shower floor had black and substances near the shower walls and around the center of the shower floor. An observation on 01/20/26 at 11:43 AM of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor had white substances under the sink and around the toilet. The shower floor had black and substances near the shower walls and around the center of the shower floor. In an interview on 01/22/26 at 10:05 AM, Housekeeping S stated she had been at the facility for nearly 19 years. She stated she cleaned the rooms on the Veteran's Way Hall. She stated they were to clean the entire room, which included the bathrooms, Air conditioning units, the mini fridges, and floors. She was shown pictures of the concerns observed in Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10, She stated if the rooms were not thoroughly cleaned it could cause respiratory problems. In an interview on 01/22/26 at 10:05 AM, the Housekeeping Supervisor stated he had been at the facility for 8 years. He stated he trained housekeeping to clean from the back of the room to the front. He stated they mop, dust, clean bathrooms. He was shown pictures of the concerns observed in Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10, and he stated it could impact the reputation of the facility. He stated the areas of concern would be addressed today. In an interview on 01/22/26 at 11:30 AM, The Administrator was told about the concerns observed in Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10. He stated they had plenty of staff in housekeeping and he expected the rooms to be thoroughly cleaned. He stated he would follow up with the Housekeeping Supervisor to ensure corrections were made. Review of the facility's policy on Safe/Comfortable/Homelike Environment (01/2022) revealed Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics includes cleanliness and order.

Based 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 four of twelve residents (Residents #73, #29, #36, and #117) reviewed for infection control. 1. The facility failed to ensure CNA K performed hand hygiene while providing incontinent care for Resident #73 on 01/21/2026.2. The facility failed to ensure RN E wore a gown while changing Resident #29's g-tube dressing on 01/20/2026.3. The facility failed to ensure LVN C wore a gown while doing Resident #36's treatment, who had an indwelling catheter (flexible tube inserted into the bladder to remove the urine), on 01/20/2026.4. The facility failed to ensure CNA F wore a gown and pair of gloves while changing Resident #117's linens, who was undergoing dialysis (a medical treatment that removes waste products from the blood), on 01/20/2026.These failures could place residents at risk of cross-contamination and development of infections.Findings include:Resident #73Record review of Resident #73's Face Sheet, dated 01/21/2025, reflected a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included Parkinson's Disease (movement disorder of the nervous system), hypertension (elevated blood pressure), and atherosclerotic heart disease of native coronary artery (buildup of plaque that leads to narrowed or blocked arteries supplying blood to the heart). Record review of Resident #73's Quarterly MDS Assessment, dated 12/02/2025, reflected moderately impaired cognition with a BIMS score of 12. Section H (Bowel and Bladder) indicated Resident #73 was incontinent of bowel and bladder. Record review of Resident #73's Comprehensive Care Plan, initiated 01/13/2026, reflected he was incontinent of bowel and bladder related to functional decline, decreased mobility, history of urinary tract infection, and diagnosis of benign prostatic hyperplasia (enlarged prostate which can block urine flow from the bladder). Interventions included to use disposable briefs and change as needed, and monitor for signs and symptoms of urinary tract infection. During an observation and interview on 01/21/2026 at 9:27 AM, CNA J and CNA K were preparing to provide incontinent care for Resident #73. CNA K pulled down the front of the brief and cleaned Resident #73. She dropped the wipes into a trash bag near her. CNA J rolled the resident to his left side. CNA K cleaned Resident #73's bottom, removed the soiled brief, and dropped it in the trash bag. CNA K removed the soiled gloves and dropped them into the trash bag. She did not use hand sanitizer. CNA K removed a pair of gloves from the pocket of her scrub top and put them on her hands. She then placed a clean brief under Resident #73 and secured the brief in front. CNA K assisted CNA J to reposition Resident #73 and covered him with the blanket. CNA J and CNA K used hand sanitizer from a pump on the wall to clean their hands. CNA K stated she should have used hand sanitizer when she changed gloves. She stated she normally used hand sanitizer, but she was nervous and forgot. She stated she probably should not have carried gloves in the pocket of her scrub top to use for resident care. She stated it was important to keep from spreading infection. During an interview on 01/21/2026 at 9:41 AM, ADON L stated staff should use hand sanitizer with every glove change. She stated CNA K should have taken a small bottle of sanitizer in the room with her supplies. She stated CNA K should not have used gloves she carried in her pocket. She stated staff would receive in-service training on cross contamination and infection control measures while providing incontinence care. During an interview on 01/21/2026 at 10:30 AM, the DON stated CNA K should have sanitized her hands before applying clean gloves. She stated CNA K should have taken a pair of clean gloves from the box on the wall in Resident #73's room, not from the pocket of her top. She stated they had already begun to provide in-service training. She stated it was important to prevent the spread of germs and infection.Resident #29Record review of Resident #29's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing).Record review of Resident #29's Comprehensive MDS Assessment, dated 12/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #29's Comprehensive Care Plan, dated 11/12/2025, reflected the resident required tube feeding and one of the goals was that the feeding tube insertion site would be free from signs and symptoms of infection.Record review of Resident #29's Physician Order, dated 12/04/2025, reflected CLEANSE G-TUBE STOMA WITH NSS, PAT DRY AND APPLY DRY DRESSING.Observation on 01/20/2026 at 1:50 PM revealed RN E was about to check Resident #29's g-tube site. She washed her hands and put on a pair of gloves. She removed the old dressing to be able to assess the g-tube site. After assessing the site, she removed her gloves, washed her hands, and put on a pair of gloves. After putting on a pair of gloves, she covered the g-tube site with a new dressing. She did not wear a gown when she removed the dressing and when she put on the new dressing. It was observed that there was a sign outside the resident's door that the resident was on EBP and PPE was required because the resident had a g-tube.In an interview on 01/20/2026 at 2:12 PM, RN E stated she should have worn a gown because Resident #29 had a g-tube. She said she forgot to do so. She said a gown was required for residents with g-tubes to prevent spread of infection from resident-to-resident. She said the gown served as a protection from contact with body fluids that might be transferred through the clothes.Resident #36Record review of Resident #36's Face Sheet, dated 01/21/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with acute kidney failure (kidneys stop working).Record review of Resident #36's Comprehensive MDS Assessment, dated 01/07/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter.Record review of Resident #36's Comprehensive Care Plan, dated 01/07/2026, reflected the resident had a foley catheter and one of the interventions was to use enhanced barrier precautions.An observation on 01/20/2025 at 9:12 AM revealed LVN C was inside Resident #36's doing a treatment. It was observed that she was leaning on the resident's bed while doing the treatment. She was not wearing a gown.In an interview on 01/20/2026 at 1:27 PM, LVN C stated Resident #36 had a catheter and if she would be doing a treatment that required contact, she should wear a gown to prevent transfer of microorganisms and spread of probable infection. She said she was leaning forward and might have had contact with the resident's bed. She said she put on a pair of gloves but should have worn a gown for an extra layer of protection.Resident #117Record review of Resident #117's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with renal failure.Record review of Resident #117's Quarterly MDS Assessment, dated 12/25/2025, reflected the resident had moderate cognitive impairment with a BIMS score of 10. The Quarterly MDS Assessment indicated that the resident was undergoing hemodialysis (medical treatment that filters waste and excess fluids from the blood when the kidney can no longer function).Record review of Resident #117's Comprehensive Care Plan, dated 01/12/2026, reflected the resident needed hemodialysis and one of the interventions was to monitor signs and symptoms to access site.Record review of Resident #117's Physician Order, dated 12/22/2025, reflected HEMODIALYSIS 3X/WEEK EVERY T-TH-SAT Needs Hemo-dialysis r/t Renal failure End stage renal disease requiring Hemodialysis 3x a week every . EVERY T-TH-S @1100 every shift every Tue, Thu, Sat related to END STAGE RENAL DISEASE (a condition where the kidneys can no longer function adequately); DEPENDENCE ON RENAL (relating to the kidneys) DIALYSIS. PLEASE SEND DIALYSIS BINDER AND SHEET WITH PATIENT, FILL OUT REQUIRED INFORMATION AND WHEN LEAVING AND RETURN.An observation on 01/20/2026 at 9:32 AM revealed that CNA F went inside Resident #117's room with some linens with her. She put on a pair of gloves and started to change the resident's linen. She took off the old linens and replaced them with new ones. She did not wear a gown. There was a sign outside the resident's door that the resident was on enhanced barrier precautions and required PPE.During an interview and observation on 01/20/2026 at 9:34 AM, LVN C stated Resident #117 was on EBP because she was undergoing dialysis. She said CNA F was just changing the linens and was not doing any care. She then read the sign and saw that PPE was required for changing linens. She then went inside the room and told CNA F that she should wear a gown when she changed Resident #117's linens.In an interview on 01/20/2026 at 9:39 AM, CNA F stated she should have worn a gown when she was changing Resident #117's bedding because the resident was on EBP and the signage outside the room clearly indicated to use PPE when changing the linens. She said the resident was not in the bed but she could introduce germs from her scrubs or she could get germs from the bed and transfer them to another resident that she would later have contact with.In an interview on 01/22/2026 at 8:23 AM, the DON stated that when a resident was on EBP, staff should wear a gown and a pair of gloves when handling the resident or the resident's beddings to prevent any transfer of MDROs (Multi-Drug Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics). She said these organisms might transfer to the scrub suits and then might be transferred to other residents. She also said that there was a sign outside the doors of the residents that were on EBP to remind the staff to wear PPE. She said all the residents with indwelling medical devices, like feeding tube, urinary catheter, and dialysis port, were on EBP. She said the expectation was for the staff to be mindful with what they were doing to protect the residents from all kinds of infections. She said she already initiated an in-service about EBP and infection control and would closely monitor the staffs' adherence to the policy.In an interview on 01/22/2026 at 8:57 AM, ADON B stated that the staff must wear a gown when PPE was required. She said if there was a sign outside a resident's door that the resident was on EBP, then gowns should be worn, in addition to the gloves, for an extra layer of protection from splashes of blood or bodily liquids that could be infected and then could be transferred to other residents. She said the staff might also bring home any infection that adhered to the clothing. She said deviation from the said procedure could result in cross contamination and spread of infection, if there was any. She said the expectation was for the staff to be mindful and compliant with the policy of infection control. She said the DON already started an in-service about EBP and infection control.In an interview on 01/22/2026 at 9:27 AM, the Administrator stated that the expectation was for the staff to adhere to the policy of infection control. He said the staff should wear a gown if the residents were on EBP. He said the staff should always make sure that they were aware that their actions could cause infections. He said, if there was a sign outside the residents' door, the staff should stop and read what was in the signage to see if they needed to wear a gown or not. He said he would collaborate with the DON and the ADONs to re-educate the staff about the importance of wearing PPE when required. Record review of the facility's policy, IPCP Standard and Transmission-Based Precautions undated, reflected Enhanced Barrier Protections (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provideopportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).Record review of the facility's signages outside the resident's room who were on EBP reflected Enhanced Barrier Protections . Providers and Staff Must also: Wear gloves and gowns for the following High-Contact Resident Care Activities . Changing Linens . urinary catheter . feeding tube.

Based on observations, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under property temperature controls, and permitted only authorized personnel to have access to the keys for four of eighteen residents (Residents #35, #105, #102, and #150) reviewed for medication storage.1. The facility failed to ensure LVN H did not leave Resident #35's medication on top of the medication aide's cart unattended on 01/21/2026. 2. The facility failed to ensure a bottle of over-the-counter peroxide was not in Resident #105's room on 01/20/2026.3. The facility failed to ensure that a nasal spray was not inside Resident #102's room on 01/20/2026.4. The facility failed to ensure an antifungal and topical (delivering medications directly to the skin) roll-on analgesic were not inside Resident #150's room on 01/20/2026These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions. Findings include:Resident #35Record review of Resident #35's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #35's Comprehensive MDS Assessment, dated 11/28/2025, reflected the resident was cognitively (resident capable of normal cognition and needs little support) intact with a BIMS 14. The Comprehensive MDS Assessment indicated the resident had hypertension.Record review of Resident #35's Comprehensive Care Plan, dated 12/10/2025, reflected that the resident had hypertension and one of the interventions was to give medications as ordered. Record review of Resident #35's Physician's Order, dated 01/05/2026, reflected (Propranolol HCl) Give 1 tablet by mouth two times a day for HTN related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP less than 110 DBP less than 60 HR less than 60.An observation on 01/21/2026 at 7:49 AM revealed that LVN H was preparing Resident #35'medication. While preparing the resident's anti-hypertensive medication, he dropped two pills of the said medication. He picked up the excess pill, put it in a small cup, and placed it on top of the cart. He continued to prepare the resident's medications and then went inside the resident's room to administer them. He left the cup with medication on top of the cart unattended when he went inside the resident's room. The cart was facing the hallway and was parked across from the resident's room.During an observation and interview on 01/21/2026 at 7:51 AM, LVN H stated he should not have left Resident #35's medication on top of the cart unattended. He said he should have disposed of it before leaving his cart because a resident might pick it up and take it. He said the resident who took it might be taking the medications crushed and might choke on it. He took the medication and disposed of it.In an interview on 01/22/2026 at 8:23 AM, the DON stated the excess pill should have been disposed immediately because a resident might get hold of it, consume it and choke on it or was allergic to it. She said the expectation was that no medication would be left on top of the cart unattended. She said she already started an in-service about medication administration. In an interview on 01/22/2026 at 8:57 AM, ADON B stated that staff should not leave any medications unattended because a resident might get hold of it, drink it, and choke from it or be allergic to it. She said the DON already started an in-service about not leaving the medications unattended on top of the carts.In an interview on 01/22/2026 at 9:27 AM, the Administrator stated that the expectation was for the staff would not leave medications on top of the cart unattended because of the risk for any resident to take something that was not needed. He said he would collaborate with the DON and the ADONs to re-educate the staff about not leaving any medications on top of the cart unattended. Resident #105Record review of Resident #105's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses which included dementia (loss of thinking, remembering, and reasoning skills) and cognitive communication deficit. Record review of Resident #105's Quarterly MDS Assessment, dated 12/31/2025, indicated the resident did not have a BIMS assessment conducted. The staff assessment for mental status was not completed. Record review of Resident #105's Comprehensive Care Plan, dated 01/20/2026, reflected alteration in neurological status related to disease process including dementia and history of cerebral ischemia (brain does not receive enough blood flow). An intervention was to cue resident and reorient as needed.Record Review of Resident #105's Physician's Orders revealed there was no order to use peroxide. During an observation and interview on 1/20/26 at 9:51 AM, Resident #105 was sitting on the side of his bed. There was a bottle of peroxide on the counter near the door of his room. Resident #105 stated he did not know how long it had been there or when it was used. During an interview on 01/20/2026 at 10:12 AM, LVN I stated the peroxide should not have been in Resident #105's room. She stated she had not noticed it on the counter in his room. She stated some residents were confused and it should not be out where a resident could get it. LVN I stated they would remove it from the resident's room. During an interview on 01/20/2026 at 10:15 AM, ADON B stated the bottle of peroxide should not have been in Resident #105's room. She stated a resident who wandered or was confused might ingest it or try to use it for other reasons. During an interview on 01/21/2026 at 10:30 AM, the DON stated the peroxide should not have been in Resident #105's room. She stated her expectation was for staff to monitor to ensure potentially harmful items were not left in residents' rooms. Resident #102 Record review of Resident #102's Face Sheet, dated 01/21/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and dementia (a condition characterized by loss of memory and ability to reason).Record review of Resident #102's Quarterly MDS Assessment, dated 12/02/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease and dementia.Record review of Resident #102's Comprehensive Care Plan, dated 12/16/2025, reflected the resident had chronic obstructive pulmonary disease monitor difficulty in breathing. Record review of Resident #102's Physician Order, dated 02/16/2024, reflected Saline Nasal Spray Solution (Saline) 1 spray in each nostril every 2 hours as needed for Congestion.Observation and interview on 01/20/2026 at 9:44 AM revealed Resident #102 was in his bed, awake. It was observed that a nasal spray was on top of the resident's side table and was on plain view. The resident said it had always been in his side table and he did not know if somebody noticed it.Observation and interview on 01/20/2026 at 9:49 AM, ADON A stated he did not notice the nasal spray inside Resident #102's room when he did his morning round. He said the nasal spray should be inside the cart and the staff should be the one administering it. He said he was not sure if the resident was using it, but if he did, the resident might use it more than the recommended dose and could result to irritation. He also said that confused resident might also get hold of the nasal spray. He said sometimes family members would bring the medication and would not let the staff know. He said they would also educate the family members about the potential harm of medications inside the rooms of the residents. ADON A went inside the resident's room and took the resident's nasal spray.Resident #150Record review of Resident #150's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia and osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other). Record review of Resident #150's Comprehensive MDS Assessment, dated 01/10/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident had dementia and osteoarthritis.Record review of Resident #150's Comprehensive Care Plan, dated 01/20/2025, reflected that the resident had alteration in musculoskeletal status related to fibromyalgia and one of the interventions was to give analgesics as ordered.Record review of Resident #150's Physician's Order, dated 01/08/2026, reflected Lidocaine External Patch 4% (Lidocaine) Apply to Bilateral Knees topically (applied to the surface of the skin) one time a day related to UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE. Apply QAM and Remove QHS and remove per schedule.Record review of Resident #150's Physician Order on 01/20/2026 reflected resident #150 did not have orders for topical roll-on analgesic and antifungal powder.During an observation and interview on 01/20/2026 at 9:13 AM, revealed Resident #150 was in her bed, awake. It was observed that an antifungal powder and a topical analgesic were on the resident's side table and was on plain view. She said she was not using the medications but they have always been on her side table. In an interview on 01/21/2026 at 11:23 AM, LVN C stated the antifungal powder and the topical analgesic should not be inside Resident #150's room because the resident might use them inappropriately or might use them more than the recommended. She said confused residents might consume them as well that could result to upset stomach and nausea. She said she knew the resident had an order for analgesic patches but not sure if she had orders for antifungal and topical analgesic. She said if there were no orders, she would check if the medications were needed and would request for orders. She went inside the resident's room and saw the medications. She talked to the resident and took the medications.In an interview on 01/22/2026 at 8:23 AM, the DON stated that medications should not be stored inside the residents' rooms unless they have an assessment for self-medication. She said nasal spray, antifungal powder, and topical analgesic should be inside the carts to secure them. She said the staff should be the one administering them if the residents had orders for the said medications. She said the residents might use them inappropriately that could result in adverse reactions. She said the expectation was there would be no medications inside the rooms of the residents and that staff should scan the room for any medications. She said she already started an in-service about medication storage.In an interview on 01/22/2026 at 8:57 AM, ADON B stated that nasal sprays, antifungal powder, and topical analgesics should not be inside the residents' rooms and should be in the carts. She said the medications should be secured so the residents, especially the confused resident, would not get a hold of them and misuse them. She said the staff should be mindful that no medications were inside the rooms. She said this was not only applicable for the nurses but the CNAs must report to the nurse if they saw any. She said the DON already started an in-service about medication storage.In an interview on 01/22/2026 at 9:27 AM, the Administrator stated that the expectation was for the staff to make sure there was no medications inside the resident's rooms because the residents might consume the medications or use them inappropriately. He said he would collaborate with the DON and the ADONs to re-educate the staff about no medications inside the rooms of the residents.Record review of the facility's policy, Medication Administration Policy/Procedure - Nursing Services revised July 2013 reflected POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician . PROCEDURES . 1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications.Record review of the facility's policy, Drug Storage Policy/Procedure - Nursing Services revised July 01, 2024 reflected POLICY: It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals . PROCEDURES . 2. Drugs and/or biologicals should not be left unsecured/unattended.Record review of the facility's policy, Physician Orders Policy & Procedure revised November 2022 reflected Policy: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs . Procedures . 8. Drugs and biological orders must be recorded on the Physician's Order Sheet in the resident's chart.

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, the comprehensive person-centered care plan, and the residents' goals and preferences for five of sixteen residents (Residents #12, #87, #32, #91, and #102 ) reviewed for respiratory care.1. The facility failed to ensure Resident #12's BiPAP mask was stored in a bag when not in use on 01/20/2026.2. The facility failed to ensure Resident #87's breathing mask was stored in a bag when not in use on 01/20/2026. 3. The facility failed to ensure Resident #32's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 01/20/2026. 4. The facility failed to ensure Resident #91's breathing mask (a medical device used to deliver medication in the form of mist directly to the lungs) was stored properly when not in use on 01/20/2026.5. The facility failed to ensure Resident #102's nasal canula was properly stored in a bag when not in use on 01/20/2026.These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include:Resident #12Record review of Resident #12's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. He had a diagnosis of acute respiratory failure with hypoxia (sudden decrease of oxygen levels in the blood).Record review of Resident #12's Quarterly MDS (tool used to measure health status) Assessment, dated 12/29/2025, reflected intact cognition with a BIMS (tool used to measure cognitive status) score of 11. Section O (Special Treatments, Procedures, and Programs) indicated his respiratory treatments included non-invasive mechanical ventilation (delivers airway pressure to assist breathing through a mask). Record review of Resident #12's Comprehensive Care Plan, dated 12/10/2025, did not reflect the BiPAP machine. Record review of Resident #12's Physician's Orders, dated 11/24/2025, reflected to use the BiPAP at bedtime related to acute respiratory failure with hypoxia. An observation and interview on 01/20/2026 at 9:14 AM revealed Resident #12 lying in bed awake. A BiPAP with an attached nasal mask (covers only your nose and delivers pressurized air directly through the nasal passage) not stored in a bag and laid on the resident's nightstand. Resident #12 stated he wore the BiPAP nasal mask at bedtime.Resident #87Record review of Resident #87's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He had a diagnosis of iron deficiency anemia (the body lacks enough iron to produces healthy blood cells, which carries oxygen throughout the body).Record review of Resident #87's Quarterly MDS (tool used to measure health status) Assessment, dated 12/13/2025, reflected moderately impaired cognition with a BIMS (tool used to measure cognitive status) score of 11. Section O (Special Treatments, Procedures, and Programs) indicated Resident #87 received respiratory treatments. Record review of Resident #87's Comprehensive Care Plan, dated 12/10/2025, did not reflect breathing treatments. Record review of Resident #87's Physician's Orders, dated 12/10/2025, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 6 hours as needed for SOB administer 3ml via nebulizer. An observation on 01/20/2026 at 9:02 AM revealed Resident #87 lying in bed asleep. A nebulizer was on the nightstand. The face mask and tubing was connected to the nebulizer. It was not stored in a bag. During an interview on 01/20/2026 at 10:12 AM, LVN I stated Resident #87's breathing mask should have been stored in a bag. She stated Resident #12's BiPAP mask should have also been in a bag. LVN I stated she had not noticed the items were not bagged. She stated it was important to prevent contamination and infection. Resident #32Record review of Resident #32's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #32's Quarterly MDS Assessment, dated 10/22/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease and was on oxygen therapy. Record review of Resident #32's Comprehensive Care Plan, dated 12/10/2025, reflected the resident was at risk for increased SOB and one of the interventions was give oxygen therapy as ordered. Record review of Resident #32's Physician's Order, dated 11/19/2025, reflected O2 AT 3 L/MIN CONTINUOUS PER Nasal cannula every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA (insufficient amount of oxygen in the body); MORBID (SEVERE) OBESITY WITH ALVEOLAR HYPOVENTILATION (breathing that is too shallow or too slow to meet the needs of the body); CHRONIC OBSTRUCTIVE PULMONARY DISEASE.Observation on 01/20/2026 at 9:55 AM revealed Resident # 32 was in her bed with eyes closed. It was observed that a nasal cannula was attached to an oxygen tank at the back of the resident's wheelchair. The nasal cannula was not bagged and was on the floor. It was also observed that there was no bag at the back of the wheelchair.During an observation and interview on 01/20/2026 at 9:57 AM, RN E stated the nasal cannula was supposed to be bagged when Resident #32 was not using it to prevent respiratory infection. She said she did not notice that the resident's nasal cannula was on the floor when she checked the resident. She said she did not know who was the last one who transferred the resident and did not know how long it had been on the floor. She disconnected the nasal cannula, threw it in the trash can, and said she would get a new nasal cannula and a bag.Resident #91 Record review of Resident #91's Face Sheet, dated 08/13/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with fatigue (persistent state of physical or mental exhaustion) and anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissue).Record review of Resident #91's Quarterly MDS Assessment, dated 11/27/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated the resident had fatigue and anemia. Record review of Resident #91's Comprehensive Care Plan, dated 07/29/2025, reflected the resident had hypoxia and one of the interventions was give aerosol (substance released in fine mist) or bronchodilators (medication that caused widening of the air passages) as ordered.Record review of Resident #91's Physician's Order, dated 12/16/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally four times a day for Wheezing for 14 Days.During an observation and interview on 01/20/2026 at 9:20 AM revealed Resident #91 was in his bed, awake. It was observed that a nebulization machine was on top of the resident's side table with a breathing mask connected to it. The breathing mask was inside the drawer and was not bagged. There was no bag inside the drawer. The resident said he was not using it anymore and he did not know why it was still inside his room. He said he could not remember if the staff were bagging it or not.Observation and interview with LVN C on 01/21/2026 at 8:13 AM, LVN C stated Resident #91's order for the breathing treatment was already done. She said the resident only had it for fourteen days. She said if it was already done, the breathing mask should have been disconnected but if it was still inside the resident's room then it should be bagged in case it would be used again. She went inside the resident's room, disconnected the breathing mask, and threw it in the trash can. She said there might be an emergency that a breathing treatment was needed and the resident would be using a dirty breathing mask that could eventually cause respiratory infection. Resident #102Record review of Resident #102's Face Sheet, dated 01/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #102 had acute respiratory failure with hypoxia (low oxygen intake) and a need for assistance with personal care.Record review of Resident #102's Quarterly MDS Assessment, dated 11/08/25, reflected Resident #102 had an intact cognitive response. The Quarterly MDS Assessment reflected the resident had active diagnoses of respiratory failure and congestive heart failure.Record review of Resident #102's Physician Orders dated 01/21/26, reflected O2 at 3 L/MIN Continuous via nasal cannula. In an observation and interview on 01/20/26 at 11:55 AM, LVN T stated Resident #102 went out on a smoke break at 11:30 AM. She observed the nasal canula sitting on top of the bed unbagged and she stated it should be bagged because it could cause an infection.During an interview on 01/20/2026 at 10:15 AM, ADON B stated the nebulizer mask and BiPAP mask should have been stored in a bag. She stated nursing staff were responsible for ensuring they were bagged and kept clean for infection control. During an interview on 01/21/2026 at 10:30 AM, the DON stated the nebulizer mask and BiPAP mask should have been stored in a bag. She stated residents inhale when putting the masks on. She stated the nursing staff were responsible for ensuring the items were bagged to prevent contamination and for infection control. In an interview on 01/22/2026 at 8:23 AM, the DON stated the nasal canula and the breathing masks should be bagged whenever the residents were not using them. She said whoever transferred the resident should have placed the nasal canula inside a bag and if there was no bag, then they should look for one or ask for one. If the resident was not using the nebulizer anymore, then the breathing mask should have been thrown away, if it was still inside the room then it should still be bagged. She said she already initiated and in-service about bagging the nasal cannula and the breathing masks. She said, moving forward, she would randomly monitor the staff if they were bagging them when not in use.In an interview on 01/22/2026 at 8:57 AM, ADON B stated breathing masks and nasal canula should be stored properly to prevent cross contamination and respiratory infections. She said whoever administered the breathing treatment was responsible for cleaning it and storing it in a plastic bag. She said whoever transferred any resident with a nasal cannula should put it inside a plastic bag, so it would be clean for the next use. She said the expectation was for the staff to bag the nasal cannula and the breathing mask when not in use. She said the DON already started an in-service about respiratory care.In an interview on 01/22/2026 at 9:27 AM, the Administrator stated the expectation was for the staff to bag the nasal cannula and the breathing mask when not in use to prevent respiratory issues. He said he would collaborate with the DON and the ADONs to re-educate the staff about bagging the nasal canula and the breathing masks. Record review of the facility's policy Oxygen Equipment Policy/Procedure - Nursing Clinical revised May 2007 reflected POLICY: It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner . PROCEDURES . 1. Oxygen Tanks, Connectors and Concentrators . E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms . 2. Nebulizer Equipment Procedures . F. Store, clean, and dry until next use.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for five of eighteen residents (Residents #22, #27, #49, #105, and #122) and three of six direct staff (ADON A, MA G, and LVN H) reviewed for accident hazard.1. The facility failed to ensure Resident #22 did not have 2 cans of aerosol air freshener spray in his room on 01/20/2026. 2. The facility failed to ensure Resident #27 did not have a can of Lysol spray in his room on 01/20/2026. 3. The facility failed to ensure Resident #49 did not have a pump bottle of hand sanitizer, a can of Lysol spray, and sanitizing wipes in his room on 01/20/2026.4. The facility failed to ensure Resident #105 did not have a can of aerosol air freshener spray in his room on 01/20/2026.5. The facility failed to ensure Residents #122's bed was lowered to the lowest position possible while she was lying in the bed.6. The facility failed to ensure ADON A did not leave a container of germicidal (substance that destroys germs and microorganism) wipes on top of his cart on 01/20/2026.7. The facility failed to ensure MA G did not leave a container of germicidal wipes on top of her cart on 01/20/2026.8. The facility failed to ensure LVN H did not leave a container of germicidal wipes on top of his cart on 01/21/2026.These failures could prevent the residents from having an environment that was free from toxic chemicals. Findings include:1. Resident #22Record review of Resident #22's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included malignant neoplasm of urinary organ (bladder cancer), heart failure (heart muscle doesn't pump blood as well as it should), and chronic kidney disease (progressive damage and loss of kidney function). Record review of Resident #22's MDS Nursing Home and Swing Bed Tracking, dated 12/29/2025, did not include Section C (Cognitive Patterns). The MDS Assessment indicated Resident #22 admitted to the nursing facility from a hospital. It did not reflect the resident's acts of daily living. Record review of Resident #22's Comprehensive Care Plan, dated 12/19/2026, reflected he was at risk for impaired cognitive function or impaired thought process related to cognitive communication deficit. One intervention was Needs supervision/assistance with all decision making. During an observation on 01/20/2026 at 9:07 AM, Resident #22 was observed lying in bed asleep. A can of air freshener spray was on his nightstand. There was also a can of air freshener spray on a counter at the entrance of his room. 2. Resident #27Record review of Resident #27's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with neurocognitive disorder with Lewy bodies (progressive decline in mental function that affects thinking, behavior, movement, and sleep). Record review of Resident #27's MDS Interim Payment Assessment, dated 01/11/2026, indicated a BIMS Assessment was appropriate but was not conducted. The staff assessment for mental status was not completed. Section GG (Functional Abilities) indicated Resident #27 required assistance with mobility and self-care needs. Record review of Resident #27's Comprehensive Care Plan, dated 01/16/2026, reflected the resident was at risk for impaired cognitive function or impaired thought processes related to a diagnosis of dementia. Interventions included to Engage in simple, structured activities that avoid overly demanding tasks and Give step by step instruction on at a time as needed to support cognitive function. During an observation and interview on 01/20/2026 at 10:09 AM, Resident #27 was lying in bed asleep. A family member was sitting at the table in his room. There were personal items on the table. There was also a bottle of Lysol spray and a bottle of multi-surface cleaner on the table. The family member stated the resident was unable to get up and get the cleaning products. The family member stated she ate and spent time on projects at the table and liked to clean up after herself.3. Resident #49Record review of Resident #49's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with cognitive communication deficit (difficulty communicating because of impaired cognitive function). Record review of Resident #49's Quarterly MDS Assessment, dated 01/05/2026, indicated severe cognitive impairment with a BIMS score of 04. Section GG (Functional Abilities) indicated Resident #49 required assistance with mobility and self-care needs. Record review of Resident #49's Comprehensive Care Plan, dated 01/19/2026, reflected he was at risk for impaired cognitive function or impaired thought process related to cognitive communication deficit. One intervention was to Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. An observation on 01/20/2026 at 9:10 AM revealed Resident #49 was not in his room. There was a 32 ounce pump bottle of alcohol hand sanitizer on his nightstand. There was a can of Lysol spray, a container of germicidal wipes, and a container of Lysol sanitizing wipes on the counter at the entrance of his room.During an observation an interview on 01/20/2026 at 9:27 AM, Resident #49 was sitting near the nurse's station in his wheelchair. An interview was attempted but Resident #49 did not answer questions appropriately related to his cognitive status. LVN I was standing near the nurse's station and stated Resident #49 was a fall risk and near the nurses' station so staff could monitor him. 4. Resident #105Record review of Resident #105's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses which included dementia (loss of thinking, remembering, and reasoning skills) and cognitive communication deficit. Record review of Resident #105's Quarterly MDS Assessment, dated 12/31/2025, indicated a BIMS assessment was appropriate for the resident but was not conducted. The staff assessment for mental status was not completed. Section GG (Functional Abilities) indicated Resident #105 required set-up with some, but was independent with most self-care needs. Record review of Resident #105's Comprehensive Care Plan, dated 01/20/2026, reflected alteration in neurological status related to disease process including dementia and history of cerebral ischemia (brain does not receive enough blood flow). An intervention was to cue resident and reorient as needed. During an observation and interview on 01/20/2026 at 9:51 AM, Resident #105 was sitting on the side of his bed. There was a can of air freshener spray on the counter near his door. Resident #105 stated he did not know how long it had been on the counter or when it was used. During an interview on 01/20/2026 at 10:12 AM, LVN I stated family members may have left the air freshener sprays and cleaning products in the residents' rooms. LVN I stated they should not have been out where any resident could get to them. She stated some residents were confused and it was not safe to have the items in reach. She stated they would check the rooms on her hall to ensure they were removed. During an interview on 01/20/2026 at 10:15 AM, ADON B stated there should not have been aerosol sprays, cleaning products, or peroxide in the residents' rooms. She stated some residents use oxygen or have asthma or COPD. She stated the aerosol sprays could exacerbate (make worse) respiratory illnesses. She stated a resident who wandered or was confused could ingest the products or try to use them for other reasons. 5. Resident #122Record review of Resident #122's Face Sheet, dated 01/21/26, reflected she was an [AGE] year-old female admitted to the facility on [DATE] and relevant diagnoses included muscle weakness and history of falls.Record review of Resident #122's Quarterly MDS assessment, dated 10/11/25, reflected the resident had a severe cognitive impairment. For ADL care, it reflected the resident required extensive assistance and an active diagnosis of muscle weakness and history of falls.Record review of Resident #122's Comprehensive Care Plan, dated 10/30/25, reflected the resident was a fall risk, and an intervention included the resident's bed being in the lowest position possible.In an interview and observation on 01/20/26 at 01:16 PM, LVN O stated Resident #122 was a fall risk and her bed should be in a low position to reduce the height of the fall and prevent injuries. LVN O observed the bed not in a low position and she proceeded to lower the bed.In an interview on 01/22/26 at 8:51 AM, the DON was advised of Resident #122's bed not being in a low position. She stated the resident's bed should be in a lot position because if she fell the impact would not be as bad. She stated the nurses should be checking to ensure the resident's bed was in the lowest position and the CNAs should ensure the resident's bed was lowered to the lowest position after providing care. 6. An observation on 01/20/2026 at 9:47 AM revealed ADON A was called to check on a resident's call light. He locked his cart and went to the resident's room. A container of germicidal wipes was on top of his cart that was facing the hallway. it was observed that several residents were passing by the cart.In an interview on 01/22/2026 at 8:43 AM, ADON A stated there should be no germicidal wipes on top of the carts because residents might pull some wipes and rub them on their skin and eyes that might cause irritations. He said the container of germicidal wipes should be locked inside the carts7. An observation on 01/20/2026 at 2:25 PM revealed a container of germicidal wipes was on top of a cart in a hallway near the nurses' station. The cart parked was facing the hallway and several residents were sitting near the cart.In an interview on 01/20/2026 at 2:27 PM, MA G stated they would always put the container of germicidal wipes on top of the cart because they use it to clean the cart. She said the wipes only contain alcohol and did not think they should be stored inside the cart.In an interview on 01/21/2026 at 8:19 AM, MA G stated she just learned from the day prior that they need to store the containers of germicidal wipes inside the carts for safety reasons. She said confused residents might consume them and could cause an upset stomach.8. An observation on 01/21/2026 at 10:47 AM revealed a container of germicidal wipes was on top of a cart that was facing the hallway and was unattended. During an observation and interview on 01/21/2026 at 10:49 AM, ADON B stated the germicidal wipes should be stored inside the cart for safety reasons. She said residents might think they were ordinary wipes and use them to clean their eyes, nose, ears, and skin. She said it might cause irritation and toxicity. She said anything that indicated Keep out of reach of children. should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. She took the container of germicidal wipes and put it inside the nurse's station. In an interview on 01/21/2026 at 10:56 AM, LVN H stated that that he should have secured the germicidal wipes before leaving the cart because residents might use it improperly or even eat it. He said the container of germicidal wipes should be locked inside the cart.During an interview on 01/21/2026 at 10:30 AM, the DON stated the aerosol sprays and cleaning products should not have been in the residents' rooms. She stated aerosol sprays were not allowed because they were combustible and oxygen was used in the building. She stated germicidal wipes should be stored in a nurse's cart. She stated one resident's family came on weekends and cleaned his room while at the facility. She stated they would notify all residents' families not to bring aerosols or cleaning products to the facility. She stated her expectation was for staff to monitor residents' rooms to ensure those types of items were not left in any resident's room. In an interview on 01/22/2026 at 8:23 AM, the DON stated that the containers of germicidal wipes should not be placed or left on top of the cart because they have chemicals that could cause adverse effects if consumed or had contact with the skin, eyes, and mouth. She said the container of germicidal wipes was closed but somebody could open it pull some wipes with their bare hand. She said the wipes were handled with gloves on because they have chemical on them to eliminate germs on surfaces. She said the containers should be inside the carts. She said she already started an in-service about not leaving any germicidal wipes on top of the carts for resident safety.In an interview on 01/22/2026 at 9:27 AM, the Administrator stated that the containers of germicidal wipes should be inside the carts and not within reach of any residents. He said some residents might accidentally use them that could result to skin or eye irritation. He said he would collaborate with the DON and the ADONs to re-educate the staff about not placing or leaving the germicidal wipes on top of the carts.Record review of the facility's policy Safety, Resident Policy/Procedure revised July 2023 reflected POLICY: It is the policy of this facility to create a safe environment for the resident . PROCEDURES . 7. Conduct a room search should there be concern that prohibited/unsafe items are being stored in the room.Record review of Safety Data Sheet on 01/21/2026 reflected Safety Data Sheet Medline Micro-Kill Two Germicidal Wipes . Section 2. Hazards Identification . Classification . acute toxicity - oral . eye irritant . flammable liquids . Hazard Statements: Causes serious eye irritation . Flammable liquid and vapor . May cause drowsiness or dizziness . Storage: Keep out of the reach of children.The facility's policy Quality of Care (12/2023) reflected It is the policy of the facility to provide an environment that remain free of accidents and hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Resident #28, # 87, #136, and #147) reviewed for ADL care provided to dependent residents. The facility failed to ensure Residents #28, #87, #136, and #147 received their scheduled showers for January 2026. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings included: Record review of Resident #28's Face Sheet, dated 01/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #28 had diagnoses of muscle weakness and need for assistance with personal care. Record review of Resident #28's Quarterly MDS Assessment, dated 12/26/25, reflected the resident had moderate cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnoses of muscle weakness and need for assistance with personal care. The resident required total assistance for ADL care. Record review of Resident #28's Comprehensive Care Plan, dated 12/23/25, reflected the resident had an ADL self-care deficit and the resident was totally dependent on staff to provide ADL care. Record review of the shower sheets for Resident #28 for January 2026, revealed no showers being provided to the resident until 01/21/26. In an interview and observation on 01/20/26 at 12:00 PM, Resident #28 stated he had only received maybe two bed baths since he had been at the facility. He stated he wanted his scheduled showers but was only given excuses by the nursing staff why he could not get a shower. The Resident's hair was matted in the back. Record review of Resident #87's Face Sheet, dated 01/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #87 had diagnoses of muscle weakness and need for assistance with personal care. Record review of Resident #87's Quarterly MDS Assessment, dated 12/13/25, reflected the resident had moderate cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnoses of muscle weakness and need for assistance with personal care. The resident required substantial assistance for ADL care. Record review of Resident #87's Comprehensive Care Plan, dated 12/11/25, reflected the resident had an ADL self-care deficit and the resident required assistance with bathing/showering. Record review of the shower sheets for Resident #87 for January 2026, revealed one shower was provided to the resident on 01/05/26. In an interview on 01/20/26 at 10:52 AM, Resident #87 stated he had only received one shower so far in January 2026. He stated he was scheduled for showers on Tuesday, Thursday, and Saturday. He stated he liked receiving his showers and had only refused one shower because he was too tired from doing physical therapy, but they had not rescheduled it. Record review of Resident #136's Face Sheet, dated 01/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #136 had diagnoses of muscle weakness and lack of coordination. Record review of Resident #136's Quarterly MDS assessment, dated 12/31/25, reflected the resident had an intact cognitive response. The Quarterly MDS Assessment reflected the resident had active diagnoses of muscle weakness and lack of coordination. The resident required substantial assistance for ADL care. Record review of Resident #136's Comprehensive Care Plan, dated 10/22/25, reflected the resident had an ADL self-care deficit and the resident required assistance with bathing/showering. Record review of the shower sheets for Resident #136 for November 2025, December 2025, and January 2026, revealed no showers being provided to the resident, but instead bed baths. In an interview and observation on 01/20/26 at 11:07 AM, Resident #136 stated he had been at the facility for nearly a year and had only received bed baths. He stated he really wanted showers but was told by CNAs they did not have a shower chair large enough to hold him. He stated the bed baths cannot clean him as thoroughly as showers could. The resident was observed with a black substance under his fingernails. Record review of Resident #147's Face Sheet, dated 01/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #147 had diagnoses of muscle weakness and lack of coordination. Record review of Resident #147's Initial MDS assessment, dated 01/11/26, reflected the resident had an intact cognitive response. The MDS revealed the resident required substantial assistance for ADL care. Record review of Resident #147's Comprehensive Care Plan, dated 01/10/26, reflected the resident had an ADL self-care deficit and the resident required assistance with bathing/showering. Record review of the shower sheets for Resident #147 for January 2026, revealed one shower provided to the resident on 01/14/26. In an interview on 01/20/26 at 12:33 PM, Resident #147 stated he had been at the facility for 10 days and had only received one shower since being there. He stated he was scheduled for 3 showers a week and staff had made excuses why he could not receive them. He stated he wanted his showers. In an interview on 01/20/26 at 1:20 PM, ADON B, LVN I, and CNA A were told about Residents #28, #87, #136, and #147 complaining about not receiving their showers on a consistent basis. ADON B stated she had been trying to reinforce to staff the importance of ensuring showers were being documented on shower sheets. CNA A stated he had provided a shower to Resident#87 on 01/12/26, but he did not complete a shower sheet for the resident. ADON B stated protocol was for CNAs to complete shower sheets for the residents and then update the resident's clinical records. CNA A stated if residents did not get their scheduled showers they could have skin problems. LVN I stated if residents did not receive their scheduled showers they could have skin breakdown. In an interview on 01/21/26 at 9:50 AM, ADON B was informed by the Surveyor of Resident #28 and #136 complaining of not receiving showers. She stated Resident #28 was aggressive with staff and often refused showers and only did bed baths. She was informed the resident stated he wanted showers and his hair was also observed to be matted. She was also informed there was no documentation in the resident's progress notes indicating he was refusing showers nor was there a care plan for his refusal of showers. ADON B was informed Resident #136 stated he wanted showers but CNAs kept telling him there was no shower chair large enough for him. She stated Resident #136 was also cared planned for refusing showers. She was informed that Resident #136's progress notes were reviewed going back to November 2025 and there was no documentation of an attempt to provide the resident with a shower, nor was there any documentation of the resident refusing a showers. She stated staff, including herself, should have documented attempts made to offer showers to the resident and his refusals. She stated the residents not receiving their showers could result in skin breakdown. In an interview on 01/22/26 at 8:51 AM, the DON was informed of Residents #28, #87, #136, and #147 complaining about not receiving their showers and she stated ADON B had advised her of the residents not having shower sheets indicating the residents received showers. She stated if the resident refused a shower, a bed bath should be offered. She stated if the resident wants a bed bath instead of a shower the CNA should inform the nurse, and the nurse should confirm the resident agreed to the bed bath and it should be documented. She stated if the resident refused a shower and bed bath, the nurse should attempt to persuade the resident to take a shower or bed bath and contact a family member to encourage them as well. She stated if the residents did not receive scheduled showers they could have skin breakdown. Record review of the facility's policy on Activities of Daily Living (ADL), Supporting, dated December 2001, revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including assistance with hygiene (bathing, dressing, grooming, and oral care).

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment for three (Resident #10, #29, and #36) of eight residents reviewed for resident rights. 1. The facility failed to ensure LVN C closed Resident #10's door while checking his blood sugar and administering his insulin on 01/21/2026.2. The facility failed to ensure LVN C closed Resident #36's door before lifting his shirt to turn off his life vest on 01/20/2026.3. The facility failed to ensure RN E pulled the privacy curtain while changing Resident #29's g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) dressing on 01/20/2026.These failures could place the residents at risk of not having their personal privacy maintained while treatment was provided that could result to the residents feeling uncomfortable during treatment.Findings included: 1. Record review of Resident #10's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with type 2 diabetes mellitus (high blood sugar).Record review of Resident #10's Quarterly MDS Assessment, dated 01/04/2026, reflected the resident had moderate impairment with a BIMS score of 12. The Quarterly MDS Assessment indicated that the resident had diabetes mellitus and was taking insulin.Record review of Resident #10's Comprehensive Care Plan, dated 01/12/2026, reflected the resident had diabetes mellitus and one of the interventions was to provide diabetes medications as ordered.Record review of Resident #10's Physician Order, dated 12/21/2025, reflected Insulin Regular Human Injection Solution 100 UNIT/ML (Insulin Regular (Human)) Inject as per sliding scale: if 70 - 200 = 0; 201 - 250 = 2; 251 - 300 = 2; 301 - 500 = 3 Greater than 300 administer 3 units, subcutaneously (administer under the skin) before meals and at bedtime for DM II related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS.An observation on 01/21/2025 at 11:33 AM revealed LVN C was about to check Resident #10's blood sugar. She sanitized her hands, put on a pair of gloves, then sanitized the table. She put a paper towel on top of the table where she placed her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside the resident's room and positioned herself in front of Resident #10. The resident was in his wheelchair, in front of his door, and could be seen from the hallway and the TV room. It was noted that two individuals were standing in the TV room. LVN C did not close the door while she was checking the resident's blood sugar and the treatment that she was doing could be seen from the hallway. In an interview on 01/21/2026 at 11:49 AM, LVN C stated she forgot to close the door while she was checking Resident #10's blood sugar. She said the door should be closed to provide privacy during treatment or care. She said the resident might get embarrassed that other people could see what his treatments were. In an interview on 01/21/2026 at 11:54 AM, Resident #10 stated that some nurses would close his door when his blood sugar was being checked or if his insulin was given but some would not. He said he got used to the staff not closing his door but it would be nice if his door was closed when given his insulin or if his blood sugar was being checked.2. Record review of Resident #29's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing).Record review of Resident #29's Comprehensive MDS Assessment, dated 12/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #29's Comprehensive Care Plan, dated 11/12/2025, reflected the resident required tube feeding and one of the goals was that the feeding tube insertion site would be free from signs and symptoms of infection.Record review of Resident #29's Physician Order, dated 12/04/2025, reflected CLEANSE G-TUBE STOMA WITH NSS, PAT DRY AND APPLY DRY DRESSING.Observation on 01/20/2026 at 1:50 PM revealed RN E was about to change Resident #29's g-tube site. It was observed that the resident was in her wheelchair in front of her bed and her roommate was also inside her room, in her bed. RN E washed her hands and put on a pair of gloves. She removed the soiled dressing, assessed the resident's g-tube site, and put on a new dressing after the assessment. She did not pull the privacy curtain when she did the treatment.In an interview on 01/20/2026 at 2:06 PM, RN E stated she should have pulled the privacy curtain when she was assessing resident #29's g-tube site for privacy reasons. She said the door should be closed every time care and treatment were being provided.3. Record review of Resident #36's Face Sheet, dated 01/21/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with ventricular fibrillation (abnormal heart rhythm).Record review of Resident #36's Comprehensive MDS Assessment, dated 01/07/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident had ventricular fibrillation.Record review of Resident #36's Comprehensive Care Plan, dated 01/07/2026, reflected the resident had ventricular fibrillation and one of the interventions was to wear a life vest (wearable defibrillator [devices that apply current to the heart to restore normal heartbeat] that could stop abnormal heart rhythm) daily.An observation on 01/20/2026 at 9:12 AM revealed LVN C was inside Resident #36's room standing at bedside, facing the hallway, and fixing something on the resident's chest. It was observed from the hallway that she lowered the resident's blanket and then raised the resident's upper clothing. It was observed that ADON B went inside the resident's room and closed the door.In an interview on 01/20/2026 at 9:27 AM, LVN C stated she was turning off Resident #36's life vest because the order indicated to turn it off in the morning and that was why she needed to lift the resident's clothes. She said if she was doing a treatment, then she should have closed the door for privacy.In an interview on 01/20/2026 at 1:26 PM, Resident #36 stated he had a life vest and had a battery that was being turned off by a nurse every morning. He said it was under his upper clothing and the nurse needed to raise his shirt or his hospital gown in order to turn it on and off. He said he did not notice if the staff closed the door or not and but it won't hurt if the door would be closed.In an interview on 01/22/2026 at 8:23 AM, the DON stated that the door should be closed every time the staff provided care or treatment to give privacy and prevent improper exposure of any body part. She said turning off the life vest, checking the blood sugar, and assessing the g-tube site were treatments done for the resident so their doors should be closed so others, like non-clinical personnel, visitors, and other residents would not see the treatments being done. She said the door should be closed or the privacy curtain pulled to avoid embarrassment. She said, aside from being embarrassed, closing the door and pulling the privacy curtain could make the residents more comfortable during treatment. She said the expectation was for the staff to provide privacy during treatment. She said she already started an in-service about providing privacy during treatment. In an interview on 01/22/2026 at 8:43 AM, ADON A stated the staff should close the door or pull the privacy curtain when they were providing care to the residents. He said the staff needed to get used to providing privacy during treatment so that individuals that did not have anything to do with the residents' care would not see it. He said it did not matter if the residents mind or not, but the expectation was for the staff should be sensible enough that if they were in the residents' position, they might want their door closed during treatment. He said the DON already started an in-service about closing the door during treatment.In an interview on 01/22/2026 at 8:57 AM, ADON B stated that the staff should close the door when they were doing any kind of treatment to the residents for privacy. She said the expectation was for the staff to provide privacy by closing the residents' door or pulling the privacy curtain. She said the DON already started an in-service about privacy.In an interview on 01/22/2026 at 9:27 AM, the Administrator stated that the staff must make sure that the residents were provided privacy when treatment was being done so they would be comfortable when treatment was provided. He said the expectation was for the staff to be mindful about privacy when providing treatment. He said he would collaborate with the DON and the ADONs to re-educate the staff about the importance of providing privacy.Record review of the facility's policy, Resident Rights Services revised October 04, 2016, reflected As a resident of this nursing facility, you have the right to a dignified existence . Privacy and Confidentiality. You have the right to personal privacy . personal privacy, including accommodations, medical treatment.

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 for the facility's only kitchen, reviewed for food and nutrition services. Specifically, the facility failed to ensure that the dining area coffee station and ice machines were maintained in a clean and sanitary manner to prevent contamination of food and beverages. These failures could place residents at risk for cross contamination and air-borne illnesses. Findings include:Observations on January 20, 2026 at 9:04 A.M, while approaching the kitchen to conduct the assigned kitchen tour for survey, the surveyor walked through the dining area. Upon entry into the dining area, the surveyor immediately observed the coffee station to be visibly filthy. Spilled coffee was observed on the countertops, on the exterior surfaces of the coffee machine, and on the floor directly in front of the coffee station. The coffee residue was dry, indicating it had been present for an extended period of time and had not been recently cleaned. During continued observation of the facility, one ice machine located in the main hallway was observed to be visibly dirty. Debris was observed on both the interior and exterior surfaces of the ice machine. The ice scoop used for resident service was observed to be visibly soiled, with brown spots and residue present, indicating it had not been properly cleaned or sanitized. In an interview on January 22, 2026 at 9:30 AM, the Dietary Manager stated that coffee stations are expected to be cleaned daily and that ice machines are cleaned on a routine schedule. She stated that the kitchen ice machine is typically cleaned weekly and that the main hallway ice machine is cleaned by maintenance. She stated that if she observed an ice machine or scoop in a visibly dirty condition, the equipment would be drained, sanitized, or replaced prior to reuse. When shown a photo of a dirty ice scoop, she stated she would likely replace it if it appeared in that condition. In an interview on January 22, 2026 at 9:50 AM, a Dietary Aide stated that the coffee machine is cleaned daily and deep cleaned weekly. She stated that ice machines are deep cleaned weekly and that the Dietary Manager typically performs the deep cleaning. When shown a photo of the ice machine, she stated that if she observed it in that condition, she would immediately clean it and notify the Dietary Manager. She stated that cleaning is documented on a log located in the kitchen. In an interview on January 22, 2026 at 9:55 AM, a [NAME] stated that the coffee machine is cleaned every morning and that ice machines are cleaned weekly or as needed. He stated that if mold, debris, or residue were observed in an ice machine, he would unplug the machine, notify the Dietary Manager, and place an out-of-order sign on the equipment until it was cleaned. He confirmed that cleaning activities are documented on a log in the kitchen. In an interview on January 22, 2026 at 10:05 AM, ADMIN stated that dietary sanitation should be monitored daily and that staff are expected to address cleanliness concerns immediately when observed. ADMIN acknowledged that the facility has had prior citations related to food sanitation and stated that corrective actions are monitored through the facility's Quality Assurance and Performance Improvement (QAPI) process on a monthly basis. In an interview on January 22, 2026 at 10:15 AM, the Maintenance Supervisor stated that maintenance cleans the ice machine monthly and that a contracted professional service performs deep cleaning every three months. He stated that the professional service had been on site within the past one to two weeks. He stated that cleaning activities are tracked electronically and agreed to provide documentation of the cleaning log.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one (LVN D) of three LVNs and reviewed for pharmaceutical services.The facility failed to ensure LVN D did not put and leave her personal beverage on top of the nurse's cart on 01/20/2026.This failure could place residents at risk for potential overdose, adverse effects, cross contamination, and potential interference with medication preparation.Findings included: An observation on 01/20/2026 at 9:35 AM revealed a cup from a coffee shop was on top of a med cart parked in a hallway and was unattended. The cup was left beside the apple sauce that was used during medication administration.During an observation and interview on 01/20/2026 at 9:37 AM, LVN D stated it was her coffee and she should not leave it on top of the cart because it could cause cross contamination and accidentally be mixed with the medications she was preparing. She said a resident might be able to drink it and might get scalds if it was hot. She took the cup and said she would dispose of it.In an interview on 01/22/2026 at 8:23 AM, the DON stated that staff should never put their personal drinks on top of the med carts. She said aside from the risk of cross contamination, some residents might take it and drink its content. She said if the content was hot, the resident might be burned. She said it may contribute also to choking if the resident who drank it was using thickener for his drinks. She said its content might also spill on the medications the staff were preparing. She said it might also spill on the carts, and they needed to replace all the medications that were damaged. She said their policy might not include putting personal beverages on top of the cart, but it was the best practice.In an interview on 01/22/2026 at 8:57 AM, ADON B stated no personal beverages should be on the medication carts because aside from being a clutter, that might contribute to medication error and staff might bring some microorganism from their home or coffee shop to the medication cart. She said the DON already started an in-service about no personal beverages in the carts.In an interview on 01/22/2026 at 9:27 AM, the Administrator stated personal beverages should be in the break room and not on top of the carts because of the danger of hot spillage or contaminating the medications that were being prepared. He said he would collaborate with the DON and the ADONs to re-educate the staff about not having any personal drinks on the cart.Policy for not having any personal beverages on top of the cart requested on 01/21/2026 at 8:17 AM via email to the Administrator but was not provided prior to exit.

Based on observations, interviews, and record review, the facility failed to follow policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety for 1 of 6 residents (Resident #102) reviewed for safe smoking. The facility failed to complete a Smoking assessment for Resident #102 upon his admittance to the facility on [DATE]. This failure could place the resident at risk of harming himself when smoking. Findings include:Record review of Resident #102's Face Sheet, dated 01/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #102 had acute respiratory failure with hypoxia (low oxygen intake) and a need for assistance with personal care. Record review of Resident #102's Quarterly MDS Assessment, dated 11/08/25, reflected Resident #102 had an intact cognitive response. The Quarterly MDS Assessment reflected the resident had active diagnoses of respiratory failure, congestive heart failure, and tobacco use. Record review of Resident #102's Comprehensive Care Plan, dated 11/08/25, reflected a plan of care for smoking and an intervention was to complete a smoking assessment as needed. Record review of Resident #102's clinical records did not contain a smoking assessment for the resident. In an interview on 01/21/26 at 10:00 AM, the Social Worker was told there was no smoking assessment observed in Resident #102's records. The Social Worker stated the resident should have had an assessment completed when he was admitted to the facility on [DATE] by the admitting nurse and she should have caught it when she completed her audits but it was overlooked. She stated the resident needed a smoking assessment completed to ensure there were no dangers for him. In an interview on 01/22/26 at 8:51 AM, the DON was told about Resident #102 not having a smoking assessment completed. She stated the SW had informed her of this. She stated the SW should have assessed the resident as soon as she found out he was a smoker. She stated if the resident did not receive a smoking assessment, he could harm himself when smoking. Record review of facility's policy, Smoking Policy, undated, reflected The purpose of our policy is to provide maximum safety to all of our residents. We want to provide a safe environment for all residents, as well as accommodate the wishes of those who elect to smoke. This policy applies to all residents who chose to smoke. There will be a smoking assessment of any resident who wishes to smoke on admission by the SW or licensed nurse.

Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of eight residents (Resident #87 and Resident #12) reviewed for care plans. 1. The facility failed to ensure Resident #87's Comprehensive Care Plan reflected oxygen therapy and nebulizer with a breathing mask (used to receive medication by breathing in mist through the nose and mouth).2. The facility failed to ensure Resident #12's Comprehensive Care Plan reflected a BiPAP machine (noninvasive ventilation that helps you breathe). These failures could place the residents at risk of not receiving the necessary care and services needed. Findings include:Resident #87Record review of Resident #87's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included iron deficiency anemia (the body lacks enough iron to produce healthy blood cells, which carries oxygen throughout the body) and diabetes (elevated blood glucose).Record review of Resident #87's Quarterly MDS (tool used to measure health status) Assessment, dated 12/13/2025, reflected moderately impaired cognition with a BIMS (tool used to measure cognitive status) score of 11. Section O (Special Treatments, Procedures, and Programs) Diagnoses) indicated Resident #87 received oxygen therapy. Record review of Resident #87's Comprehensive Care Plan, dated 12/10/2025, did not reflect oxygen therapy or breathing treatments via nebulizer. Record review of Resident #87's Physician's Orders, dated 12/21/2025, reflected a PRN (as needed) order to administer oxygen 2-3 liters per minute via nasal cannula to keep the oxygen saturation above 92%. Record review of Resident #87's Physician's Orders, dated 12/10/2025, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 6 hours as needed for SOB administer 3ml via nebulizer.Resident #12Record review of Resident #12's face sheet, dated 01/22/2026, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses which included acute respiratory failure with hypoxia (sudden decrease of oxygen levels in the blood), diabetes (elevated blood sugar levels), and chronic kidney disease (gradual loss of kidney function).Record review of Resident #12's Quarterly MDS Assessment, dated 12/29/2025, reflected moderately impaired cognition with a BIMS score of 11. Section O (Special Treatments, Procedures, and Programs) indicated Resident #12's respiratory therapy included mechanical ventilation (delivers airway pressure to assist breathing through a mask). Record review of Resident #12's Comprehensive Care Plan, dated 12/10/2025, did not reflect a BiPAP machine. Record review of Resident #12's Physician's Orders, dated 11/24/2025, reflected to use BiPAP at bedtime related to acute respiratory failure with hypoxia. An observation and interview on 01/20/2026 at 9:14 AM revealed Resident #12 lying in bed. A BiPAP with an attached nasal mask (covers only your nose and delivers pressurized air directly through the nasal passage) was on the resident's nightstand. Resident #12 stated he had used a face mask before, but it was too tight, and the nasal mask was more comfortable. He stated he wore it at nighttime.During an interview on 01/22/2026 at 12:26 PM, the MDS Coordinator opened her laptop to review Resident #87 and Resident #12's chart. She stated the respiratory items were not included in the care plans but should have been. She stated it was important for nurses to know the interventions in place to keep the residents safe. The MDS Coordinator stated she was responsible for the care plans of the residents on the hall where Resident #87 and Resident #12 resided. During an interview on 01/22/2026 at 12:35 PM, the DON stated residents should have had respiratory items included in care plan. She stated it was important to monitor and give appropriate care and treatment. She stated care plans allow staff to measure results and determine if care provided was effective. During an interview on 01/22/2026 at 12:52 PM, ADON B stated she had looked at Resident #87 and Resident #12's care plans and the respiratory items were not included. She stated it was important to be able to look at a care plan and see the resident's history. She stated a resident who admitted to the facility with COPD (disease that restricts breathing) may or may not use oxygen. She stated staff could look at the care plan to see if there was a history of a resident using a BiPAP or if the resident refused to use it. She stated if a resident had an episode of shortness of breath, staff could look at the care plan to see if the resident had a history of respiratory issues. Record review of facility's policy, Comprehensive Care Planning, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #102) of eighteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #102 room was in a position that was accessible to the resident on 01/20/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #102's Face Sheet, dated 01/21/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with convulsions (sudden irregular movement of the body) and muscle weakness.Record review of Resident #102's Quarterly MDS Assessment, dated 12/02/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated the resident was independent for transfer, toileting hygiene, shower, dressing, and bed mobility.Record review of Resident #102's Comprehensive Care Plan, dated 12/16/2025, reflected the resident was at risk for falls related to convulsions and weakness and one of the interventions was to be sure the resident's call light was within reach.Observation and interview on 01/20/2026 at 9:44 AM revealed Resident #102 was in his bed, awake. It was observed that the resident's call light was on the floor at the head of the bed. The resident said he used his call light, but it was nowhere to be found. Observation and interview on 01/20/2026 at 9:49 AM, ADON A stated call lights should always be within reach of the residents because that was how they called the staff if they needed something. He said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. He went inside the resident's room and saw the call light on the floor. He pulled the call light from the floor, put it where the resident could reach it, and told the resident where the call light was. He said whoever checked on the resident should have made sure that the call light was with the resident. he said everybody was responsible in making sure that the call lights were within reach always for all the residents. He said he would start an in-service about call lights.In an interview on 01/22/2026 at 8:23 AM, the DON stated that call lights were inside the residents' rooms so they can call the staff for assistance, a glass of water, pain medication, or because they needed to be changed. She said if the call lights were not within reach, their needs would not be met. The DON said the call lights were for all residents and all the staff were responsible for the call lights. The DON said the expectation was for the staff to scan the residents' room when they did their rounds and ensure the call lights were within reach of the residents before they leave the room. The DON said they already started an in-service about call light placement and would continually educate the staff about the importance of call lights for the residents. In an interview on 01/22/2026 at 9:27 AM, the Administrator stated that call lights should be within the reach of the residents at all times. He said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. The Administrator said the residents might fall trying to get up to get what they needed. He said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. He said he would collaborate with the DON and the ADONs about the issue regarding call lights.Record review of facility's policy Call Light/Bell Policy/Procedure - Nursing Clinical revised May 2020 reflected POLICY: It is the policy of this facility to provide the resident a means of communication with nursing staff .PROCEDURES . 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Resident #81 and Resident #93) of twenty-one residents reviewed for dignity.1. The facility failed to ensure RN E was not standing when assisting Resident #81 with his drinks on 01/20/2026.2. The facility failed to ensure RN E was not standing when assisting Resident #93 with her food on 01/20/2026.These failures could place the residents at risk of not having their right to a dignified existence maintained that could lead to embarrassment.Findings included: 1. Record review of Resident #81's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting the left side, and speech deficits following cerebral infarction (insufficient oxygen in the brain causing stroke).Record review of Resident #81's Comprehensive MDS Assessment, dated 12/30/2025, reflected the resident had severe (resident required significant assistance and support in daily life) impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident required set-up assistance when eating.Record review of Resident #81's Comprehensive Care Plan, dated 01/16/2026, reflected the resident had alteration in muscular status and one of the interventions was to anticipate and meet the needs.An observation on 01/20/2025 at 1:03 PM revealed RN E was walking around the dining area. When she reached Resident #81's table, she picked up the resident's glass and assisted the resident to drink. She was standing when she assisted the resident to have a drink. After giving the resident, a sip of his drink, she continued to walk around the dining area.Observation and interview on 01/20/2026 at 2:09 PM revealed Resident #81 sitting on his wheelchair inside his room. When asked if it was okay for any staff to stand when assisting him for lunch, the resident did not reply.2. Record review of Resident #93's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness, dysphagia (difficulty in swallowing), and pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection). Record review of Resident #93's Comprehensive MDS Assessment, dated 12/03/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident required set-up assistance when eating.Record review of Resident #93's Comprehensive Care Plan, dated 11/08/2025, reflected the resident had ADL self-care performance deficit and one of the goals was for the resident to maintain his current level of function in eating.An observation on 01/20/2026 at 1:06 PM, after giving Resident #81 a sip of his drink, RN E continued to walk around the dining area. When she reached Resident #93's table, she picked up Resident #93's fork, took a piece of food using the fork, and gave it to the resident. RN E was standing up when she gave the piece of food to the resident. She then walked around the dining area again.In an interview on 01/20/2026 at 1:18 PM, RN E stated that she should be sitting down when assisting somebody in the dining area. She said she assisted Resident #81 and Resident #93 while waiting for somebody to assist them. She said, but still, she should have sat down. She said, when assisting somebody during mealtimes, she should sit down so she would be face to face with the resident. She said standing up was not a way of showing respect and dignity. Observation and interview on 01/20/2026 at 2:19 PM revealed Resident #93 was sitting on her wheelchair inside her room. When asked if it was okay for any staff to stand when assisting her for lunch, the resident did not reply.In an interview on 01/22/2026 at 8:23 AM, the DON stated staff should sit down next to the resident when assisting the residents during mealtimes. She said sitting beside the resident promoted dignity and respect, allowed close observation of the resident's eating habits, and ensured the resident was not in any distress. She said not sitting beside the resident to assist in eating did not uphold dignity and respect. She said sitting beside the resident also allowed close observation of the resident's eating habits like if the residents were swallowing the food, if there was a problem in swallowing, if the resident was pocketing the food, if the residents were choking. She said the expectation was for all the staff to provide all the residents a dignified existence. She said she already initiated an in-service about dignity and would closely monitor the staffs' adherence to the policy. She said it did not matter if the residents were affected or not but still, the staff should be mindful and think that if they were in the residents' shoes, do they want others to see them exposed and to be assisted by somebody that was standing up.In an interview on 01/22/2026 at 8:57 AM, ADON B stated that the staff assisting a resident during mealtime should be sitting alongside the resident to provide dignity. She said sitting beside the resident would allow better observation of the resident's needs during mealtime. She said sitting beside the resident encouraged interaction and promoted safety when eating. She said the expectation was for the staff to provide dignity, not only during mealtimes but every time the staff provided care to the residents. She said the DON already started an in-service about dignity. In an interview on 01/22/2026 at 9:27 AM, the Administrator stated that staff should not be standing up when assisting the residents in the dining area. He said the expectation was for the staff to always have in mind that the residents have the right for a dignified existence and it should be provided during all interactions with the residents. He said he would collaborate with the DON and the ADONs to re-educate the staff about the importance of providing dignity of the residents.Record review of the facility's policy, Resident Rights Services revised October 04, 2016, reflected As a resident of this nursing facility, you have the right to a dignified existence . Respect and Dignity. You have the right to be treated with respect and dignity.

Based on observations, interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for neglect allegations. The facility failed to ensure they reported the FM's concern about the care Resident #1 received at this Nursing Facility. This failure could place all residents at risk if the facility did not follow the HHSC guidelines for reporting allegations resulting in the residents having emotional turmoil and decreased health and psycho-social well-being.Findings included: Record review of Resident #1's admission MDS Assessment, dated 09/13/25, revealed, a [AGE] year old male who admitted [DATE] with a BIMS score of 07 (Severe cognitive impairment). He used a walker and wheelchair for mobility and was dependent on dressing. He needed supervision/ touching assistance with eating, oral and personal hygiene. He needed substantial/maximal assistance with showers and toileting and partial assistance with sitting and standing and transfers. He was occasionally incontinent and not rated for bowel movement. He had diagnoses of atrial fibrillation, renal insufficiency, UTI, DM, CVA, malnutrition, muscle weakness, fatigue, repeated falls, difficulty walking, unsteadiness on feet, other speech/language deficits following CVD, constipation and disorientation. He had rare pain occasionally and had a fall within the last six months prior to admission. And he had two falls since admission with injury except major. Record review of Resident #1's Care Plan, dated 09/11/25, revealed he was at risk for impaired cognitive function or impaired thought processes, at risk for infection related to UTI during recent hospitalization, at risk for ADL self-care performance deficit related to disorientation: CVA Bell's palsy, AMS, UTI, at risk for falls related to history of falls, multiple falls during recent hospitalization, multiple falls during stay with the FM, muscle weakness, unsteadiness on feet fatigue, repeated falls, at risk for pain related to rib fracture, complaints of rib pain during recent hospitalization, at risk for has urinary infection and at risk for altered cardiovascular status related to cardiac pacemaker placement, at risk for atrial fibrillation, at risk for CVA. And at risk for renal insufficiency. Record review of Resident #1's Nurses note dated 09/14/25 at 12:32 pm by LVN C revealed, Resident continues on follow up for PO (by mouth) antibiotic Cefdinir 300 mg (milligram) 1 cap (capsule) for UTI. No adverse drug effects noted. Resident is tolerating the medication well. Continues on fall follow up Day 2/3. Resident is awake, alert and oriented x 2. No s/sx (signs and symptoms) of SOB (Shortness of breath), distress or pain voiced. No delayed injuries. Fall precautions in place, bed in the lowest position, fall mat at bedside. Call light and bed remote within reach. Record review of Resident #1's Nurses note dated 09/14/2025 at 1:24 pm by LVN C revealed, Resident is having right sided weakness and was having difficulty feeding self. Unable to grip his spoon at lunch time to feed himself, vitals taken 127/69, 70, 97.8F, 18, 98% RA (room air). Resident is alert and oriented x 2-3. Speech is clear. Resident was able to eat by [sic] breakfast by himself. Informed the Doctor regarding the weakness. N/O (new order) received from the Doctor to send resident to the hospital for further testing and CAT scan to r/o (rule out) stroke. Informed the FM. Informed the DON. Called EMS to arrange transportation to the hospital. They will arrive here shortly to take resident to the hospital. Interview on 09/14/25 was attempted with Resident #1 but he was at another facility in another town. Interview on 09/25/15 at 3:40 pm, the FM stated Resident #1 went to the hospital 09/14/25. The FM stated on 09/15/25 they went to the facility and told the SW A and ADON B about the nurses not paying attention to Resident #1's change of condition and his falls. The FM stated they were very upset and told SW A and ADON B that the hospital said Resident #1 had more rib fractures. They stated they were upset with LVN C for not sending Resident #1 out sooner than he did 09/14/25 for looking like he had a stroke. They stated feeling the facility knew they had done something wrong because they cancelled Resident #1's care plan meeting scheduled for 09/15/25. They stated they wanted to have Resident #1's care plan meeting anyway, to complain about his care at this facility. Interview on 09/25/25 at 4:05 pm , LVN C stated he was the weekend supervisor 09/14/25 and he saw Resident #1 around 6:00 am, and he was fine and responded normally to him when he asked him questions and he did not have any stroke like symptoms. He stated Resident #1 did not have any falls during his shift but he had fallen twice two days prior and they were doing neuro checks. He stated the FM came to visit late morning and took Resident #1 to his room and then she said Resident #1 was having stroke like symptoms. He stated telling the FM Resident #1 ate his breakfast without assistance and was doing fine and would check him out. He stated he assessed Resident #1 and he was fine and his vitals and neuro checks were within normal limits. He stated Resident #1 did not have any knots on his head or anywhere else. He stated he checked Resident #1's chest and he said he had no pain. He stated he had no rib pain, no slurred speech, his right arm was not flaccid and fingers not contracted. He stated the FM left the facility sometime after 11:00 am. He stated he moved resident #1 back to the common area by the nurses station then around 12:30 pm he noticed Resident #1 was not able to grip his spoon to eat during lunch so CNA D assisted him with his meal. He stated he was doing fine eating with assistance. He stated he assessed Resident #1 then his Doctor and the FM were notified. He stated Resident #1's Doctor told him to send him out for a CT scan to determine if he had a stroke. He stated around 1:00 pm he called for EMS to transfer Resident #1 and then he was transferred to the hospital. Interview 09/25/25 at 5:45 pm, ADON B stated Resident #1 had a change of condition for a possible stroke Sunday 09/14/25 and was sent to the hospital. She stated she and SW A had a meeting with the FM on 09/15/25 about concerns with LVN C not sending Resident #1 to the hospital sooner. She stated the FM also had concerns about the two falls Resident #1 had at this facility and had more rib injuries now. She stated the FM said she was going to tell everyone about how Resident #1 was treated at this nursing facility. She stated the FM felt Resident #1 was not taken care of properly. She stated after the meeting 09/15/25 she reported the FM's complaint to the DON and Administrator. She stated the FM was very upset and the FM just wanted to tell them how she felt without reviewing his records. Interview on 09/25/25 at 6:02 pm, SW A stated Resident #1 went to the hospital 09/14/25 for having a possible stroke. She stated the FM visited the facility on 09/15/25 about Resident #1 falling the night after he admitted and a second fall after that. She stated the FM said Resident #1's recent hospital report revealed he had more injured ribs from falling. She stated they tried to explain to the FM they had done their best to prevent him from falling by frequently monitoring and toileting him and keeping his bed in the lowest position but the FM was upset. She said she told the FM the facility doctor, assessed him and he was fine after he had fallen 09/11/25 and 09/12/25. She stated after the FM left the facility 09/15/25 she spoke to the DON and Administrator about the FM's complaints and how upset she was. Interview on 09/25/25 at 6:10 pm, the DON stated Resident #1 admitted [DATE] with a history of falls at home and he went to the hospital for a change of condition 09/14/25. She stated prior to Resident #1 admitting to this nursing home he fell at the hospital. She stated she found out by reviewing Resident #1's hospital records he had a rib that was fractured at the hospital. She stated after Resident #1 admitted to this nursing facility, he had two falls but they were minor injuries on 09/11/25 and 09/12/25 and neuro checks were being done. She stated the morning of 09/15/25, SW A said she spoke to the FM about Resident #1's falls and why was he not sent to the hospital sooner. She stated she was not able to attend the meeting because of being on a phone call and ADON B was already in the meeting. She stated by the time she was off the phone the FM had already left this facility. She stated she did not call the FM to get more information. She stated this facility did not need to report this complaint to HHSC because they did everything they could have done for Resident #1. She stated they did not investigate to see if the allegations was true because she reviewed his medical record and did not see any issues. She stated they did not fail to report Resident #1's falls or change of condition to his doctor and the FM. Interview on 09/25/25 at 6:43 pm, the Administrator stated Resident #1 was at the facility for a very short time. He stated Resident #1 had two falls while he was at this facility with minor injuries and on 09/14/25 Resident #1 had a change of condition and was sent to the hospital. He stated the FM did not directly complain to him about Resident #1 but ADON B said on 09/15/25, the FM expressed concerns about additional ribs being fractured from falling. He stated the FM had concern about Resident #1's fall, something about falls with injury on 09/12/25 and 09/13/25. He stated he was responsible for reporting abuse and neglect allegations to HHSC and they should be reported in two hours of being notified. He stated he did not report the FM complaint 09/14/25 to the State Agency because there was no neglect. He stated they did not investigate the allegation and based on all that they did he did not feel it was needed. He stated after being notified by ADON B about Resident #1 being diagnosed with more rib fractures he did not feel it was reportable to the State Agency because it was not true. He stated there was no report of Resident #1 having a change of condition prior to being sent to the hospital 09/14/25. He stated the FM never reached out and called or left him a message about any concerns. He stated he did not contact the FM to gather more information. Record review of the facility's Abuse and Neglect policy dated 11/2017 and revised 10/2023 revealed, Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility. Purpose: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.H. Reporting/ Response: 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on observation, interview, and record review the facility failed to ensure a safe and decent living environment for one (Common Area) of 2 common areas reviewed for decent living environment. The facility failed to ensure Medication Aide A did not speak loudly and inappropriately while on a personal call around a group of residents in the common area on 09/04/2025. This failure could place residents at risk for a less peaceful and decent living environment. Findings included: In an observation on 09/04/25 at 3:12 PM, Medication Aide A could be heard down the hallway speaking loudly. Medication Aide A was observed as she stood at the medication cart near a common area and a nurse's station, with two residents in her immediate area, and seven additional residents that sat in the common area watching television. Medication Aide A was observed as she spoke on her personal cellphone, and she stated, I am so livid I could punch them in the face. Medication Aide A was observed for 2 additional minutes before she looked around and exited the building through a side door. In an interview on 09/04/25 at 3:45 PM, Medication Aide A stated she was not talking on the phone long, turned around, saw the Surveyor, and then walked outside. She stated she might have said something about punching someone in the face. Medication Aide A stated the call was about her family member. She stated she was not talking about any residents. Medication Aide A stated the risk of taking a phone call and the manner of the phone call was a resident would think she was talking about them. In an interview on 09/05/25 at 12:11 PM, The DON stated all staff were not allowed to take personal calls on the floor. She stated all staff were aware of that rule. The DON stated Medication Aide A did talk loudly most of the time. The DON stated the risk of the staff taking personal, loud phone calls was it would violate the resident's right to have peace in their home. In an interview on 09/05/25 at 12:35 PM, the Assistant Administrator stated the DON spoke and in-serviced Medication Aide A yesterday regarding their personal phone policy. He stated Medication Aide A was disciplined. The Assistant Administrator stated the risk of staff taking personal phone calls and speaking in a certain manner on the phone calls was concerns with dignity of a resident and a violation of their right to feel safe. The Assistant Administrator stated some residents might have PTSD, and that particular phone call could have disrupted residents with that diagnosis. The Assistant Administrator stated personal phone calls should have been avoided. Record review of the facility's undated policy titled, Your Rights and Protections as a Nursing Home Resident, reflected the following: Be Treated with Respect: You have the right to be treated with dignity and respect, as wellas make your own schedule and participate in the activities you choose.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received care and treatment consistent with professional standards of practice to promote healing and to prevent further development of skin breakdown or pressure ulcers for three (Resident #22, Resident #30, and Resident #87) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #22's and Resident #87's wounds were measured on the weekly skin assessment per facility policy. 2. The facility failed to ensure Resident #22, Resident #30, and Resident #87 were repositioned or turned to prevent skin breakdown and promote healing of pressure sores per facility policy, care plans, and physician orders. These failures could place residents at risk for worsening pressure ulcers, new pressure ulcers, or discomfort. Findings included: Record review of Resident #22's Admission MDS assessment dated [DATE] revealed Resident #22 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes, a fracture of the upper end of the humerus (arm bone near the shoulder), malnutrition, muscle weakness, and obesity with a BMI of 50-59.9. Section C of the MDS assessment revealed Resident #22 had a BIMs score of 12 (indicated moderate cognitive impairment). Section GG of the MDS assessment revealed Resident #22 was dependent on staff and required staff to provide all effort to roll to either side. Section M of the MDS assessment revealed Resident #22 had two pressure ulcers upon admission. Record review of Resident #22's care plan with a revision date of 3/25/2025 revealed Resident #22 had pressure ulcers or potential to develop pressure ulcers related to decreased mobility. The care plan listed an intervention to complete a weekly head to toe skin assessment. Record review of Resident #22's weekly skin assessment dated [DATE] revealed Resident #22 admitted with two pressure ulcers: 1. Stage two (partial thickness loss of the skin and an open wound) on the right buttock that measured 0.5x0.5x0.1cm 2. Stage two (partial thickness loss of the skin and an open wound) on the left buttock that measured 0.8x0.7x0.1cm Record review of Resident #22's weekly skin assessment dated [DATE] revealed no measurements were taken of pressure ulcers. Record review of Resident #22's weekly skin assessment dated [DATE] revealed no measurements were taken of pressure ulcers. In an observation on 3/21/2025 at 9:11 a.m., CNA D and CNA E provided incontinent care to Resident #22. While Resident #22 was turned on her right side a quarter sized open wound on the left buttocks was observed. After incontinent care was completed, CNA D and CNA E positioned Resident #22 flat on her back and buttocks in the bed. Pillows were placed under Resident #22's right arm. In an interview on 3/21/2025 at 9:36 a.m., Resident #22 stated the staff never turned her on her side or used pillows to reposition her. Resident #22 stated she would allow the staff to place pillows under her because her back did sink into the bed. Resident #22 was not aware she had a pressure ulcer or how long it had been there. In an interview on 3/21/2025 at 9:40 a.m., CNA D stated they turned residents every two hours, so residents would not develop pressure ulcers. CNA D stated Resident #22 did not like to turn, so they just used the air mattress. In an interview and observation on 3/21/2025 at 10:59 a.m., Resident #22 was lying flat in the bed with no pillows under her back or buttocks. Resident #22 stated the staff had not put a pillow under her yet, but they might be busy. In an observation on 3/21/2025 at 11:34 a.m., Resident #22 was observed lying flat in bed with no pillows under her back or buttocks. In an observation on 3/21/2025 at 2:35 p.m., Resident #22 was observed lying flat in bed with no pillows under her back or buttocks. In an observation on 3/21/2025 at 4:20 p.m., Resident #22 was observed lying flat in bed with no pillows under her back or buttocks. - Record review of Resident #30's Quarterly MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diabetes, stroke, malnutrition, and hemiplegia or hemiparesis (weakness or paralysis of one side of the body). Section B of the MDS assessment indicated Resident #30 was in a persistent vegetative state or had no discernible consciousness (loss of cognitive function or awareness). Section GG of the MDS assessment revealed Resident #30 had an impairment of all extremities (legs and arms). Section M of the MDS assessment revealed Resident #30 was at risk for developing pressure ulcers and had zero pressure ulcers at that time. Record review of Resident #30's care plan with a revision date of 3/06/2025 revealed Resident #30 had potential for pressure ulcers and should be repositioned as tolerated. On 3/06/2025 the care plan was updated to include Resident #30 had developed a stage three (full thickness tissue loss) pressure ulcer to the upper right back and should be repositioned as tolerated. Record review of Resident #30's weekly skin assessment dated [DATE] revealed Resident #30 developed a stage three (full thickness tissue loss) pressure ulcer to the upper right back on 3/05/2025. Measurements on 3/12/2025 were 2.4x5.0x1.0cm. Record review of Resident #30's weekly skin assessment dated [DATE] revealed the stage three pressure ulcer to Resident #30's upper right back measurements were 1x3.6x0.4cm. Record review of Resident #30's physician order dated 3/06/2025 revealed an order to turn and reposition Resident #30 every two hours and as needed. In an observation on 3/21/2025 at 12:29 p.m., Resident #30 was lying in bed flat on his buttocks with his right shoulder slightly elevated. A pink foam wedge was under the right shoulder. No other pillows or wedges were observed. In an observation on 3/21/2025 at 2:40 p.m., Resident #30 was lying in bed flat on his buttocks with his right shoulder slightly elevated. A pink foam wedge was under the right shoulder. No other pillows or wedges were observed. In an observation on 3/21/2025 at 4:27 p.m., Resident #30 was lying in bed flat on his buttocks with his right shoulder slightly elevated. A pink foam wedge was under the right shoulder. No other pillows or wedges were observed. - Record review of Resident #87's Quarterly MDS dated [DATE] revealed Resident #87 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hip fracture, dementia, and lack of coordination. Section C of the MDS assessment revealed Resident #87 had a BIMs score of 09 (indicated moderate cognitive impairment). Section GG of the MDS assessment revealed Resident #87 had impairment of range of motion in both arms. Section M of the MDS assessment revealed Resident #87 was at risk for developing pressure ulcers but had zero pressure ulcers at that time. Record review of Resident #87's care plan with a revision date of 2/01/2025 revealed Resident #87 had developed a stage four (full thickness tissue loss with exposed bone, tendon, or muscle) and interventions included to turn and reposition the resident as tolerated. The care plan also revealed Resident #87 was on hospice services for heart disease. Record review of Resident #87's weekly skin assessment dated [DATE] revealed Resident #87 had five wounds develop while in the facility: 1. Site 1 was an unstageable (wound bed was not visible due to dead tissue) pressure ulcer on the left heel that developed on 12/11/2024 with measurements of 3.8x2.8x0cm on 2/19/2025 2. Site 2 was an unstageable (wound bed was not visible due to dead tissue) pressure ulcer on the right heel that developed on 1/08/2025 with measurements of 5.8x2.3x0cm on 2/19/2025 3. Site 3 was a suspected deep tissue injury (discolored intact skin or blister caused by pressure or skin shearing) on the left lateral (side away from the middle) lower leg that developed on 1/08/2025 with measurements of 2.1x1.1x0cm on 2/19/2025 4. Site 4 was a suspected deep tissue injury (discolored intact skin or blister caused by pressure or skin shearing) on the left dorsal foot (upper surface of foot) that developed on 1/08/2025 with measurements of 1.5x1.7x0cm on 2/19/2025 5. Site 5 was an unstageable (wound bed was not visible due to dead tissue) wound on the sacrum that developed on 1/10/2025 with measurements of 6.3x8.7x2.5cm on 2/19/2025 Interventions listed on this skin assessment included to turn or reposition the patient every two hours. Record review of Resident #87's weekly skin assessment dated [DATE] revealed Resident #87 had five wounds: 1. Site 1 was an unstageable (wound bed was not visible due to dead tissue) pressure ulcer on the left heel that developed on 12/11/2024 was not measured on 3/19/2025 2. Site 2 was an unstageable (wound bed was not visible due to dead tissue) wound on the right heel that developed on 1/08/2025 with measurements of 4.1x4.1x0cm on 3/19/2025 3. Site 3 was a suspected deep tissue injury (discolored intact skin or blister caused by pressure or skin shearing) on the left lateral (side away from the middle) lower leg that developed on 1/08/2025 with measurements of 1.8x1.2x0cm on 3/19/2025 4. Site 4 was a suspected deep tissue injury (discolored intact skin or blister caused by pressure or skin shearing) on the left dorsal foot (upper surface of foot) that developed on 1/08/2025 with measurements of 0.7x1x0cm on 3/19/2025 5. Site 5 was an unstageable (wound bed was not visible due to dead tissue) on the sacrum that developed on 1/10/2025 with measurements of 5.8x6.7x2.2cm on 3/19/2025 In an interview and observation on 3/21/2025 at 11:18 a.m., Resident #87 was lying flat in bed. One pillow was located under Resident #87's lower legs. Resident #87 stated sometimes the staff turned her, and she did not mind if they did. Resident #87 had difficulty answering questions due to cognitive impairment but was pleasant. In an observation on 3/21/2025 at 2:38 p.m., Resident #87 was lying flat in bed. One pillow was located under Resident #87's lower legs. In an observation on 3/21/2025 at 4:25 p.m., Resident #87 was lying flat in bed. One pillow was located under Resident #87's lower legs. - In an interview on 3/25/2025 at 10:29 a.m., LVN G stated she was the wound care nurse for the facility. LVN G stated if a resident was not turned every two hours, then bed sores could occur. LVN G stated nurses and CNAs on the floor monitored to ensure residents were turned. LVN G stated she also checked if residents were turned when she does wound care. LVN G reported if she had concerns about residents not being turned then she would tell the floor nurses or ADONs. LVN G stated she did not provide wound care for Resident #22 and was not familiar with that resident. LVN G stated Resident #87 and Resident #30 should have been repositioned. In an interview on 3/25/2025 at 11:28 a.m., ADON F stated skin assessments were completed weekly and nurses measured the wounds. ADON F stated the DON and nurses should monitor and ensure wounds were measured weekly. ADON F stated if there were no wound measurements she would know if wounds were getting larger, but a new nurse would not know. ADON F stated to prevent wounds, resident needed to be repositioned every two hours or more often. ADON F stated if residents were not repositioned then they could be in pain. ADON F stated there was no reason Resident #30 would not be repositioned every two hours. ADON F stated Resident #30 had developed new wounds recently, but they were healing. ADON F stated the charge nurses and ADONs should monitor and ensure residents were turned. ADON F stated her expectation was for residents to be turned every two hours. In an interview on 3/25/2025 at 9:42 a.m., the DON stated pressure sores were prevented by repositioning residents every two hours, providing skin care, and by monitoring the residents' nutritional status. The DON stated if a resident was not turned every two hours, then it could lead to pressure injuries. The DON reported the charge nurses monitored to ensure residents were turned every two hours. The DON stated her expectation was that there would not be any skin breakdown if they were doing what they were supposed to do. In an interview and observation on 3/25/2025 at 11:53 a.m., the DON reported Resident #22 admitted with wounds. The DON opened her laptop and confirmed measurements were obtained for wounds on 3/13/2025 but were not obtained again. The DON reported Resident #22 was sent to the hospital on 3/24/2025 and she did not know what the wound measurements were prior to the resident's transfer. The DON stated wounds were measured to determine if they were improving or deteriorating. The DON reported that wounds should have been measured with each weekly skin assessment that was completed. The DON stated the wound care nurse had assigned Resident #22's wound care to the floor nurses because the wounds were small. The DON stated she and the wound care nurse monitored wound measurements weekly. The DON stated she expected wounds to be measured weekly. The DON stated Resident #22 should have been repositioned as tolerated. Record review of facility's policy titled Skin and Wound Monitoring and Management, with a revision date of 01/2022, revealed It is the policy of this facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The policy also revealed A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to: 1) Measuring the skin injury. The policy also revealed Prevention: In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: . c. Reposition the patient.

Based on interview and record review, the facility failed to include pertinent information when notifying the resident's emergency contact and failed to immediately notify the responsible party when there was a change in condition for one (Resident #13) of four residents reviewed for notification of changes. The facility failed to ensure Resident #13's responsible party was notified on 2/24/2025 that Resident #13 was transferred to the hospital for dehydration and acute renal failure. The facility failed to ensure Resident #13's emergency contacts were notified what hospital Resident #13 was transferred to on 2/24/2025. These failures could place residents' responsible parties at risk of not being informed of changes in the residents' conditions and of not knowing where residents were located. Findings included: Record review of Resident #13's Admission MDS assessment dated [DATE] revealed Resident #13 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dehydration, cognitive communication deficit (difficulty communicating needs), malnutrition, and renal insufficiency or end stage renal disease (kidney failure). Section C of the MDS assessment revealed Resident #13 had a BIMS score of 12 (indicated moderate cognitive impairment). Record review of Resident #13's care plan with a closed date of 2/27/2025 revealed Resident #13's contact information would be updated with Power of Attorney or legally authorized representative information. Resident #13's care plan also revealed the resident was at risk for impaired cognitive function or impaired thought processes. Record review of Resident #13's face sheet dated 3/21/2025 revealed Resident #13's POA was listed as emergency contact number one with his name and phone number. Resident #13's friend was listed as emergency contact number two. Record review of Resident #13's progress notes on 2/24/25 at 9:22 p.m. entered by RN A revealed an order was received from the doctor to send Resident #13 to the hospital for dehydration and acute renal failure. This note revealed the resident and responsible party were notified. Record review of Resident #13's progress notes on 2/24/2025 at 10:03 p.m. entered by RN A revealed the name of Resident #13's representative that was notified was the friend who was emergency contact number two. In an interview on 3/21/2025 at 10:18 a.m., Resident #13's friend (emergency contact two) reported he received a message from the facility indicating Resident #13 was being sent to the hospital for dehydration. The friend stated the facility did not tell him what hospital Resident #13 was sent to. The friend stated they had to find Resident #13 because the facility did not know where Resident #13 was. The friend reported they went to the facility, and Resident #13 was not there. The friend stated they had to call the police because the facility could not find Resident #13. The friend reported the facility made several phone calls and determined Resident #13 was transferred from one hospital to another hospital. Record review of Resident #13's friend's (emergency contact number two) voicemail dated 2/24/2025 at 9:26 p.m. revealed a message was left indicating the call was from the facility, and Resident #13 was being sent to the hospital for dehydration. The voicemail did not indicate to what hospital. In an interview on 3/21/2025 at 3:46 p.m., RN A reported she received an order from the doctor to send Resident #13 to the hospital because Resident #13 had acute renal failure. RN A stated Resident #13 asked her to call his friend (the second emergency contact) and let the friend know he was being transferred to the hospital. RN A stated she called the friend (the second emergency contact) twice, but no one answered. RN A stated she left a voicemail for the friend (the second emergency contact). RN A stated she did not attempt to call the POA because there was not a name next to the number on the face sheet. RN A stated the family and emergency contact should always be contacted if there was a change in condition. RN A did not state what could happen if the POA was not notified of a change in condition. In an interview on 3/24/25 at 8:55 a.m., Resident #13's POA stated he was not notified on 2/24/2025 that Resident #13 was transferred to the hospital, and he did not know where the resident was at that time. The POA stated he wanted to be notified and was unable to find the resident. The POA reported Resident #13's friend (the second emergency contact) had received a message but had not spoke with anyone at the facility. The POA stated after Resident #13's friend (the second emergency contact) notified him that Resident #13 was sent to the hospital that he had to call the hospital which told him the resident was not there. The POA reported they did not know what hospital Resident #13 was at. The POA stated the police had to be called by Resident #13's friend (the second emergency contact) to the facility to determine Resident #13 was transferred from the initial hospital to another hospital. In an interview and observation on 3/25/2025 at 9:42 a.m., the DON reported the nurses are expected to notify the first contact for transfers or changes in condition. The DON stated the POA should always be notified unless the resident requested someone else to be notified. The DON reported that the day after Resident #13 was sent to the hospital that Resident #13's friend (second emergency contact) went to the facility to find Resident #13. The DON stated the friend had gone to the hospital, but Resident #13 was not there. The DON reported the friend's husband went outside and called the police while the facility staff were making calls to determine where Resident #13 was. The facility staff were able to contact the hospital and determined Resident #13 was sent to another hospital. The DON reported the initial hospital did not notify the facility of the transfer to another hospital. The DON opened her laptop and confirmed Resident #13's face sheet had a name and number listed for Resident #13's POA. The DON stated she expected that the POA would be notified first for any changes in condition, and the risk would be that the POA would not be able to make decisions pertaining to the resident. The DON reported the ADONs and herself were responsible for monitoring who was notified of changes in condition. Record review of the facility's policy titled Change of Condition, with a revision date of 07/2015, revealed the Licensed nurse will inform family/responsible party of change of condition and document notification. Record review of Resident Rights from the CMS website accessed on 3/26/2025 at https://downloads.cms.gov/medicare/your_resident_rights_and_protections_section.pdf revealed, The nursing home must notify your doctor and, if known, your legal representative or an interested family member when the following occurs . the nursing home decides to transfer or discharge you from the nursing home.

Based on interview and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one (Resident #99) of five residents reviewed for falls. CNA B failed to reposition Resident #99 safely while in a shower chair in the shower room causing Resident #99 to have a fall on 2/17/2025. This failure could affect the residents by placing them at risk for discomfort, pain, and/or injury. Findings included: Record review of Resident #99's Quarterly MDS assessment dated [DATE] revealed Resident #99 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, cognitive communication deficit (difficulty communicating needs), and absence of right foot. Section C of the MDS assessment revealed a BIMs score of 03 (indicated severe cognitive impairment). Section GG of the MDS assessment revealed Resident #99 was dependent with showering and required the helper to provide all of the assistance or the assistance of two or more helpers while showering. Record review of Resident #99's care plan with a revision date of 2/19/2025 revealed Resident #99 was totally dependent on staff to provide baths. On 2/19/2025 an intervention was added that stated Resident #99 required two staff members for repositioning in the shower. Record review of Resident #99's progress note dated 2/17/2025 at 6:35 p.m. by LVN C, revealed LVN C was called to the shower room by CNA B. The note revealed LVN C saw Resident #99 sitting on the bathroom floor and leaning halfway on the shower chair with a mechanical sling under her. The note revealed CNA B told LVN C she was adjusting the mechanical lift sling under Resident #99 when the resident slid out of the shower chair. The note revealed CNA B lowered Resident #99 to the floor. The note revealed Resident #99 did not have injuries. In an interview on 3/21/2025 at 3:35 p.m., CNA B stated she was showering Resident #99, and Resident #99 had a mechanical lift sling under her. CNA B reported this was a sling with an opening under the resident's bottom, so the resident's bottom could be cleaned. CNA B stated the sling was covering Resident #99's bottom, and she was unable to clean it properly. CNA B stated she tried to tug on the sling, so she could wipe Resident #99's bottom. CNA B reported a normal person could support themselves, but she had no legs. CNA B reported she was standing in front of the resident when she tugged on the sling, but Resident #99 was covered in soap. CNA B reported Resident #99 was slippery, had no legs, and started sliding out of the front of the chair. CNA B reported she was holding the sling and guided her to the ground. CNA B stated no one else was in the shower room with them, but she called LVN C for assistance after the fall. In an interview on 3/25/2025 at 9:42 a.m., the DON stated if a resident was transferred to a shower chair with a mechanical lift, then staff should get additional help to realign the sling. The DON stated staff should never pull the sling to reposition the resident because that can cause the resident to slide on the shower chair. The DON reported all CNAs were trained and in-serviced on safety transfers. The DON reported the floor nurses were responsible for monitoring the CNAs. The DON stated her expectation was for residents to be safely repositioned in shower chairs and that there were no falls. The DON stated the risks to the resident if not positioned safely was that residents could fall and have an injury. In an interview on 3/25/2025 at 2:20 p.m., LVN C reported he was sitting at the nurse's station facing the shower room when CNA B waved for him to go to the shower room. LVN C stated when he entered the shower room, Resident #99 was sitting in the floor against the shower chair. LVN C stated he assessed Resident #99, and there were no injuries. LVN C reported that CNA B told him she attempted to reposition Resident #99 because she was not sitting up. LVN C reported CNA B told him that she had to lower Resident #99 to the floor. LVN C stated CNA B should have called for help to reposition Resident #99 because the resident was much larger than CNA B. LVN C stated the risk for not calling for help is that there could be an accident. LVN C reported staff completed an in-service after the incident. In an interview on 3/25/2025 at 3:03 p.m., the DON reported an in-service was completed with the morning and day shift for two halls. The DON reported the staff on the other halls were not in-serviced. The DON reported no monitoring documentation was completed, but the nurses were supposed to monitor the CNAs. Record review of in-service dated 2/18/2025, revealed topics were 1. While providing care for residents that required hoyer lift during showers. Please ensure that resident is positioned correctly in the shower chair for fall prevention. 2. Call for assistance when needed. 21 signatures were noted. Record review of the facility's policy titled Fall Management System, with a revision date of 6/2018, revealed This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents.

Based on interview and record review the facility failed to implement the facility's own written abuse and neglect prevention policy and procedure for one (Resident #32) of six residents reviewed for abuse and neglect. The Administrator failed to immediately suspend one staff member (the CNA) pending investigation when an allegation of physical abuse of Resident #32 was made in a verbal statement by family member on 1/28/25. This failure could place residents at risk of a lack of protection from being abused pending the investigation of an allegation of abuse. Findings included: Review of Resident #32's face sheet reflected an [AGE] year-old male, admitted on [DATE], with diagnoses of Unspecified Sequalae of unspecified Cerebrovascular Disease (neuro-logic deficits that persist after a cerebrovascular accident or stroke), muscle weakness, COVID-19, Cataract, Convulsions, Cerebral Infraction ( ischemic stroke, occurs when blood flow to the brain is interrupted, causing brain tissue to die), difficulty in walking, Hyperlipidemia (abnormally high levels of lipids in the blood, including cholesterol and triglycerides), recurrent Depressive Disorders, essential Hypertension, Occlusion and Stenosis of right middle cerebral artery (can occur due to a buildup of plaque in the artery), Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side (refers to a stroke (brain tissue damage due to lack of blood flow) that has occurred on the left side of the brain, specifically in the area that control the non-dominant side of the body), and dysphagia (difficulty swallowing). Review of Resident #32's Quarterly MDS Assessment, dated 11/28/24, reflected his sight and hearing were adequate, and he was able to express himself, be understood by others, and to understand others. His BIMS score was 7, indicating severely cognitive impairment. He had no indicators of depression, or psychosis, and exhibited no behavioral problems. Further review of section GG revealed he was dependent on staff for chair/bed-to-chair transfer. Review of the facility January 2025 Grievances revealed that on 01/28/2025 an aide putting Resident #32 to bed was not very gentle. The resolution stated that aide counseled by DON, statement obtained, and training done. Under the satisfied column a yes was placed. Record review of Resident #32's care plan, undated, revealed a focused area, initiated on 01/22/2020, Resident #32 had potential impairment to skin integrity immobility. The goal initiated on 01/22/20, revealed Resident #32 would be free from injury through the review date. The interventions initiated 01/22/20 included to use caution during transfer and bed mobility to prevent striking arms, legs, and hands against any sharp surfaces. During an interview on 02/05/25 at 4:28 PM, the ADON revealed that on 01/28/2025 she was met by the family member of Resident #32 in the hallway, and she reported to her that the CNA was rough with Resident #32 and that he almost fell off the bed during transfer from chair to bed. The ADON stated she walked with the family member back into the room where the CNA had finished changing Resident #32 and the ADON observed the Resident #32 resting peacefully in bed there was no distress. The ADON asked the CNA to leave the room with her and told her she was no longer to work with Resident #32 after that the ADON went and informed the ADM who was with the DON. The ADON told the ADM and DON that the family member reported to her that the CNA was rough with the resident during transfer. The ADON stated the ADM and her left the room and went back to Resident #32 room, she conducted a head-to-toe assessment there was no bruising, skin tears or pain noted and then the ADM asked the resident questions. While the ADM interviewed Resident #32 the ADON left the room to talk to the CNA and asked her what happened and the CNA expressed what was alleged did not happen and then the CNA was moved to different hall. The ADON revealed she and the DON started reeducating the staff that day on the abuse and neglect policy. During an interview on 2/7/25 at 10:33 AM, the DON revealed that she was made aware of alleged abuse of Resident #32 by the ADON. The ADON came to my office on 1/28/25 at unknown time and the ADM was present when ADON entered and stated that Resident 32's family member alleged that she witnessed CNA being rough while she transferred Resident #32 from his chair to bed. The DON went to remove CNA from Resident #35's care but did not conduct an interview with the CNA until next day 1/29/25. The DON stated that the CNA wasn't suspended just moved to different hall. The DON stated the staff member was not suspended because when we conducted our investigation, we did not confirm alleged abuse. The DON stated that when a resident confirmed allegations of abuse that is when the staff member is suspended while they conducted the investigation. During an interview on 2/7/25 at 11:47 AM, the ADM revealed that the ADON immediately reported that Resident #32's family member alleged that a staff member kicked Resident #32 and was rough during his transfer from chair to bed. The ADM stated that the staff member was removed from resident care immediately but was not suspended because Resident #32 stated he didn't feel he had been abused. The ADM said with an allegation of abuse we first interview the resident to see if they feel they were abused, if the resident confirms they feel abused we will suspend the alleged staff member, report it to state, conduct a head to toe assessment and start investigation once investigation complete will submit what we found to state and if unsubstantiated will allow the staff to return to work, but that staff member is not to work with resident anymore. The ADM stated that there was no risk to the other residents because we did not confirm the alleged abuse. The ADM stated that he would have to review the facilities policy for a refresher if staff member had to be suspended if the resident did not confirm the alleged abuse. During an interview on 2/7/25 at 1:16 PM, the Clinical Resource Nurse revealed that she had provided education to the facility and would quiz staff on the types of abuse and procedure of who and when to report an allegation of abuse. The Clinical Resource Nurse stated that when there is an allegation of abuse that involved staff member the facilities policy was to suspend staff member involved immediately pending investigation. The Clinical Resource Nurse stated that the risk to the other resident to allow an alleged perpetrator to work with other residents during investigation would put the risk of the other residents being abused. An interview on 2/7/25 at 2:05 PM with CNA revealed Resident #32 family member was present upon her entry of room and family member requested that Resident #32 be put in bed as he had fell asleep in chair. The CNA stated she had repositioned his chair to assist with transfer of Resident #32 she then stood in front of Resident #32 chair placed her arms under his and lifted him up, but once she lifted Resident #32 his body stiffened up and to prevent both her and Resident #32 from falling she laid the resident on his back across the bed, then she was able to reposition Resident #32 then she changed resident in front of family member. The CNA stated the family member then left the room as she finished cleaning Resident #32 up and then the ADON came into the room and got me and told me and stated that I could not work with Resident #32 any longer the CNA stated she was confused but continued to work. The CNA said that Resident #32 was a one person assist and had never stiffened up during transfer before and she just wanted to prevent the resident from a fall. She stated she decided to lay him across the bed, no part of his body hit the floor and at no point was she rough or kicked the resident during transfer. The CNA said that the DON talked to her the next day (1/29/2025) before she started her shift about what had taken place in Resident #32's room during the transfer and took my statement. The CNA stated that she was not suspended just reeducated on care for residents, to ask for help if needed and switched halls with another aide. Review of the facility Grievance Resolution Form dated 01/28/2025 received by SW on Resident #32 summary statement of the resident's grievance stated CNA was putting resident to bed, was not gentle. The person who reported the grievance was Resident #32's family member. The steps they took to investigate the grievance was SW immediately notified the ADM, investigated, and did not find any signs/forms of abuse. The summary of findings revealed the CNA states this never happened and no injuries or concerns with Resident #32. The corrective action taken as a result of the grievance followed up with family member regarding concern and CNA was removed from Resident #32 section, head to toe assessment done and no finding of abuse and neglect. The ADM signed on 01/29/2025. Review of the facility investigation documentation for a family member reported allegation of abuse by a staff member, submitted to the ADM on 1/28/25, reflected Resident #32's family member alleged that a staff member kicked and was rough with Resident #32 while she transferred from chair to bed. In the investigation materials provided, a statement by the ADM, dated 01/28/25 reflected Upon being notified that a complaint had been made by Resident #32's family member concerning about the Resident #32's care, I immediately visited the resident and interviewed him concerning the complaint. I asked if the resident felt like he had been abused and resident responded that he did not. I then asked if Resident #32 had been kicked or thrown off the bed as the family member had reported and the resident again responded that he did not. The resident denied any pain and the ADON stated that she would be doing a skin assessment on the resident as the family member had reported a fall had occurred. The resident denied any allegation of abuse and the resident is able to make his wishes known. I have had multiple interactions with this resident on previous occasions. Additionally, provided was a statement by CNA dated 1/29/25 at 2:14 PM reflected I, CNA assigned to Resident #32 on 1/28/25 2-10 shift, I brought Resident #32's roommate in the room and family member was visiting and asked me to lay resident #32 in the bed due to Resident #32 sleep on chair. Upon transfer Resident #32 leaned and was stiff on transfer laid cross the bed but did not fall or hit any part of the body. I then repositioned resident and changed soiled brief and made resident comfortable. Review of the facility Abuse Prevention Program policy, revision dated October 2022, reflected: G) Protection: 3. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves an employee, the facility will: Immediately remove the employee from the care of any resident Suspend the employee during the pendency of the of the investigation.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for one of five residents (Resident #1) reviewed for notification of changes. -The facility failed to notify the physician when LVN C observed and documented a new wound on Resident #1's left toe, when Resident #1 was a high risk for infection due to comorbidities. -The facility failed to notify Resident #1's RP when LVN C observed and documented a new wound on Resident #1's left toe, when Resident #1 was a high risk for infection due to comorbidities. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not having their physician notified concerning their medical needs which would cause a delay in treatment and a decline in health. Findings include: Record review of Resident #1's face sheet, dated 12/28/23, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: type II diabetes (inability to regulate blood glucose), muscle weakness, acute osteomyelitis of left ankle and foot (inflammation of bone caused by infection), peripheral vascular disease (circulation disorder) and dementia (loss of memory and thinking). Record review of Resident #1's quarterly MDS assessment, dated 11/20/23, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, revised 9/13/23, reflected he had an ADL self-care deficit related to dementia, deconditioning, debility and left heel ulcer, with interventions which included staff providing physical assistance with daily self-care as needed. Further review reflected Resident #1 had a diabetic ulcer unstageable to the left heel and was at risk for further skin breakdown due to immobility and diabetes. Interventions included administering treatments as ordered and monitoring for effectiveness, assess/record/monitor wound healing, report improvements and declines to MD, encourage to turn and reposition, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #1's orders, dated 12/28/23, reflected an order to consult with MD for wound care. There were no active orders for wound care. Record review of Resident #1's weekly skin assessment, dated 12/7/23, reflected he had multiple wounds to right leg, and an old wound to left heel. Record review of Resident #1's weekly skin assessment, dated 12/14/23, reflected he had multiple wounds to right leg, left toe and an old wound to left heel. Record review of Resident #1's progress notes reflected there was no further documentation about notification to the MD regarding the new wound found on Resident #1's left toe according to his weekly skin assessment on 12/14/23. Record review of in-service titled Weekly skin/ulcer assessment, dated 12/14/23, reflected all nurses were educated by the DON on weekly skin/ulcer assessments and notifying the RP and DON on changes. Record review of Resident #1's hospital records, dated12/28/23, reflected the resident was admitted to the hospital due to gangrene of his bilateral toes and lethargy. Resident #1 was diagnosed with osteomyelitis (inflammation of bone caused by infection) of right 3rd and 2nd toes, left great toes infection, chronic left heel ulcer, chronic anemia, severe tibia artery disease (circulatory disorder), and possible chronic kidney disease. Resident #1 had his left leg amputated below the knee on 12/21/2023 and his right leg was amputated below the knee on 12/26/23. Observation on 12/28/23 at 9:45 AM of Resident #1 at a local hospital, revealed he was lying in bed recovering from having a double below-knee amputation. Resident #1 was unable to be interviewed due to language barrier. In an interview on 12/28/23 at 9:46 AM, Resident #1's RP stated Resident #1 used a wheelchair for mobility; however, he was able to transfer independently and could do most ADLs independently. The RP stated Resident #1 was having a hard time adjusting to his limited abilities after having both legs amputated. The RP stated Resident #1 was active, able to communicate, and alert; however, when family visited him at the nursing facility on 12/28/23, he was disoriented, non-communicative, and did not recognize anyone. The RP stated it was then he noticed the toes on both of Resident #1's feet had turned black and once they complained to the nursing staff, Resident #1 was transported to the local hospital. The RP stated the nursing facility had not reported any changes in Resident #1's condition to him. In an interview on 12/28/23 at 10:28 AM at the local hospital, MD A stated he was the attending MD for Resident #1. MD A stated Resident #1 was admitted to the local hospital in 02/2023 due to wound infections with interventions which included debridement and antibiotic treatment. MD A stated Resident #1's recent amputation of both legs was due to infection and gangrene of multiple toes. MD A stated due to Resident #1's history he could not determine Resident #1's current condition was due to neglect by the facility without knowing information about treatment he was receiving at the facility; however, MD A stated Resident #1's age and diagnoses could have caused the infection to worsen rapidly, within less than a week without treatment. In an interview on 12/28/23 at 12:07 PM, LVN D stated she worked at the facility for 2 months. She stated she usually only worked the weekends but started working during the week about two weeks ago, while the facility's full-time wound care nurse was out. She stated she did wound care on Resident #1's left shin, and her last time providing care to him was a month ago because the wound was resolved. She stated she did not do wound care on Resident #1's feet because he did not have wounds on his feet at the time. She stated she knew because it was protocol to assess the feet when doing wound care on his legs. LVN D also stated she would check the orders and treatment assessment records to check for other treatments the resident needed, and he was not receiving any other wound care. In an interview on 12/28/23 at 12:48 PM, the DON stated she worked at the facility for about 3 weeks. She stated LVN C documented on 12/14/23 on Resident #1's weekly skin assessment he had a wound on his left toe that was not there the week prior. The DON stated LVN C informed her she did not notify the MD or report it to anyone because she thought the wound was already being treated. The DON stated her expectation was for the nurses to document any changes to the residents, check the orders for treatment and notify herself, the MD, and RP. The DON stated there were a lot of residents in the facility with wounds, so she had already provided an in-service on skin assessments and notification to all nurses on 12/14/23 as a precaution and prior to being aware that Resident #1 had a new wound. The DON stated LVN C received the training and still failed to notify anyone of Resident #1's new wound. The DON stated LVN C was terminated for failing to follow the facility's policy. In an interview on 12/28/23 at 1:37 PM, CNA E stated he worked at the facility for four months. He stated he worked with Resident #1 and the resident often refused showers and other care. CNA E stated about a week prior to 12/18/23, when Resident #1 was transferred to the hospital, he noticed Resident #1 was not eating and had severe diarrhea. CNA E also stated Resident #1 had a bad odor that smelled like it was coming from a wound. CNA E stated he reported this to the charge nurse, who was LVN C, and she stated she would notify the MD. CNA E stated he did not know if it was reported to the MD. In an interview on 12/28/23 at 2:25 PM, MD B stated she was one of the attending MDs at the nursing facility. She stated she typically saw Resident #1 once a month unless there was an issue. MD B stated Resident #1 admitted to the facility in 02/2023 with an infection in his foot after being treated at a local hospital. MD B stated it was recommended at that time Resident #1 have an amputation due to being high risk for infections, but his family declined, and Resident #1 was treated with IV antibiotics. MD B stated Resident #1 was also seeing a wound care specialist outside of the facility and his wounds had healed. She stated he would have intermittent wounds on his shins/legs from bumping them, but overall, he healed to her knowledge. MD B stated Resident #1 did not have any active orders for wound care, but she would have given one had she been notified that it was needed, especially due to Resident #1's history and comorbidities. MD B stated it was her expectation for the nurses to notify of any changes to her, and they were usually good about doing so. She stated she was not in front of the charts, but she could not recall being made aware of a new wound on Resident #1's left toe prior to him going to the hospital on 12/18/23. She stated her first-time hearing of any issues for Resident #1 was on the day he was sent to the hospital. In a further interview on 12/28/23 at 5:45 PM, the DON stated the risk of not notifying the MD of a change in condition such as a wound could be it leading to a severe situation like sepsis and potentially death. In an interview on 01/17/24 at 10:48 PM, the DON stated since the facility's failure, processes were put in place to ensure it did not happen again. The DON stated a skin sweep of all residents in the facility was started on 12/19/23, with no change in condition or major skin issues found. She stated all CNAs were in-serviced on 12/20/23 on conducting skin assessments during ADL care and reporting any skin issues or change of condition to the charge nurses. The DON stated further education with CNAs would include reminding them to also report concerns or change of condition to management, including herself, the ADONs, or the Administrator. The DON stated all CNAs were informed to document any skin issues found during showers on the resident's shower sheets and to also report everything to the nurse no matter when it was found. The DON stated all nurses were in-serviced on 12/20/23 on addressing change of condition immediately and reporting to the MD, DON, and RPs. The DON stated all staff were also in-serviced on 12/20/23 on reporting abuse and neglect. The DON stated she and the ADONs were conducting daily monitoring of skin assessments completed by the nurses to screen for new skin issues/change of condition and to monitor the condition of existing skin issues. The DON stated there would also be continuous education and reminders to all staff on the importance of skin assessments and immediately reporting any change of condition. The DON stated all CNAs and nurses were given skin assessment skills checkoffs to ensure their understanding on how to conduct them. The DON stated all nurses were expected to know how to assess all shades of skin for discoloration and wounds based on nursing skills obtain in nursing school. In an interview on 01/17/24 at 11:12 PM, LVN Q stated she was the full-time wound care nurse at the facility. She stated she worked with Resident #1 and last provided wound care to him on 11/7/23 when the wound on his right shin was resolved. LVN Q stated all of Resident #1's wounds had resolved and there were no new orders for wound care besides a standing order to consult with the MD for wound care of any new wounds. LVN Q stated she the nurses and CNAs had a good rapport with her and would usually inform her of new wounds and skin issues found on the residents. She stated the CNAs knew to inform the charge nurses of new wounds or any change of condition of the residents, but if they saw her in the hallways, they would inform her also. LVN Q stated she had not been informed that Resident #1 had any new wounds or a change of condition since 11/7/23 after all his wounds were resolved. LNV Q stated Resident #1 had dementia and was Spanish speaking only, so he would often refuse ADL care and not interact with staff due to confusion and language barriers. LVN Q stated she was able to communicate with him in Spanish so he would comply with her more; however, she was had not worked with him since 11/7/23. She stated she was also on vacation for two weeks starting on 12/15/23, which was during the time LVN C found the new wounds. LVN Q stated Resident #1 had already discharged from the facility when she returned to work. LVN Q stated she was never made aware of the new wounds to Resident #1's toes. She stated she also was not aware of multiple wounds on his right leg. LVN Q stated the only wound to Resident #1's right leg that she was aware of was the one she was treating on his right shin that was resolved on 11/7/23. LVN Q stated Resident #1 often had superficial scratches and scabs from bumping his leg on the wheelchair, but he did not have any active orders for wound care. In an interview on 01/17/24 at 12:46 PM, LVN R stated she worked PRN weekends at the facility and worked with Resident #1 on 12/17/23, the day before he was transferred to a local hospital. LVN R stated Resident #1 was acting his normal self and did not display any signs of pain or discomfort. LVN R stated the CNA did not report any change of condition of Resident #1 to her. She stated Resident #1 did not have diarrhea or a change in appetite on 12/17/23 or anything that needed to be reported to the MD. LVN R stated she was not aware of any new wounds that Resident #1 had. She stated she remembered an old wound that Resident #1 had on his left ankle or foot that had been resolved, but no new wounds. LVN R stated Resident #1 had an odor from refusing to shower, but he did not have a distinct odor that wound come from an infected wound that she could recall on 12/17/23. LVN R stated Resident #1 would always refuse his showers. LVN R stated Resident #1 was friendly with her but would even refuse for her to shower him. LVN R stated Resident #1 was mostly independent and could dress himself, so the chance for CNAs to observe skin issues was limited, especially with Resident #1 not being able to communicate with them. LVN R stated the chance for wounds or new skin issues to be found would be during the weekly skin assessments done by the nurses. LVN R stated any new skin issues found on a resident would have to be assessed by the nurse and reported to the MD, DON, and RP immediately. In an interview on 01/17/24 at 3:28 PM, the Administrator stated to ensure that staff were conducting proper skin assessments and reporting all skin issues/change of condition, the DON and ADONs would continue monitoring all skin assessments and the monitoring and findings would be discussed with the team every morning during standup meeting for him to ensure that it was being done. The Administrator stated ongoing education would also continue with all staff and disciplinary actions would be taken for any staff not following protocols and processes put in place. The Administrator stated processes put in place regarding the facility's failure was addressed at the QAPI meeting held on 01/17/24. Record review of Resident #1's shower sheets, dated 12/5/23, 12/14/23, and 12/16/23, reflected the resident refused all showers. There was no documentation of skin issues on any of the shower sheets reviewed. No additional shower sheets could be provided. Record review of Resident #1's 24-hour reports, from 12/14/23-12/18/23, reflected there was no documentation of new skin issues or change of condition until 12/18/23 when LVN C reported the resident was sent out to the hospital for left great toe and right second toe being gangrene like. Record review of skin assessments dated 12/19/23-12/23/23, reflected a skin sweep of all residents in the facility with no findings. Record review of LVN C's personnel file reflected she was terminated on 12/19/23 for failure to notify the RP and physician to request an order for treatment when a new wound was documented on an assessment. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance prior to the survey: Interviews were conducted with CNA E (1st shift), Nurse Aide I (1st shift), LVN F (2nd shift), CNA G (2nd shift), and LVN H (2nd shift), LVN J (3rd shift), CNA K (3rd shift), CNA L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), LVN O (2nd shift), LVN P (1st shift), LVN R (3rd shift) . All licensed staff were able to provide competency regarding in-service over policy on change of condition and when to communicate acute changes in residents' status to MD, DON, and responsible party. All licensed staff were able to state that all residents received skin assessments at least weekly, and more frequently for residents with existing skin issues. They were able to state that any new skin issues or worsening of existing skin issues should be assessed and immediately reported to the DON, MD, and RP, and any new orders followed. All CNAs were able to provide competency regarding in-service over change in condition, skin assessments during ADL care, and when to report changes in condition to the nurse. All CNAs were able to state that opportunities to assess residents' skin was during ADL care such as showers or incontinent care and when repositioning a resident. They were able to state that any change in condition or observation of skin issues should be immediately reported to the charge nurse. All CNAs were also able to state that if the issue was not addressed, they would report it to the DON. Interview and record review of Residents #2, #3, #4, #5, #6, and #7, who all received wound care, revealed there were no changes in condition and all residents had interventions in place to help prevent complications from wounds. Interview with Resident #2's RP revealed the residents wounds were healing and her legs were getting stronger. Interview with Resident #3 revealed he was satisfied with the wound care he was receiving, and the resident denied being in pain. Interview with Resident #4 stated he received wound care as ordered and had no concerns. Interview with Resident #5's RP revealed he had no concerns with the wound care the resident was receiving and that he was notified when there was a change in condition. Interview with Resident #6 revealed no concerns with the wound care she was receiving. Interview with Resident #7 revealed the wound care nurse was great and he had no concerns. In an observation and record review on 01/17/24 of Resident #2, the resident was observed to have an open wound to her right lower leg with and a scab on a resolved wound to left shin. Record review of Resident #2's skin assessment, dated 01/17/24, reflected Resident #2 had one wound to her right lower leg. Record review of Resident #2's orders reflected an active order for daily wound care to right lower leg until resolved. Record review of Resident #2's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #3, the resident was observed to have an open wound to his left ankle and dark discoloration to lower left leg from poor circulation. Record review of Resident #3's skin assessment, dated 01/17/24, reflected he had one wound to his left medial (inner) ankle. Record review of Resident #3's orders reflected an active order to wash and dry his left leg twice daily, and an active order to provide wound care to left inner ankle every Wednesday. Record review of Resident #3's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #4, the resident was observed to have an open wound to his left heel. Resident #4 was wearing cushioned heel protectors. Record review of Resident #4's skin assessment, dated 01/17/24, reflected he had one wound to his left heel. Record review of Resident #4's orders reflected an active order for daily wound care to left heel. Record review of Resident #4's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #5, the resident was observed to have an open wound to her left heel and a resolved wound to the back of her neck. Investigator was unable to observe the wound on Resident #5's coccyx. Resident #5 was observed wearing a cushioned heel protector on left heel. Record review of Resident #5's skin assessment, dated 01/17/24, reflected she had a wound to her left heel and coccyx, and a resolved wound on neck. Record review of Resident #5's orders reflected an active order for daily wound care and heel protector to left heel, daily wound care to coccyx, and daily wound care to back of neck until resolved. Record review of Resident #5's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #6, the resident was observed to have open wounds to her left heel and left Achilles. Investigator was unable to observe Resident #5's sacrum. Record review of Resident #6's skin assessment, dated 01/17/24, reflected Resident #6 had a wound to her left heel, left Achilles, and a resolved wound to her sacrum. Record review of Resident #6's orders reflected an active order for daily wound care to left heel and left Achilles. Record review of Resident #6's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #7, the resident was observed to have a surgical wound to his left below-knee amputation. Record review of Resident #7's skin assessment, dated 01/17/24, reflected he had a surgical wound to his left below-knee amputation medial (inner) and left below-knee amputation lateral (side of). Record review of Resident #7's orders reflected an active order for daily wound care to the resident's left below-knee amputation. Record review of Resident #7's TAR reflected wound care was being administered as ordered. Record review of Resident #7's nursing notes, dated 01/09/24, reflected the resident had a change of condition of the wound to his left below-knee amputation that was indicative of an infection. The MD was notified on 01/09/24 and new orders for antibiotics and an appointment for a debridement procedure was scheduled for 01/11/24. Further review of the nursing notes reflected the debridement procedure was completed on 01/11/24. In an interview on 01/17/24 at 1:00 PM, the LVN Q stated Resident #7 was the only resident in the facility who had a change of condition of wounds. She stated he was the MD was notified and Resident #7 was ordered to have a debridement procedure that was done on 01/11/24. Record review of in-service titled Change of condition/Abuse & Neglect, dated 12/20/23, reflected all staff were educated by the DON on monitoring skin/wounds, notifying the nurse of any changes of condition with residents, incontinent care, turning/repositioning, and charge nurses addressing change in condition as soon as possible, which included when to notify MD, RP of new orders, filling out incident reports, obtaining new orders, documentation and notifying the DON . Record review of the facility's policy titled Significant Change in Condition, revised 05/2007, reflected in part the following: Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedures: 1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . -Change in mental status -Any sign or symptom of infection . -Change in medical condition . 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions . 3. The resident will be placed on the 24-hour report and nursing will provide no less than three days of observation, documentation, and response to any interventions 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards, comprehensive person-centered care plan and resident choices for 1 of 5 residents (Resident #1) reviewed for quality of care. -The facility failed to notify the physician and provide interventions to monitor and treat Resident #1 when LVN C observed and documented a new wound on his left toe. Resident #1 was high risk for infection due to comorbidities. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not having their physician notified concerning their medical needs which would cause a delay in treatment and a decline in health. Findings include: Record review of Resident #1's face sheet, dated 12/28/23, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: type II diabetes (inability to regulate blood glucose), muscle weakness, acute osteomyelitis of left ankle and foot (inflammation of bone caused by infection), peripheral vascular disease (circulation disorder) and dementia (loss of memory and thinking). Record review of Resident #1's quarterly MDS assessment, dated 11/20/23, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, revised 9/13/23, reflected he had an ADL self-care deficit related to dementia, deconditioning, debility and left heel ulcer, with interventions which included staff providing physical assistance with daily self-care as needed. Further review reflected Resident #1 had a diabetic ulcer unstageable to the left heel and was at risk for further skin breakdown due to immobility and diabetes. Interventions included administering treatments as ordered and monitoring for effectiveness, assess/record/monitor wound healing, report improvements and declines to MD, encourage to turn and reposition, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #1's orders, dated 12/28/23, reflected an order to consult with MD for wound care. There were no active orders for wound care. Record review of Resident #1's weekly skin assessment, dated 12/7/23, reflected he had multiple wounds to right leg, and an old wound to left heel. Record review of Resident #1's weekly skin assessment, dated 12/14/23, reflected he had multiple wounds to right leg, left toe and an old wound to left heel. Record review of Resident #1's progress notes reflected there was no further documentation about notification to the MD regarding the new wound found on Resident #1's left toe according to his weekly skin assessment on 12/14/23. Record review of in-service titled Weekly skin/ulcer assessment, dated 12/14/23, reflected all nurses were educated by the DON on weekly skin/ulcer assessments and notifying the RP and DON on changes. Record review of Resident #1's hospital records, dated12/28/23, reflected the resident was admitted to the hospital due to gangrene of his bilateral toes and lethargy. Resident #1 was diagnosed with osteomyelitis (inflammation of bone caused by infection) of right 3rd and 2nd toes, left great toes infection, chronic left heel ulcer, chronic anemia, severe tibia artery disease (circulatory disorder), and possible chronic kidney disease. Resident #1 had his left leg amputated below the knee on 12/21/2023 and his right leg was amputated below the knee on 12/26/23. Observation on 12/28/23 at 9:45 AM of Resident #1 at a local hospital, revealed he was lying in bed recovering from having a double below-knee amputation. Resident #1 was unable to be interviewed due to language barrier. In an interview on 12/28/23 at 9:46 AM, Resident #1's RP stated Resident #1 used a wheelchair for mobility; however, he was able to transfer independently and could do most ADLs independently. The RP stated Resident #1 was having a hard time adjusting to his limited abilities after having both legs amputated. The RP stated Resident #1 was active, able to communicate, and alert; however, when family visited him at the nursing facility on 12/28/23, he was disoriented, non-communicative, and did not recognize anyone. The RP stated it was then he noticed the toes on both of Resident #1's feet had turned black and once they complained to the nursing staff, Resident #1 was transported to the local hospital. The RP stated the nursing facility had not reported any changes in Resident #1's condition to him. In an interview on 12/28/23 at 10:28 AM at the local hospital, MD A stated he was the attending MD for Resident #1. MD A stated Resident #1 was admitted to the local hospital in 02/2023 due to wound infections with interventions which included debridement and antibiotic treatment. MD A stated Resident #1's recent amputation of both legs was due to infection and gangrene of multiple toes. MD A stated due to Resident #1's history he could not determine Resident #1's current condition was due to neglect by the facility without knowing information about treatment he was receiving at the facility; however, MD A stated Resident #1's age and diagnoses could have caused the infection to worsen rapidly, within less than a week without treatment. In an interview on 12/28/23 at 12:07 PM, LVN D stated she worked at the facility for 2 months. She stated she usually only worked the weekends but started working during the week about two weeks ago, while the facility's full-time wound care nurse was out. She stated she did wound care on Resident #1's left shin, and her last time providing care to him was a month ago because the wound was resolved. She stated she did not do wound care on Resident #1's feet because he did not have wounds on his feet at the time. She stated she knew because it was protocol to assess the feet when doing wound care on his legs. LVN D also stated she would check the orders and treatment assessment records to check for other treatments the resident needed, and he was not receiving any other wound care. In an interview on 12/28/23 at 12:48 PM, the DON stated she worked at the facility for about 3 weeks. She stated LVN C documented on 12/14/23 on Resident #1's weekly skin assessment he had a wound on his left toe that was not there the week prior. The DON stated LVN C informed her she did not notify the MD or report it to anyone because she thought the wound was already being treated. The DON stated her expectation was for the nurses to document any changes to the residents, check the orders for treatment and notify herself, the MD, and RP. The DON stated there were a lot of residents in the facility with wounds, so she had already provided an in-service on skin assessments and notification to all nurses on 12/14/23 as a precaution and prior to being aware that Resident #1 had a new wound. The DON stated LVN C received the training and still failed to notify anyone of Resident #1's new wound. The DON stated LVN C was terminated for failing to follow the facility's policy. In an interview on 12/28/23 at 1:37 PM, CNA E stated he worked at the facility for four months. He stated he worked with Resident #1 and the resident often refused showers and other care. CNA E stated about a week prior to 12/18/23, when Resident #1 was transferred to the hospital, he noticed Resident #1 was not eating and had severe diarrhea. CNA E also stated Resident #1 had a bad odor that smelled like it was coming from a wound. CNA E stated he reported this to the charge nurse, who was LVN C, and she stated she would notify the MD. CNA E stated he did not know if it was reported to the MD. In an interview on 12/28/23 at 2:25 PM, MD B stated she was one of the attending MDs at the nursing facility. She stated she typically saw Resident #1 once a month unless there was an issue. MD B stated Resident #1 admitted to the facility in 02/2023 with an infection in his foot after being treated at a local hospital. MD B stated it was recommended at that time Resident #1 have an amputation due to being high risk for infections, but his family declined, and Resident #1 was treated with IV antibiotics. MD B stated Resident #1 was also seeing a wound care specialist outside of the facility and his wounds had healed. She stated he would have intermittent wounds on his shins/legs from bumping them, but overall, he healed to her knowledge. MD B stated Resident #1 did not have any active orders for wound care, but she would have given one had she been notified that it was needed, especially due to Resident #1's history and comorbidities. MD B stated it was her expectation for the nurses to notify of any changes to her, and they were usually good about doing so. She stated she was not in front of the charts, but she could not recall being made aware of a new wound on Resident #1's left toe prior to him going to the hospital on 12/18/23. She stated her first-time hearing of any issues for Resident #1 was on the day he was sent to the hospital. In a further interview on 12/28/23 at 5:45 PM, the DON stated the risk of not notifying the MD of a change in condition such as a wound could be it leading to a severe situation like sepsis and potentially death. In an interview on 01/17/24 at 10:48 PM, the DON stated since the facility's failure, processes were put in place to ensure it did not happen again. The DON stated a skin sweep of all residents in the facility was started on 12/19/23, with no change in condition or major skin issues found. She stated all CNAs were in-serviced on 12/20/23 on conducting skin assessments during ADL care and reporting any skin issues or change of condition to the charge nurses. The DON stated further education with CNAs would include reminding them to also report concerns or change of condition to management, including herself, the ADONs, or the Administrator. The DON stated all CNAs were informed to document any skin issues found during showers on the resident's shower sheets and to also report everything to the nurse no matter when it was found. The DON stated all nurses were in-serviced on 12/20/23 on addressing change of condition immediately and reporting to the MD, DON, and RPs. The DON stated all staff were also in-serviced on 12/20/23 on reporting abuse and neglect. The DON stated she and the ADONs were conducting daily monitoring of skin assessments completed by the nurses to screen for new skin issues/change of condition and to monitor the condition of existing skin issues. The DON stated there would also be continuous education and reminders to all staff on the importance of skin assessments and immediately reporting any change of condition. The DON stated all CNAs and nurses were given skin assessment skills checkoffs to ensure their understanding on how to conduct them. The DON stated all nurses were expected to know how to assess all shades of skin for discoloration and wounds based on nursing skills obtain in nursing school. In an interview on 01/17/24 at 11:12 PM, LVN Q stated she was the full-time wound care nurse at the facility. She stated she worked with Resident #1 and last provided wound care to him on 11/7/23 when the wound on his right shin was resolved. LVN Q stated all of Resident #1's wounds had resolved and there were no new orders for wound care besides a standing order to consult with the MD for wound care of any new wounds. LVN Q stated she the nurses and CNAs had a good rapport with her and would usually inform her of new wounds and skin issues found on the residents. She stated the CNAs knew to inform the charge nurses of new wounds or any change of condition of the residents, but if they saw her in the hallways, they would inform her also. LVN Q stated she had not been informed that Resident #1 had any new wounds or a change of condition since 11/7/23 after all his wounds were resolved. LNV Q stated Resident #1 had dementia and was Spanish speaking only, so he would often refuse ADL care and not interact with staff due to confusion and language barriers. LVN Q stated she was able to communicate with him in Spanish so he would comply with her more; however, she was had not worked with him since 11/7/23. She stated she was also on vacation for two weeks starting on 12/15/23, which was during the time LVN C found the new wounds. LVN Q stated Resident #1 had already discharged from the facility when she returned to work. LVN Q stated she was never made aware of the new wounds to Resident #1's toes. She stated she also was not aware of multiple wounds on his right leg. LVN Q stated the only wound to Resident #1's right leg that she was aware of was the one she was treating on his right shin that was resolved on 11/7/23. LVN Q stated Resident #1 often had superficial scratches and scabs from bumping his leg on the wheelchair, but he did not have any active orders for wound care. In an interview on 01/17/24 at 12:46 PM, LVN R stated she worked PRN weekends at the facility and worked with Resident #1 on 12/17/23, the day before he was transferred to a local hospital. LVN R stated Resident #1 was acting his normal self and did not display any signs of pain or discomfort. LVN R stated the CNA did not report any change of condition of Resident #1 to her. She stated Resident #1 did not have diarrhea or a change in appetite on 12/17/23 or anything that needed to be reported to the MD. LVN R stated she was not aware of any new wounds that Resident #1 had. She stated she remembered an old wound that Resident #1 had on his left ankle or foot that had been resolved, but no new wounds. LVN R stated Resident #1 had an odor from refusing to shower, but he did not have a distinct odor that wound come from an infected wound that she could recall on 12/17/23. LVN R stated Resident #1 would always refuse his showers. LVN R stated Resident #1 was friendly with her but would even refuse for her to shower him. LVN R stated Resident #1 was mostly independent and could dress himself, so the chance for CNAs to observe skin issues was limited, especially with Resident #1 not being able to communicate with them. LVN R stated the chance for wounds or new skin issues to be found would be during the weekly skin assessments done by the nurses. LVN R stated any new skin issues found on a resident would have to be assessed by the nurse and reported to the MD, DON, and RP immediately. In an interview on 01/17/24 at 3:28 PM, the Administrator stated to ensure that staff were conducting proper skin assessments and reporting all skin issues/change of condition, the DON and ADONs would continue monitoring all skin assessments and the monitoring and findings would be discussed with the team every morning during standup meeting for him to ensure that it was being done. The Administrator stated ongoing education would also continue with all staff and disciplinary actions would be taken for any staff not following protocols and processes put in place. The Administrator stated processes put in place regarding the facility's failure was addressed at the QAPI meeting held on 01/17/24. Record review of Resident #1's shower sheets, dated 12/5/23, 12/14/23, and 12/16/23, reflected the resident refused all showers. There was no documentation of skin issues on any of the shower sheets reviewed. No additional shower sheets could be provided. Record review of Resident #1's 24-hour reports, from 12/14/23-12/18/23, reflected there was no documentation of new skin issues or change of condition until 12/18/23 when LVN C reported the resident was sent out to the hospital for left great toe and right second toe being gangrene like. Record review of skin assessments dated 12/19/23-12/23/23, reflected a skin sweep of all residents in the facility with no findings. Record review of LVN C's personnel file reflected she was terminated on 12/19/23 for failure to notify the RP and physician to request an order for treatment when a new wound was documented on an assessment. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance prior to the survey: Interviews were conducted with CNA E (1st shift), Nurse Aide I (1st shift), LVN F (2nd shift), CNA G (2nd shift), and LVN H (2nd shift), LVN J (3rd shift), CNA K (3rd shift), CNA L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), LVN O (2nd shift), LVN P (1st shift), LVN R (3rd shift) . All licensed staff were able to provide competency regarding in-service over policy on change of condition and when to communicate acute changes in residents' status to MD, DON, and responsible party. All licensed staff were able to state that all residents received skin assessments at least weekly, and more frequently for residents with existing skin issues. They were able to state that any new skin issues or worsening of existing skin issues should be assessed and immediately reported to the DON, MD, and RP, and any new orders followed. All CNAs were able to provide competency regarding in-service over change in condition, skin assessments during ADL care, and when to report changes in condition to the nurse. All CNAs were able to state that opportunities to assess residents' skin was during ADL care such as showers or incontinent care and when repositioning a resident. They were able to state that any change in condition or observation of skin issues should be immediately reported to the charge nurse. All CNAs were also able to state that if the issue was not addressed, they would report it to the DON. Interview and record review of Residents #2, #3, #4, #5, #6, and #7, who all received wound care, revealed there were no changes in condition and all residents had interventions in place to help prevent complications from wounds. Interview with Resident #2's RP revealed the residents wounds were healing and her legs were getting stronger. Interview with Resident #3 revealed he was satisfied with the wound care he was receiving, and the resident denied being in pain. Interview with Resident #4 stated he received wound care as ordered and had no concerns. Interview with Resident #5's RP revealed he had no concerns with the wound care the resident was receiving and that he was notified when there was a change in condition. Interview with Resident #6 revealed no concerns with the wound care she was receiving. Interview with Resident #7 revealed the wound care nurse was great and he had no concerns. In an observation and record review on 01/17/24 of Resident #2, the resident was observed to have an open wound to her right lower leg with and a scab on a resolved wound to left shin. Record review of Resident #2's skin assessment, dated 01/17/24, reflected Resident #2 had one wound to her right lower leg. Record review of Resident #2's orders reflected an active order for daily wound care to right lower leg until resolved. Record review of Resident #2's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #3, the resident was observed to have an open wound to his left ankle and dark discoloration to lower left leg from poor circulation. Record review of Resident #3's skin assessment, dated 01/17/24, reflected he had one wound to his left medial (inner) ankle. Record review of Resident #3's orders reflected an active order to wash and dry his left leg twice daily, and an active order to provide wound care to left inner ankle every Wednesday. Record review of Resident #3's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #4, the resident was observed to have an open wound to his left heel. Resident #4 was wearing cushioned heel protectors. Record review of Resident #4's skin assessment, dated 01/17/24, reflected he had one wound to his left heel. Record review of Resident #4's orders reflected an active order for daily wound care to left heel. Record review of Resident #4's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #5, the resident was observed to have an open wound to her left heel and a resolved wound to the back of her neck. Investigator was unable to observe the wound on Resident #5's coccyx. Resident #5 was observed wearing a cushioned heel protector on left heel. Record review of Resident #5's skin assessment, dated 01/17/24, reflected she had a wound to her left heel and coccyx, and a resolved wound on neck. Record review of Resident #5's orders reflected an active order for daily wound care and heel protector to left heel, daily wound care to coccyx, and daily wound care to back of neck until resolved. Record review of Resident #5's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #6, the resident was observed to have open wounds to her left heel and left Achilles. Investigator was unable to observe Resident #5's sacrum. Record review of Resident #6's skin assessment, dated 01/17/24, reflected Resident #6 had a wound to her left heel, left Achilles, and a resolved wound to her sacrum. Record review of Resident #6's orders reflected an active order for daily wound care to left heel and left Achilles. Record review of Resident #6's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #7, the resident was observed to have a surgical wound to his left below-knee amputation. Record review of Resident #7's skin assessment, dated 01/17/24, reflected he had a surgical wound to his left below-knee amputation medial (inner) and left below-knee amputation lateral (side of). Record review of Resident #7's orders reflected an active order for daily wound care to the resident's left below-knee amputation. Record review of Resident #7's TAR reflected wound care was being administered as ordered. Record review of Resident #7's nursing notes, dated 01/09/24, reflected the resident had a change of condition of the wound to his left below-knee amputation that was indicative of an infection. The MD was notified on 01/09/24 and new orders for antibiotics and an appointment for a debridement procedure was scheduled for 01/11/24. Further review of the nursing notes reflected the debridement procedure was completed on 01/11/24. In an interview on 01/17/24 at 1:00 PM, the LVN Q stated Resident #7 was the only resident in the facility who had a change of condition of wounds. She stated he was the MD was notified and Resident #7 was ordered to have a debridement procedure that was done on 01/11/24. Record review of in-service titled Change of condition/Abuse & Neglect, dated 12/20/23, reflected all staff were educated by the DON on monitoring skin/wounds, notifying the nurse of any changes of condition with residents, incontinent care, turning/repositioning, and charge nurses addressing change in condition as soon as possible, which included when to notify MD, RP of new orders, filling out incident reports, obtaining new orders, documentation and notifying the DON . Record review of the facility's policy titled Significant Change in Condition, revised 05/2007, reflected in part the following: Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedures: 1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . -Change in mental status -Any sign or symptom of infection . -Change in medical condition . 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions . 3. The resident will be placed on the 24-hour report and nursing will provide no less than three days of observation, documentation, and response to any interventions 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of three residents reviewed for post-surgical aftercare. The facility failed to ensure Resident #1 received the necessary level of assistance and that staff were aware of physician's orders and PT evaluations to prevent injury. Resident #1 required revision surgery to the right shoulder. The noncompliance was identified as PNC. The IJ began on 09/13/23 and ended on 09/15/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of not receiving care and/or treatment recommended by physician. Findings included: Record review of the Acute Care Hospital After Visit Summary dated 08/31/23 to 09/04/23 revealed the following lifting restrictions: okay to work on active assisted range of motion with passive stretch, no active internal rotation as of now. Record review of Resident # 1's Admission MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted on [DATE]. He had a diagnosis of aftercare following joint replacement surgery, presence of artificial right shoulder joint, hypertension (high blood pressure), cerebral vascular accident (stroke) and need for assistance with personal care. He had a BIMS of 12 (moderate cognitive impairment). He required extensive assistance with bed mobility and transfers and used a motorized wheelchair. Record review of the Physical Therapy PT Evaluation & Plan of Treatment dated 09/05/2023 revealed the following precautions: fall risk, RUE NWB (right upper extremity non-weightbearing), AAROM (assisted active range of motion) with passive stretch, and no active internal rotation, left sided weakness. Record review of Resident #1's Physician Order Recap report dated 09/04/2023 to 09/22/2023 reflected the following orders with a start date of 09/04/23 and an end date of 10/08/23: may participate in activity plan as not in conflict with treatment plan. Progress mobility as tolerated and Weight bearing as tolerated. There were no orders from admission 09/04/23 to 09/22/23 that were specific to the Acute care hospital lifting restrictions and or the PT evaluation precautions. Record review of Resident #1's Progress Note dated 09/08/23 at 7:31pm revealed a change of condition for Left [sic. RIGHT] shoulder swelling, he was sent to an Acute Care Hospital emergency room . Record Review of the Acute Care Hospital emergency room After Visit Summary for Resident #1 dated 09/08/23 reflected he was seen in the ER for right shoulder pain and swelling. An x-ray was taken at 8:15pm and revealed total reverse shoulder arthroplasty dislocation (arm bone is not in shoulder socket). Per ED physician note it stated replaced shoulder appears to be dislocated anteriorly (behind). Also, likely that this has been dislocated for days. Aftercare directions read: Do not lift anything, do not push, or pull things, do not lift arm above shoulder and follow up with orthopedic surgeon on Monday (9/11/23). Record review of the Physician Order Recap Report for Resident #1 from 09/08/23 to 09/22/23 revealed there were no orders with post dislocation restrictions, limitations, or aftercare. Record review of the Orthopedic Follow-up dated 09/22/23 revealed Resident #1 had decreased range of motion since last visit, pain along the right shoulder, and deformity at the shoulder. X-ray completed during follow up revealed an anterior dislocation of his reverse total shoulder prosthesis. Due to this dislocation, it was noted that Resident #1 will require revision surgery of the right shoulder. Record review of Resident #1s Physician Order Recap Report dated 09/22/23 to 10/08/23 revealed the following orders: Monitor sling in place to right shoulder every shift for post-op care with a start date of 09/22/23 and an end date of 10/08/23. non-weight bearing to right shoulder and sling is in place every shift for dislocation with a start date of 09/22/23 and an end date of 10/08/23. Record review of Resident #1s Acute Care Hospital After Visit Summary dated 10/9/23 to 10/9/23 revealed that he was admitted for dislocation of prosthetic joint shoulder and had surgical interventions during this stay. He was discharged with the following restrictions: non-weight bearing to operative extremity, no lifting with operative extremity, no shoulder range of motion ok to gently straighten and bend elbow, keep sling on at all times, progressive mobility as tolerated, and no driving. Record review of Resident #1's Physician Order Summary Report dated 10/25/23 revealed an order that stated Keep sling on at all times except during shower or bathing with a start date of 10/10/23. No lifting with operative extremity, contact PCP for any distress or questions concerns, SOB, chest pain with a start date of 10/10/23. No shoulder range of motion allowed it is ok to gently straighten and bend the elbow with a start date of 10/10/23. Non weight bearing to RUE (right upper extremity) with a start date of 10/09/23. Use mechanical lift for all transfers with a start date of 10/09/23. Interview on 10/25/23 at 11:32am with Resident #1 revealed he needed a lot of help taking care of himself since he was first admitted on [DATE]. He stated he cannot use his left arm because of a past stroke and his right side he could not use because he just had surgery on his shoulder. He stated he needed help to move in bed, to transfers to the wheelchair, and to wash up because both his right and left arms were not functional. He stated some time before he went to theER on [DATE] he was rolled on his right shoulder during ADL care, and it felt loose after that. He stated he has swelling and pain and that's when he asked to be sent to the hospital. Interview on 10/25/23 at 2:15pm with CNA J revealed he was not aware of any limitations or restrictions Resident #1 had for his right shoulder. He stated he cared for resident between 09/04/23 and 09/22/23. During that time, he provided care to resident by himself (one person assistance) with bed mobility and transfers. He stated he did not receive any information from the facility about Resident #1 not being able to assist with his ADLs. He stated Resident #1 would help with ADLs by pulling himself over, using the side rails and he would feed himself and help transfer to his motorized scooter and once in the scooter he would smoke using his affected arm. He was unaware of where he could find patient care specific information like how to transfer them or if they were incontinent, he stated he would ask the nurse. Interview on 10/25/23 at 3:25pm with CNA K revealed Resident #1 would use his right arm for things like eating or moving around in bed or to assist with ADLs like rolling to the side to remove soiled linens from underneath him. She was unsure of any restrictions or limitations that he had with the right arm. She was unsure if Resident #1 was cleared to bear weight or use the right arm for ADLs. She stated if a new resident were admitted she would ask the nurse how to transfer them and how much help they needed. If resident were to have any restrictions she would ask the nurse, and there was no physical place this information could be found. Interview on 10/26/23 at 2:39pm with CNA L revealed Resident #1's ADLs could be performed with one person when he first got here. He would use the right arm all the time to help roll over by grabbing the side rails. She stated she was not aware of any restrictions or limitations he had for the right arm, and he used to do everything. She stated if she needed to know how to care for a resident, she would ask the nurses to see how they transfer, eat or how many people were needed to care for them. She stated if she had a new admission, she would have to wait for the nurses to check on the resident so they can gather the plan of care information. Interview on 10/26/23 at 1:49pm with LVN M revealed that Resident #1 was a one person assist with ADLs when he was first admitted . She stated he had more use of the right arm, and he could feed himself and use his motorized wheelchair on his own. She stated she could not recall if he had any orders that would restrict him from using the right arm. She also stated the CNAs get instructions on how to care for the residents by word of mouth from the nurses or the therapy department. She stated with new admissions the nurses were responsible to transcribe the medication orders and send them to the facility doctor to verify. From there she stated medical records picked up the after-visit summary to upload it for the department heads to review for accuracy. Interview on 10/26/23 at 2:18pm with RN N revealed Resident #1 was receiving care with one person assist when he was first admitted . He would utilize his right arm to help with bed mobility by pulling himself over, using the side rail, he would stand and pivot transfer using his right arm to pull up and hold on to the nurse or CNA transferring him to the wheelchair. She also stated that he did not have any restriction with the use of his right arm. She stated when a resident was newly admitted , the CNAs would have to ask the nurse for the details on how to care for the resident and there was no place the CNAs would be able to find how to transfer the residents or any patient specific care information. The information was relayed verbally. She also stated the charge nurse was responsible to input all the orders and then turn in the after-visit summary to medical records takes the paper works to upload it, she was unsure who checked it from there. In an interview on 10/25/23 at 4:12pm with the DSD revealed the facility did an in-service training for the CNAs and nurses on proper transfers due to Resident #1 stating he was not transferred properly. She was not aware of any further complications that came from the improper transfer and was only aware of the request to facilitate a hands-on training for the nurses and CNAs given by the therapy department. That in-service was completed on 09/22/23. Interview on 10/26/23 at 9:30am with the DOR revealed there was an in-service training held by his department as requested by the nursing department. He stated the training was provided to all CNAs and nurses and was on how to use the Hoyer lift and proper transfers. He stated the training was provided in mid to end of September 2023 and he was unsure of any concerns leading to this training request. In an interview on 10/26/23 at 9:40am with DON C revealed the facility decided to do in-service training after Resident #1 returned from the orthopedic follow up visit on 09/22/23 where it was revealed the resident's shoulder was dislocated. There was no disciplinary action for the staff due to being unable to determine when or how the shoulder became dislocated. During an interview on 10/26/23 at 9:54am with DON D revealed restrictions and limitations were put into place for Resident #1 after she spoke with the orthopedic surgeon following the follow-up appointment on 09/22/23. She stated there were no disciplinary actions for staff due to there being no limitations in residents' chart until 09/22/23, so they were following the proper orders. After 09/22/23 Resident #1 was non-weight bearing, bed rest, and was Hoyer transfer only. She stated she was not sure if rolling onto the right shoulder or using the right arm to pull bodyweight to once side was considered wight bearing. She stated there were no restrictions in place from 09/04/23 to 09/22/23 because there were no orders to do so. An interview on 10/26/23 at 10:15am with Administrator B revealed after her investigation initiated on 09/22/23, Resident #1's sheets were being changed during incontinent care and he was rolled to the right side and his shoulder felt different, but no pain was associated, so the CNA that rolled him to his side was reassigned, and concerns were noted to be a customer service issue that was resolved by moving the CNA from having Resident #1. She was not aware of any restrictions or limitations Resident #1 had to the right shoulder and if there was any it would be in his orders in the EMR. An interview on 10/26/23 at 12:57pm with DON D revealed Resident #1 was one person assist with ADLs including transfers and bed mobility from 09/04/23 to 09/22/23. She stated the MDS reflected two-person maximal assistance which was the wrong level of care for Resident #1 because it was the highest level of care, he received during the lookback window. She stated the charge nurses were responsible to input all the orders and notify the doctor for review and once that was done then the DON was the one who checks the after-visit summary to make sure the orders were input correctly. She stated the CNAs had access to information on how to care for the resident properly in the EMR but many of them do not utilize this system and get the information from the nurse's word of mouth. An interview on 10/30/23 at 4:10pm with the Orthopedic Surgeon Office Manager revealed Resident #1 had his initial surgery on 07/27/23. The resident was non-weightbearing and was ok to participate in therapy with specific stretches that did not include bearing weight to the right shoulder. She stated the heaviest thing that would be allowed was a coffee cup. She stated the only range of motion that was approved was gentle non-weight bearing, supporting his own weight on the shoulder, pushing, pulling or any resistance applied to the shoulder was not approved during the healing process. An interview and record review on 10/31/23 at 11:58am with DON D revealed Resident #1's shoulder was not known to be dislocated until after his orthopedic appointment on 09/22/23. A record review was completed with DON D of Resident #1's ER After Visit Summary. The discharge diagnosis of shoulder dislocation and the x-ray results which showed his right shoulder was dislocated were reviewed. She stated she was not the DON at the time this occurred, and DON C would have more information. Interview on 10/31/23 at 12:27pm with DON C revealed, after reviewing Resident #1's ER After Visit Summary dated 09/08/23, it was revealed that his right shoulder was dislocated. She stated it was not reported to the facility physician or the orthopedic surgeon because the ER doctor already told the orthopedic doctor while Resident #1 was in the ER. She also stated she felt it was a complication from the previous surgery. She stated a shoulder dislocation should be considered a change of condition and she was not sure if the care plans or orders were updated. Record review of the After Visit Summary dated 09/04/23 conducted with DON C revealed that Resident #1 had lifting restrictions orders that were not put in to the EMR. She stated that the DONs and ADONs were responsible to make sure the information was accurate after admission. She was not sure why Resident #1s restrictions were missed on admission. She stated the potential harm to the residents could be them not getting the right care if orders were missed. Record review of the policy titled Admission, Transfer and Discharge Rights, Admission Practice revealed the facility shall provide uniform guidelines in the admission of residents and admit residents who can be adequately cared for by the facility. Record review of the policy titled Safe Transfers revealed the following guidelines to ensure safe transfers included knowing the residents' abilities and limitations. The transfers status can be found in the Kardex in PCC and POC which it is labeled care instructions. Review of the Resident Rights Policy Subject: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with revision date of 11/28/2017 reflected: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals

Based on observations, interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 24 (Residents #95) residents reviewed for abuse. The facility failed to ensure to ensure CNA A was adequately trained to deescalate Resident #95's aggressive behaviors when CNA A and Resident #95 had a verbal altercation in which CNA A aggressively responded to Resident #95's verbal abuse by calling him a derogatory name and threatened she would spit in his face. An Immediate Jeopardy was identified on 09/13/23 at 5:18 PM. The IJ Template was provided to the facility on [DATE] at 5:20 PM. While the Immediate Jeopardy was removed on 09/15/23 at 12:39 PM, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure placed residents at risk for abuse, and physical or psychological harm. Findings included: Review of Resident #95's face sheet dated 09/14/23 reflected the resident was admitted to the facility 07/24/20 with diagnoses of muscle weakness, hemiplegia and hemiparesis (loss of strength on one side of the body) following cerebral infraction (stroke) effecting unspecified side (partial paralysis on one side), mental and behavior disorder. Review of Resident #95's MDS Assessment, dated 08/14/23, Resident #95's BIMs score was 14, indicating intact cognition. The mood interview assessment revealed Resident #95 was moderately depressed with a score of 11. Review of Resident #95's care plan dated 8/1/23, reflected it did not specify the resident had to be in bed by 9:30PM as an intervention. It did specify Resident #95 was wheelchair dependent and had potential to demonstrate verbal/physical behaviors (yelling, cursing, threatening, kicking, and hitting). Interventions included: When becomes agitated guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. An interview with Resident #95 on 9/13/2023 at 10:53 AM revealed staff did not want to put him in bed, and it took staff awhile to answer his call light. He stated on a recent Sunday night which would have been 9/10/23 (this date conflicts with dates from facility staff members), he and CNA A argued because she did not want to put him in bed when he wanted, and CNA A was telling him off, which upset him. Resident #95 stated he didn't tell anyone because he was waiting until the Administrator came back. The resident stated no CNAs wanted to work with him. He stated when it came to his care, he stated he should be able to tell them how to do it. Resident #95 stated they listened, but they had attitudes. An interview with Resident #95 on 9/13/2023 at 11:15 AM revealed CNA A called Resident #95 a [NAME] and said she would spit in his face. Resident #95 stated that happened in the hallway. He stated he called CNA A a [NAME] in response to her name-calling. An interview on 09/13/2023 at 1:50 PM with CNA C revealed she was not at the facility when the altercation between Resident #95 and CNA A happened, but she heard about it on 09/11/23, when she returned to work. She said she heard that Resident #95 and CNA A got into it. She said she did not know what happened, just that they had words. CNA C stated she knew she was supposed to tell the Administrator, but she didn't because she did not see it and only knew a little piece of it. She said if she had known more, she would have told the Administrator. CNA C said she did not know the whole story, so she just kept going on. She said she understood that if she heard a resident and staff member had words it could have possibly been abuse, and she was supposed to report it. She said it was supposed to be reported, so it would not happen again. An interview on 09/13/23 at 1:58 PM with LVN B revealed CNA A came to the nurse's station and Resident #95 said he wanted to go to bed (09/07/23). She said CNA A told him no, said it was past time, and walked away from him. LVN B explained it was care planned for the resident to go to bed at 9:30 PM because it took a lot of time to get him in bed and he wanted to go to bed before the shift changed, which would have been before the 10 PM to 6 AM shift. LVN B said she later saw another staff member put the resident in bed. She denied hearing anyone call anyone names and the only altercation she heard was when the aide refused to put him in bed and they were bickering at the nurse's station. She said she could not find the charge nurse at the time and did not know if someone else had informed her of the incident. She said that another staff member intervened, and the resident was put in bed. LVN B stated refusing to put a resident in bed could be neglect, and if she saw anything that could be abuse or neglect, she was supposed to inform the DON. An interview on 9/13/23 at 2:44PM with CNA D revealed at 9:30 PM one day last weekend (09/09/23-09/10/23) on night shift Resident #95 got mad at CNA A when the CNAs were checking and changing residents. He said when CNA A got to Resident #95's room, the resident was not in his room. He said in the resident's care plan it stated he had to be in his room, in bed, by 9:30 PM. CNA D said that CNA A went back to the nursing station when Resident #95 rolled his wheelchair up to CNA A, blew up on her (got upset, raised his voice, calling CNA A names), and followed her down the hall calling her insulting names. CNA D said that CNA A told Resident #95 she was going to spit in his face. CNA D said he grabbed CNA A to prevent her from further altercation. CNA D stated Resident #95 called CNA A an old [NAME], and Resident #95 acted like he was going to hit CNA A. CNA D said that was when CNA A told Resident #95 that if he touched her, she would spit on him. He said RN E was informed and she sent a text message the Administrator about the situation and the Veteran Affairs would come talk to Resident #95. CNA D stated Resident #95 was always antagonizing staff and he had called CNA D a fag before so he did not take care of him anymore either, and he felt Resident #95 had exhausted a lot of his options. An interview and observation on 09/13/23 at 2:58 PM with RN E revealed the incident between CNA A and Resident #95 occured on 09/07/23, after 9:30 PM. RN E verified the timing of the incident by a text message RN E sent to the Operations Manager. RN E stated Resident #95 was extremely particular and it took about 30 minutes to get him in bed due to the number of requests he made. RN E explained he had a rigid routine and wanted it to be followed precisely by staff. She stated because of that, it had been care planned when he was new in the facility, he agreed to be put to bed at 9:30 PM so the staff could leave when their shift ended at 10PM. She stated Resident #95 frequently pushed the limits and would intentionally not show up until after 9:30 PM even though he agreed to the arrangement. She said he did not want to be told when to go to bed. RN E stated she was not present when the incident started on 09/07/23, but CNA A later explained to her what happened. RN E stated she saw Resident #95 aggressively move his wheelchair towards CNA A, screaming at her, berating her, and calling her names. RN E stated she pulled CNA A out of the situation and into the breakroom and the resident continued to harass CNA A until they walked into the breakroom. She stated that CNA A told her that she had been there to put him in bed at 9:30 PM and he was not there. Resident #95 approached CNA A later and demanded she put him in bed. She stated that CNA A told her she told Resident #95 she could not do it and he would have to get someone from the next shift to do it, at which point Resident #95 started being aggressive, pushing his wheelchair at her, swinging at her, and saying you have to put me to bed! It's your job! RN E said that the resident was not really trying to hit CNA A as much as just take swats at her, but CNA A told RN E she felt physically threatened, was very upset, and told Resident #95 I swear, if you hit me, it will be the last day I work here, and I will spit in your face. RN E stated she sent a text message to the Operations Manager and DON, but she did not hear back from them. She stated it was late on a Friday night and the end of the shift, so they were going home anyways. Because Resident #95 had those behaviors so consistently, it did not occur to her that she needed to be more assertive about contacting the Operations Manager and DON. She stated she knew it was not an excuse, but Resident #95 was a fully alert and oriented man, and he had ostracized so many staff members and refused to allow so many into his room that it was hard to provide care for him sometimes. She stated she had failed to make a note about it in the EMR and she knew she should have done so. RN E stated she did not witness CNA A calling Resident #95 and old [NAME] but only saw him chasing her down the hall and her walking away and not responding. Nobody ever told her that CNA A had called the resident a name, and she only knew about what she saw, and what CNA told her. She showed the surveyors the text message she sent to the DON and Operations Manager on 09/07/23. Review of the text message screen shots provided by RN E reflected a message sent to the DON and Operations Manager at 9:53 PM, but did not reflect the date it was sent, however the text mentioned Friday, which would have been 09/07/23. The message was a description of Resident #95 being verbally abusive to CNA A, and CNA A being upset and saying if he hit her, it would be the last day she worked there and she would spit in his face. The message ended anyway, this is just information, it's Friday night I'll see you guys Monday. Interview on 09/14/23 at 1:16 PM with CNA A revealed CNA A was taking care of Resident #95 last week (date unknown) and before 9:30 PM came, he left his room. CNA A stated she took a picture of his room to prove he wasn't there and went back to the nursing station. Resident #95 came down to the nursing station and was asking if CNA A was going to put him in bed. CNA A told him no because he wasn't in his room by 9:30 PM and it was close to shift change (10 PM to 6 AM shift). CNA A did not indicate she was retaliating against the resident as it was an agreed upon protocol by the resident and staff that Resident #95 would need to be put in bed at 9:30 PM. Staff would not be able to put Resident #95 in bed if he was not in his room to be put in bed. Resident #95 was on the phone with someone but was calling CNA A all kinds of cuss words (profanities and name-calling). CNA A stated she had the proof of Resident #95 not being in his room, which she felt justified why she did not put Resident #95 to bed. Resident #95 then rolled his wheelchair up close to CNA A telling her to show him the proof. CNA A walked outside to get away from Resident #95 with CNA D to throw the trash away. When CNA A came back, Resident #95 started following behind her. CNA D asked CNA A if she was going to put Resident #95 to bed. CNA A stated no because he wasn't in his room by 9:30 PM. Resident #95 started cussing CNA A out telling her he can get into bed whenever he wanted to according to the care plan. Resident #95 started cussing at CNA A and when she walked off Resident #95 raised out of his wheelchair like he was about to hit CNA A. CNA A then stated this would be her last day working here if he touched her. CNA A had shower sheets in her hand and Resident #95 started swinging like he just wanted to put his hands on her. He told CNA A she better keep walking unless he was going to run her over with his wheelchair and that was when CNA A stated she would spit in Resident #95's face. CNA A did confirm she called him an old [NAME] because he called her a [NAME] and was cussing at her. CNA A stated she did not receive training on how to deescalate situations like the one with Resident #95. CNA A revealed RN E started walking down the hallway at the end so she heard Resident #95 call me out her name. CNA A stated RN E sent an auto message about what happened to management and CNA A was right there when she sent it. CNA A states RN E knew she was very upset and that she would get put on the list to not take care of Resident #95 when Monday came. CNA A also revealed her last work night was Monday 9/11/23 2-10 PM and the person that was there from the beginning till the end of the incident was CNA D. Review of notes from the Social Worker, dated 09/13/23, revealed SW came up to facility tonight at 9pm. spoke with patient for about 15 minutes. He was in good spirits sitting outside in electrical [wheelchair]. He denied depression and feeling down to SW. He stated he was having no adverse psychosocial effects related to incident with CNA. SW gave patient her work cell and encouraged him to always come to her anytime he has issues with staff etc. at [facility name]. He voiced understanding. SW to follow up with patient in [morning]. SW also asked patient if he would be aggregable to seeing psychiatrist at facility, [psychiatrist's name]. He did agree. SW notified [MD AA] who will see him next visit. He is on antidepressant currently. SW to follow up . Notes did not indicate resident was on psych services prior. Review of facility self-reports for the month of September 2023 revealed no self-reports related to the altercation with CNA A and Resident #95. Review of facility incident reports for the month of September 2023 revealed no incidents relating to the altercation between CNA A and Resident #95. Review of the facility's staffing schedule from 09/10/23 to 09/15/23 revealed CNA A worked on the 2:00 PM to 10:00 PM shifts on 09/10/23 and 09/11/23 on the hall where Resident #95 resided after the incident on 09/07/23. Review of time stamps for CNA A revealed she worked the 2:00 PM to 10:00 PM shifts on 09/08/23, 09/09/23, 09/10/23, and 09/11/23, after the incident on 09/07/23. Review of CNA A's training records reflected her date of hire was 03/31/23. CNA A received Abuse and Neglect training as part of her orientation, and in an in-service on 05/24/2023. There was no evidence on recent training regarding Resident #95's behaviors. Review of the facility policy Abuse: Prevention of and Prohibition Against, revised 10/22, reflected Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. ( .) The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This policy applies to all Facility staff ( .) Purpose: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. ( .) Definitions: To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: o Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse ( .) Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse: Prevention and Prohibition Against: ( .) Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. ( .) 2. The Facility will provide oversight and supervision of staff in connection with the above, to confirm that its policies prohibiting abuse, neglect, misappropriation of resident property, and exploitation are being implemented. ( .) An IJ was called at 5:20 PM on 09/13/2023 with the Operations Manager, DON, and Clinical Resource Nurse. The IJ template was reviewed with them during this interview and provided via email 09/13/23 immediately following it . An interview on 09/13/23 at 5:20 PM with the Operations Manager revealed they just learned about the allegation when the surveyor informed them on this date (09/13/23), and had already suspended CNA A, and staff who had not reported the allegation, and started in-servicing staff on what to report, stressing that things they heard about and did not witness were to be reported. She stated the text the RN sent her did not arrive properly as a text and went into a sent note folder so they had not been aware she sent them a text. She stated they had re-educated her and the rest of the staff on calling, not texting, and it was their policy to call to report a concern or allegation. If they had known earlier, they would have done this right away, and they were making sure staff knew to report things directly to the Operations Manager immediately. The Plan of Removal (POR) was accepted and the Operations Manager was notified on 09/15/23 at 12:39 PM. The POR reflected: [Facility Name] F600 Plan of Removal 09/13/23 Per the information provided in the IJ Template given on 09/13/23 at 5:20 PM, the facility failed to prevent actual abuse of a resident and risk of continued abuse to the resident emotionally/psychologically/physically. 1. The Medical Director was notified of IJ on 09/13/23 1813. 2. Alleged abuse perpetrator(s) and witnesses(s) who failed to report the abuse were placed on suspension on 09/13/23 pending investigation and self-report was submitted to HHSC (intake #450876). -Head to toe assessment completed by LVN charge nurse on 9/13/23 -PHQ9 assessment completed 9/13/23. -Resident interviewed by facility DON. Resident was pleased with facility actions and stated he felt safe. 3. Education initiated with all staff on abuse/neglect/exploitation including definitions of abuse/neglect/exploitation, prevention of abuse/neglect/exploitation and employee requirements for reporting abuse/neglect/exploitation to be completed by DON/Clinical Resource/ADON and Operations manager started on 09/13/23 at 1600. Notice for the requirement for all staff to receive education prior to working their next shift was delivered to all staff on 9/13/23 at 1905 [7:05 PM]. All regular staff will receive the education by 9/14/23 at 1400 [2:00 PM] or prior to their next shift at the facility, whichever comes first. PRN staff received the mandatory training notice and will receive education prior to their next shift. 4. Safe surveys were initiated with all residents by the facility LBSW on 09/13/23 at 1600 [4:00 PM]. Safe surveys will be completed on 09/14/23. 5. The ADON, DON, and Clinical resource will complete all staff competency on abuse initiated on 09/13/23 at 1815 [6:15 PM] and will be completed by 09/14/23 6. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. 7. An ad hoc QA meeting regarding items in the IJ template will be completed on 09/13/23. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, Operations Manager, and will include the plan of removal items and interventions. 8. The DON, ADON or Clinical Resource will verify staff competency with 5 staff weekly using the abuse check competency checklists for 90 days starting 09/18/23. 9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring included: An observation on at 12:47 PM on 09/14/23 revealed the Social Worker going from room to room doing safe surveys with residents. An interview on 09/14/23 at 2:24 PM with LVN B revealed she had been in-serviced on abuse and neglect, and that they needed to contact the Abuse Coordinator, the Operations Manager, right away and if she was not reachable to call the DON. She said that if it happened again, she would do it differently and report the incident in person or call the Abuse Coordinator. LVN B stated the Abuse Coordinator would decide if it was abuse or neglect, not her. She stated when there were difficult residents, she was to not engage in abusive behavior but to walk away and get help. An interview on 09/14/23 at 2:48 PM with RN E revealed the facility spent a lot of time in-servicing her on abuse on 09/13/23, and they did a competency checklist on abuse, neglect and reporting. She stated they asked about situations and what she would do. RN E stated if she suspected or saw anything that could be abuse or neglect, she would call the Abuse Coordinator on the phone, not text them, or tell them in person. She stated she sent the message and assumed they would come to her to ask questions. When RN E came to work on 09/11/23 CNA A and Resident #95 were getting along fine, neither of them said anything and she thought everything had worked out OK. She said it was possible that the staff got desensitized after Resident #95's behaviors happened so frequently and she felt bad that she had not realized how serious it was at the time. She stated if the Operations Manager or DON had gotten the message, it would have had a different outcome. She stated from now on she would be contacting them on the phone and making sure they knew. She said the training they did was good, and some of the newer people had questions answered during it. Interview on 9/14/23 at 12:51 PM with Resident #95 revealed Resident #95 had a head-to-toe assessment completed and the resident stated he did not feel unsafe at the facility. He stated he hadn't seen CNA A since and heard she got fired so he didn't have to worry about her anymore. He stated if abuse happened again, he could call the ombudsman or the Administrator. Interviews with staff from 09/14/23 at 9:00 AM to 09/15/23 at 4:00 PM reflected on 09/13/23 or 09/14/23 staff covering all shifts had been re-trained on abuse and neglect protocols, including who to report to, and what types of events were to be reported. Staff interviewed were CNA A, LVN B, CNA C, CNA D, RN E, DON, Operations Manager, LVN F, CNA G, CNA H, LVN I, LVN J, LVN K, LVN L, LVN M, MA N, CNA O, CNA P, CNA Q, CNA R, HK S, PT T, PT U, PT V, PT W, and OT X. Interviews with residents on 09/14/23 from 9:00AM to 4:00PM revealed residents had been asked if they were safe and who to report abuse to if it were to happen. Residents felt safe in the facility, and said they felt they could report problems to any staff, and were not afraid to tell the DON or the Operations Manager if they had a problem with a staff member. Residents interviewed were Resident #95, Resident #131 Resident #66, Resident #103, Resident #143, Resident #121, Resident #141, Resident #13, Resident #78, Resident #207, Resident #205, Resident #206, Resident #51, Resident #67, Resident #57, Resident #43, Resident #118, Resident #303, Resident # 86, Resident #109, Resident # 101, Resident #255, Resident #256, Resident #257, Resident #258, Resident # 137, and Resident #101. Review of in-service documentation, dated 09/13/23 and 09/14/23 reflected all regular staff were in-serviced on abuse an neglect, what needed to be reported, and the exact procedures for reporting, with the exception of some PRN staff, terminated staff who were still on the staff roster, and some regular staff who were on leave, or had not arrived for an on-coming shift yet. Review of safe surveys done on 09/13/23-09/15/23 reflected interviewable residents in all halls were interviewed about whether they felt safe in the facility, had ever had a problem with a staff member or with their care, and if they had any complaints. An interview on 09/15/23 at 11:53 AM with CNA D revealed the Operations Manager had in-serviced him on 09/13/23 and called him on 09/14/23 to suspend him. He said she went over if anything happened, and he saw it, or heard it, or heard about it, he should not hesitate to call her directly. He said it could be anything, if someone was not doing their job right, or if they treated a resident badly in any way. CNA D said if anything like the incident with Resident #95 and CNA A ever happened again, he would call the Operations Manager right away. An interview on 09/15/23 at 12:27 PM with the DON revealed they had an IJ because the staff was aware of abuse and did not report it. She expected them to report anything they have concerns about, and the administrative staff could figure out what needs to go further. They would report either to her or the Operations Manager, who is the Abuse Coordinator. They have put the Operations Manager's photos up all over the facility, so everyone knows who to report to. She said they expected staff to walk up to them and tell them in person or call them if they were not able to do that. She had explained to the staff that they want them to report more, rather than less, and they needed to report anything they think could possibly be an issue. She and the Operations Manager and a Nurse Manager would make sure the new hires were properly oriented about abuse and neglect reporting, and they would continue to monitor and educate them. They would do rounds daily, the department heads during the week, and the weekend supervisor during the weekend, to make sure residents felt safe, and were receiving care. The DON stated the facility would question a sample of staff weekly to make sure they were able to answer questions about what to do and cover all shifts. It would be on-going in their QAPI process. They would do spot checks of the night shift, and administrative nursing staff would continue to work a night shift periodically to oversee care. They would continue their policy of checking skin checks from the previous nights and weekends to make sure there were no indicators of possible abuse. An interview on 09/15/23 at 12: 39 PM with the Operations Manager revealed she believed they had an IJ because the Operations Manager and DON did not know about abuse that occurred in the facility. The policy and her expectations of the staff were that if they witnessed, or heard of, or saw anything that could be considered abuse or neglect, they were to speak with her in person or call her immediately to report it. She stated she would be overseeing all of the monitoring and continued training, and nursing management would be part of that as well. Their monitoring would consist of what was in their POR, and in addition they would be doing spot checks on every shift, beyond the POR. She said she would review those quality checks weekly to make sure every shift was covered. She said the issue of training and monitoring for abuse and reporting would be addressed in their QAPI process, ongoing. She said Resident #95 had very difficult periods, and they had staff who were afraid to come to work because of him, so they were going to meet with the VA to ask their help in finding him alternate placement. An Immediate Jeopardy was identified on 09/13/23 at 5:18 PM. The IJ Template was provided to the facility on [DATE] at 5:20 PM. While the Immediate Jeopardy was removed on 09/15/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility's need to implement and monitor the effectiveness of its corrective systems. 44894 48029

Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #1) of 6 residents reviewed for pressure ulcers. The facility failed to provide treatment and services to prevent Resident #1 from developing a bilateral (affecting both sides) deep tissue pressure injury to buttocks, before she was seen for unrelated emergency services at a local hospital on 07/10/23. An Immediate Jeopardy (IJ) was identified on 07/26/23. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems These failures could place residents at an increased and unnecessary risk of complications such as pain, acquiring new wounds, pressure ulcer/pressure injury development, worsening of existing wounds, and infection. Findings included: Record review of Resident #1's face sheet, printed on 07/17/23, revealed a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: encounter for orthopedic aftercare following surgical amputation, muscle weakness, T2DM (a chronic condition that affects the way the body processes glucose (blood sugar)) with diabetic neuropathy (nerve damage due to prolong high blood sugar levels), PVD (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), Osteomyelitis (infection of the bone), and acquired absence of left great toe. Record review of Resident #1's MDS, dated [DATE], revealed Resident #1 had a BIMS of 11 which indicated Resident #1 had a moderate cognitive impairment. Section G0110 of the MDS indicated Resident #1's functional status required one-person physical assist with ADLs. Section H indicated Resident #1 was occasionally incontinent of bowel and bladder. Section M of the MDS assessment revealed Resident #1 was at risk to develop pressure ulcers/injuries and did not have one or more unhealed pressure ulcers/injuries. Section M1040 revealed Resident #1 had surgical wound(s) that were present at the time of admission. Record review of Resident #1's care plan, dated 6/23/23, created by the DSD, indicated a care focus - Resident #1 had potential for pressure ulcer development r/t immobility, amputation L hallux (big toe), weakness but there was no goal or interventions listed. On 07/13/23, (day of surveyor entrance and after Resident #1 discharged on [DATE]) the care focus was revised by MDS CC to reflect: GOAL [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - Will have intact skin, free of redness, blisters, or discoloration by/through the review date. INTERVENTIONS [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - Administer treatments as ordered and monitor for effectiveness - Call light within reach - Follow facility policies/protocols for the prevention/treatment of skin breakdown Further review of Resident #1's care plan, dated 6/23/23, revealed a care area initiated 07/13/23 that reflected: FOCUS [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - . has episodes of bowel/bladder incontinence r/t deconditioning and debility GOAL [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - Will remain free from skin breakdown due to incontinence and brief use through the review date INTERVENTIONS [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - INCONTINENT: Check as required for incontinence. Wash, rinse, and dry Perineum [anatomy] (the area between the anus and the scrotum (a pouch of skin containing the testicles) or vulva (the female external genitals)) - Change clothing PRN after incontinence episodes Review of An Internal Medicine Progress Note entered by the NP dated and e-signed 06/26/23 at 11:24 PM indicated [Resident #1] seen and examined. Chart reviewed. Discussed with the nurse of the patient . Hx of PVD: Bilateral SFA occlusions (blockage or closing of a major lower extremity artery) . bilateral lower extremity angiography on 06/19/23 revealed left SFA occlusion and right SFA in-stent stenosis. Record review of Resident #1's weekly non pressure ulcer skin assessment, dated 6/28/23, completed by LVN A, revealed Resident #1 had surgical wound to the left great toe and left lateral heal. Documented interventions were listed as daily wound care provided, weekly wound consultations with [Doctor]. Heel protectors on. Record review of Resident #1's Skin Evaluation - PRN / Weekly, dated 7/3/23, completed by LVN B, revealed Resident #1 had bruising to the front of her left lower leg and surgical incisions to her left toes. Additional Comments were included as Bruising on admission to LLE, PICC RUE. The evaluation did not indicate skin integrity issues Resident #1's bottom. Record review of a Wound Physician progress note indicated a LATE ENTRY, Effective Date: 07/05/2023 at 11 :14 AM, entered by the WNP indicated reason for consultation - follow-up visit for wound assessment and treatment for wound on left foot surgical sites. The WNP reflected in the Wound Physician progress note that A 9-point comprehensive examination [of body areas] performed of the following sites: head and face, scalp, neck, left upper extremities, right upper extremities, right lower extremities, left foot, and right foot to examine for any new or current lesions . Wound Location: left foot; Etiology: surgical; s/sx of infection: None. Assessment and Plan: . Off load pressure point areas and turn per facility protocol while in bed as needed.\ . Minimize friction and shearing Record review of Resident #1's weekly non pressure ulcer skin assessment, dated 7/5/23 and completed by LVN A, revealed Resident #1 had surgical wound to the left great toe and left lateral heal. Documented interventions were listed as daily wound care provided, weekly wound consultations with [Doctor]. Heel protectors on. The assessment did not indicate skin integrity issues Resident #1's bottom. Record review of Resident #1's progress notes tab of her electronic health record revealed a progress note, written by LVN C on 07/10/23 at 11:10 a.m., indicated Received report that resident transferred to [hospital]. [family member] aware. A record review of hospital medical records, for admitted [DATE], indicated [Resident #1] presented to the ED on 07/10/23 at 11:35 AM EMS reports that patient was at [Specialty Appointment] for a follow up on foot wound care due to diabetes . Per EMS, aphasia (loss of ability to understand or express speech) and mild right sided facial droop was reported but patient states that her aphasia might be going of for a few weeks. Pts face appears symmetrical to RN upon assessment, but aphasia is noted. GCS = 14 (used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients). Pt comes with Foley catheter and midline in place. Hx of diabetes and cirrhosis (a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue). Record review of the hospital Wound Care Consult Note, dated 7/11/23 at 10:13 AM, revealed wounds in addition to the two surgical (left foot) wounds documented at the SNF: A wound first assessed on 07/11/23 at 12:30 AM, present on hospital admission, to the Left Dorsal (the upper surface) Foot, described as purple/red tissue discoloration w/ open areas; wound bed color - maroon, purple, pink; non-blanching (skin redness that does not turn white when pressed - is an important skin change); no drainage An Arterial Ulcer, first assessed on 07/11/23 at 12:30 AM, present on hospital admission, to the Left calf, wound bed - maroon, pink; firm; non-blanching A Pressure Deep Tissue Injury (DTI), first assessed on 07/10/23, present on hospital admission, to Resident #1 bilateral buttocks; wound bed color - maroon, purple, pink; wound bed texture - non-blanching; and blistered Record Review of SOM defined an arterial ulcer as ulceration that occurs as the result of arterial occlusive disease when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis . Arterial ulcers may be present in individuals with moderate to severe peripheral vascular disease . is characteristically painful, usually occurs in the distal portion of the lower extremity and may be over the ankle or bony areas of the foot (e.g., top of the foot or toe, outside edge of the foot). Record review of the hospital Wound Care Consult Note, dated 7/11/23 at 10:13 AM, revealed in the physical exam, multiple left foot necrotic ulcers . Left foot necrosis s/p great toe AMP--sutures noted, full thickness necrosis of the surround tissue of the AMP site . Left heel diabetic ulcers x 2, full thickness ulcer with devitalized (deaden) tissue . adjacent necrotic full thickness ulcer with dry eschar . Left dorsal foot necrotic diabetic ulcers, full thickness ulcers with dry black eschar . Sacral and bilateral buttock pressure DTI, deep purple bruising with extensive non-blanchable redness to both buttocks - POA. During an observation of wound care on Resident #1 at a local hospital on 07/14/23 at 12:16 p.m., Resident #1 was observed to have an open wound across her buttock area, covering both buttocks. By visual inspection, the length [measured from the resident's head to the toe] of the wound appeared to be about seven inches (the size of an adult hand) and the width [measured from the lateral positions on the resident] by visual inspection appeared about three inches (the size of the palm of an adult hand). The altered skin integrity appeared as shallow open ulcer(s) (break on the skin) with a bright red, pink wound bed. The surrounding area around the open ulcer(s) appeared red and irritated. A darker red, purplish discoloration noted at upper left outer area of surrounding skin. Resident #1 winced when wound was cleansed with gauze saturated with NS. Wound care completed to buttocks. Resident #1 tolerated well. In an interview on 07/13/23 at 1:24 p.m., LVN C stated she worked in the facility for roughly 3 months. LVN C stated on 07/10/23 around 11:30 a.m., she received a call from Resident #1's physician asking if facility staff noticed any drooping to the right side of Resident #1's face, which they did not see. LVN C stated Resident #1 went to the physician for a follow-up visit and was sent to the emergency room for the facial drooping. LVN C stated she assessed Resident #1 prior to her leaving for her appointment and she saw no skin integrity concerns. LVN C stated if a skin integrity issue was observed she would notify the residents family and physician for wound consultation and guidance. In a telephone interview on 07/14/23 at 11:29 a.m., the clinical director from the physician office Resident #1 was seen at on 07/10/23 stated Resident #1 was seen for a follow-up appointment. The clinical director stated Resident #1 appeared to have an altered mental status and a droop to the right side of her face, which was why the physician sent her to the emergency room . The clinical director stated the physician did not assess Resident #1's skin and had no knowledge of any skin integrity issue except her surgical incisions to her left foot. The clinical director stated the resident was diagnosed with a urinary tract infection at the hospital. In a telephone interview on 07/14/23 at 3:08 p.m., Resident #1's family member stated she had given Resident #1 a shower on 07/07/23 and noticed redness and what appeared to be blisters to her bottom. The family member stated she went to the nurse and asked for cream and was given a blue single use packet of cream, which she placed on Resident #1's bottom. The family member stated she reported the redness and blisters to the same nurse who had given her the blue packet of cream but could not recall her name. In an interview on 07/14/23 at 5:05 p.m., ADON D stated skin assessments were conducted weekly by the charge nurses. ADON D stated the responsibility of the treatment nurse to ensure the skin assessments were conducted as scheduled and accurately and to follow up on any new findings. ADON D stated to her knowledge no residents had new skin integrity issue of redness and blisters reported recently, but if redness and blisters were found the expectation was to notify the residents family, physician, and treatment nurse. ADON D stated the facility's single use barrier cream was packaged in a blue packet. In an interview on 07/14/23 at 5:31 p.m., LVN E stated she was the Resident #1's charge nurse on the 2:00 p.m. to 10:00 p.m. shift on 07/07/23. LVN E stated during her shift, no resident, family member or staff member asked her for barrier cream or reported new skin integrity issues to her. LVN E stated if new skin integrity issues are reported, they were trained to assess the resident, notify the residents family and physician and the treatment nurse. In a telephone interview on 07/17/23 at 12:25 p.m., CNA F stated she was the overnight aide for Resident #1 from 07/07/23 through 07/09/23. CNA F stated Resident #1 was able to do for herself, did not call for assistance and often declined peri care and showers because a family member would provide that for Resident #1. CNA F stated Resident #1 normally slept through her shift, so showers and peri care were declined. CNA F stated on her last shifts, Resident #1 did not complain of pain or skin integrity issues to her, and her family did not request barrier cream from her. CNA F stated when any skin integrity issues are identified, she was trained to report the issue to the charge nurse. In a telephone interview on 07/17/23 at 1:08 p.m., LVN A (WCN) stated she worked in the facility as the wound treatment nurse for roughly [AGE] years. LVN A (WCN) stated she was responsible for all wounds in the facility, except infected surgical incisions and incisions that were healing properly. LVN A (WCN) stated she was responsible for new skin assessments to ensure wound care needs were provided as needed. LVN A (WCN) stated her skin assessments were documented as progress notes and identified skin integrity issues were documented under the skin assessment. LVN A (WCN) stated skin concerns she looked for were discoloration, skin tears or abrasions and redness. LVN A (WCN) stated if new skin integrity issues were identified, she would document the finding, notify the physician, and wound doctor and start recommended wound care. LVN A (WCN) stated skin concerns identified by other facility nurses were reported to her on skin communication forms or verbally. LVN A (WCN) stated when she visited her residents to provide wound care, she only looked at the known areas of concern, unless the resident or staff notify her of new skin integrity issues. LVN A (WCN) stated Resident #1 had surgical incisions to her left toe and heel areas and received weekly wound care. LVN A (WCN) stated the only additional skin integrity issue observed was discoloration of the skin under Resident #1's left toes, which was reported to her physician and was scheduled for a follow-up on 07/10/23. LVN A (WCN) stated she had not received any reports of skin integrity issues to Resident #1's bottom, and Resident #1 had not complained of pain to her bottom. In a telephone interview on 07/17/23 at 1:56 p.m., LVN G stated she was Resident #1's overnight nurse on 07/07/23. LVN G stated Resident #1 had surgical wounds on her left foot and had not complained of any skin issues or pain to her sacral area. LVN G stated no resident or family member had requested barrier cream from her and no one report skin issues of any kind to her. LVN G stated if new skin integrity issues were identified she would assess the resident and notify the physician, family, and the treatment nurse and/or wound doctor. In a telephone interview on 07/17/23 at 4:12 p.m., LVN H stated she was Resident #1's overnight nurse on 07/08/23. LVN H stated conducted a head-to-toe assessment on Resident #1 that shift and found no skin integrity issues to her sacral area. LVN H stated she did not receive report of skin integrity issues and no resident or family member had requested barrier cream. In a telephone interview on 07/17/23 at 5:32 p.m., LVN I stated she was Resident #1's day shift nurse, the charge nurse on 07/08/23. LVN I stated redness and blisters were not reported to her from any staff, residents or family member. LVN I stated if redness was reported to her, she would conduct a skin assessment, notify the appropriate parties and monitor the area for changes. LVN I stated she had not provided barrier cream to any family members during this shift. In an interview on 07/17/23 at 5:38 p.m., the IDON stated Resident #1 was taken to a follow-up appointment on 07/10/23 and was sent to the emergency room from the doctor's office. The IDON stated the only skin integrity issues she was aware Resident #1 had was the surgical incisions to her left foot, which were the only issues documented. The IDON stated to her knowledge there was no issues with peri care or showers, she was aware of. The IDON stated she was not aware that Resident #1 had a deep tissue injury to her sacral area, that was discovered by hospital staff. The IDON stated there were no indications of redness and blisters to Resident #1's sacral area and she believed the redness could have developed as Resident #1 waited to be seen at her doctor's office. The IDON stated the treatment nurse was responsible for wound care and charges nurses were responsible for weekly skin assessments. The IDON stated there were follow behind skin assessments to ensure skin assessments were conducted accurately, as that would be insane due to the amount of skin assessments would be needed. The IDON stated if skin integrity issues are identified, the expectation is for nurses to obtain a treatment order and ensure the area is treated. The IDON stated if skin integrity areas were not identified and treated, the area could get worse. She states she planned to re-educate nursing staff on skin assessments and implement monthly skin sweeps to ensure no skin integrity issues are missed moving forward. In an interview on 07/17/23 at 7:09 p.m., the ADMIN stated the IDON notified him (prior )of the surveyor's concern regarding Resident #1's sacral area. The ADMIN stated the expectation was for staff to use shower sheets and skin assessments to document all skin integrity issues and to ensure the facility policy was followed regarding skin integrity issues and wounds. The ADMIN stated if skin integrity issues were not identified and treated, the area had potential to get worse. The ADMIN stated he planned to re-educate staff on skin assessments to ensure all skin concerns were addressed. In an interview and record review on 07/26/23 at 9:27 a.m., revealed MDS DD stated she worked as one of the facilities two MDS nurse for roughly [AGE] years. MDS DD stated she was responsible for Medicare and managed care MDS assessments and MDS CC was responsible for all other MDS assessments. MDS DD stated that LVN A (WCN), was responsible for updating any residents care plan to include any skin integrity issues. MDS DD reviewed Resident #1's care plan with surveyor and acknowledged the care plan did not list interventions for Resident #1's risk for pressure ulcers. MDS DD stated when the care plan was updated, the person should ensure the care plan was updated entirely. In an interview on 07/26/23 at 11:06 a.m., LVN A stated as the wound care nurse, she was not responsible for updating residents care plans with skin integrity issues or risks. LVN A (WCN) stated the IDON was responsible for updating care plans. LVN A (WCN) stated if she observed redness and blisters on a resident, she would report to the wound care doctor, the resident would receive an air mattress and depending on the doctor's orders, would receive wound care. In an interview on 07/26/23 at 12:35 p.m., the IDON replied to expectations with care plan development stating the MDS nurses have the skills and qualifications to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and able to recognize areas of decline to accurately develop care plans. The IDON stated leadership and department heads meet every morning to discuss resident status updates, changes in condition, and pertinent information to collaboratively with the MDS nurses to develop and update care plans as needed. In an interview on 07/27/23 at 1:04 p.m., MDS CC stated was responsible for Resident #1's care plan. MDS CC stated when the MDS assessment was completed, CAAs are triggered which must be signed by a nurse. MDS CC stated they have seven days to care plan triggers. MDS CC stated one of Resident #1's triggered CAAs was risk of pressure ulcer, which should have been care planned. MDS CC stated while she updates Resident #1's care plan pressure risk standard interventions, she might have been interrupted. MDS CC stated she thought she had completed the care plan update but had not. In an interview on 07/27/23 at 4:45 p.m., the Admin was not able to speak to the process of care plan development/update; FC care; MD Notification; Incontinent Care; IV management./dressing changes. The Admin stated his expectation was that all staff participate in facility in-services & trainings to maintain update skills and follow facility protocols on resident care. The Admin stated nursing department heads and leadership ensure nursing staff have the competency to perform their jobs appropriately and provide quality care. Record review of the facility policy entitled Skin and Wound Monitoring and Management, revised in January of 2022, read in part: POLICY: It is the policy of this facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection and prevent, new avoidable pressure injuries from developing. PROCEDURE: The purpose of this policy is that the facility provides care and services to: 1. Promote interventions that prevent pressure injury development . The Admin was notified of an Immediate Jeopardy (IJ) on 07/26/23 at 5:04 PM due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 07/27/23 at 12:58 PM and included: 1. The Medical Director was notified of IJ on 07/26/23 at 5:45pm. 2. Skin sweep (on the spur of the moment skin checks) of total census initiated 07/26/23 and will be completed 07/26/23 by CRN, Clinical Leaders, MDS Nurse, ADON and DON. 3. Review of all pressure ulcer treatments orders was initiated and will be completed. 07/26/23 by the DON. All orders were reviewed and were accurate and complete on 7/26/23. 4. Review completed by DON on 07/26/23 of all residents who are at risk for PU/PI and care plans updated for all residents at risk. 5. Education initiated with Nurses and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, notification of changes in condition, wound identification, and notification. 6. All licensed nurses will complete competency on skin assessments started on 07/26/23. 7. All CNA's will complete competency on skin check started on 07/26/23. All CNAs will have competencies/education completed prior to their next shift if unable to come in immediately. 8. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 9. An ad hoc meeting regarding items in the IJ template will completed on 07/26/23. Attendees will include the Medical Director, CRN, Admin, DON, ADON, Clinical Resources and will include the plan of removal items and interventions. 10. The DON, ADON or CRN will verify staff competency with 10 staff weekly using the skin check competency checklists. 11. All residents with pressure ulcers be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director and WCN. The DON and Admin will be responsible for ensuring this meeting is held weekly and all residents with pressure ulcers/pressure injury are reviewed. 12. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring conducted on 07/27/23 of the facility's implementation of their POR included: Interview(s) with CRN, ADON D, ADON M, and IDON indicated POR entry #2, Skin sweep (on the spur of the moment skin checks) of total census initiated 07/26/23 was completed 07/26/23 by CRN, Clinical Leaders, MDS Nurse, ADON and DON. Interview(s) with CRN, ADON D, ADON M, and IDON indicated POR entry #3, Review of all pressure ulcer treatments orders were initiated and completed by the IDON. Interview with the IDON indicated she reviewed all pressure ulcer treatment orders on 07/26/23 and the IDON stated all orders were accurate and complete. The IDON stated that she reviewed care plans of residents at risk for PU/PI and the care plans were updated. Interviews conducted with nursing staff scheduled 6a - 2p and 2p - 10p shift on 07/27/23 [ADON D, LVN Q, LVN O, CNA L, CNA K, MDS CC, MDS DD, CNA BB, NA AA, CNA Z, LVN C, CNA Y, CNA X, CNA W, CMA T, LVN S, LVN I, RN R, LVN E, CMA V, CNA U, and ADON M] stated they participated in an in-service training about changes in condition of skin, , assessing and treating wounds, appropriate interventions when skin issues are found, notifying RP/MD, consulting wound doctor on admission, conducting and documenting weekly skin assessments in PCC. The nurses summarized the topic of discussion as identifying, assessing, and monitoring wounds clinical protocol. Each nurse stated in their own words the difference between pressure and vascular/arterial ulcers, appropriate interventions when abnormal skin issues are discovered, procedure to notify physicians immediately of resident change in condition, and actions to take if unable to contact a physician. The CNAs and CMAs summarized the topic of training in their own words purpose of skin sheets, how to complete skin sheets and POC documentation, and reportable s/sx to charge nurse. Record review of in-services conducted by the CRN beginning 07/26/23 titled Skin/Wound Care reflected 10P - 6A nursing staff signatures participated in the in-service - CNA F, LVN EE, NA FF, LVN GG, CNA HH, CNA II, LVN H, CNA JJ, CNA KK, CNA LL, and CNA MM. Staff signatures from 6A - 2P and 2P - 10P shifts included, LVN S, LVN E, CMA V, LVN I, RN R, NA NN, LVN OO, RN PP, CNA AA, CNA HH, CNA QQ, CNA RR, CNA J, and CNA SS An IJ was identified on 07/26/23. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary, and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of eight residents reviewed for Urinary Tract Infection (UTI), in that: 1. The facility failed to monitor Resident #1's urinary catheter for changes in condition, recognize, and address such changes to prevent urinary tract infections. Resident #1 was hospitalized on [DATE] for acute encephalopathy (altered mental state - confused, and not acting normal) and urinary tract infection. 2. The facility failed to obtain physician orders for insertion, ongoing indwelling catheter care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures for Resident #1 after placement of an indwelling catheter on 07/06/23. 3. The facility failed to develop an individualized care plan after placement of an indwelling catheter on 07/06/23. 4. The facility failed to implement interventions for Resident #1 in accordance with the resident's needs, goals for care and professional standards of practice, to recognize, report, ongoing monitoring for changes in condition and addressing such changes related to potential CAUTI's after placement of an indwelling catheter on 07/06/23. An Immediate Jeopardy (IJ) was identified on 07/26/23. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems This failure to provide appropriate treatment and services to residents with an indwelling catheters place residents at risk of UTIs, potential CAUTI's (a urinary tract infection associated with urinary catheter use), developing complications such as injury to the urinary tract, and the development of sepsis. Findings included: A record review of Resident #1's Admission MDS (a standardized assessment tool that measures health status in nursing home residents) assessment dated [DATE] revealed a 53 y.o. female admitted on [DATE]. Resident #1 had diagnoses of HTN (when the pressure in the blood vessels is too high - 140/90 mmHg or higher); PVD (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel); DM (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high); HLD (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides); osteomyelitis, unspecified; acquired absence of left great toe; and encounter for orthopedic aftercare following surgical AMP (the loss or removal of a body part). Resident #1's BIMS score was 11, which suggested moderately impaired cognition. Resident #1 had no behavioral symptoms or exhibited rejection of care behavior during the MDS review period. In Section G - Functional Status revealed in Section G0110 of the MDS indicated Resident #1's functional status required one-person physical assist with ADLs. Section G0400 reflected Resident #1 had an impairment to the lower extremity on one side that interfered with daily functions or placed at risk of injury. Section H indicated Resident #1 was occasionally incontinent of bowel and bladder. A review of Resident #1's care plan, dated 06/23/23, revealed a care area initiated 07/13/23 that reflected: FOCUS [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - . has episodes of bowel/bladder incontinence r/t deconditioning and debility GOAL [Initiated: 07/13/23; Created on: 07/13/23; Revision on 07/13/23]: - Will remain free from skin breakdown due to incontinence and brief use through the review date INTERVENTIONS [Initiated: 07/13/23; Created on: 07/13/23; Target Date: 10/11/23]: - Ensure there is an unobstructed path to the bathroom - INCONTINENT: Check as required for incontinence. Wash, rinse, and dry Perineum [anatomy] (the area between the anus and the scrotum (a pouch of skin containing the testicles) or vulva (the female external genitals)) - Change clothing PRN after incontinence episodes - Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increase temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns Record Review of Resident #1's physician orders revealed: - Prescriber Entered Order. Start date 07/05/23: Bladder scan x 1, If retaining more than 400 mL, Insert a Foley catheter and place Foley catheter orders. One time only for urinary retention for 1 day do bladder scan. - Verbal Order. Start date 07/06/23: Bladder scan x 1, If retaining more than 400 mL, Insert a Foley catheter and place Foley catheter orders. One time only for urinary retention for 1 day. - Prescriber Entered Order. Start date 07/06/23: Place Foley catheter stat. STAT for place Foley catheter. There were no other orders for Foley care, monitor output, or Foley replacement PRN. Record review of Resident #1's July 2023 MAR reflected orders were completed as evidenced by: Bladder scan x 1, If retaining more than 400 mL, Insert a Foley catheter and place Foley catheter orders. One time only for urinary retention for 1 day [Order date 07/06/23], revealed: - 07/06/23 2:53 PM: LVN C's initials. Result: 650 ML Record review of Resident #1's July 2023 TAR reflected orders were completed as evidenced by: Bladder scan x 1, If retaining more than 400 mL, Insert a Foley catheter and place Foley catheter orders. One time only for urinary retention for 1 day do bladder scan. [Order date 07/05/23], revealed: - 07/05/23 5:16 PM: A checkmark and LVN E's initials. Result: 643 ML Place Foley catheter stat. STAT for place Foley catheter. [Order date 07/06/23], revealed: - 07/06/23 5:05 PM: A checkmark and LVN E's initials Record review of progress notes for Resident #1 revealed: - A Daily Skilled Note, dated 07/06/23 at 1:39 PM as a LATE ENTRY, entered by ADON M indicated Vital Signs: BP 132/68 (7/6/2023 at 09:02 AM); T 98.2 (7/6/2023 1:40 PM); Pulse 74 (7/6/2023 at 09:02AM); Resp 17 (7/6/2023 at 1:40 PM); Pain: No Urine is normal urine output No GU changes observed. No GU appliances used. - A progress note entered by Resident #1's attending PCP dated and e-signed 07/06/23 at 2:31 PM indicated 7/6/23: bladder scan shows distended bladder (a condition in which the bladder becomes enlarged) with volume 643 ml. Will place foley catheter. - 07/06/23 at 3:42 PM, LVN C entered: N/O (new order) for foley cath implemented . - 07/07/23 There was not a Daily Skilled or narrative note to indicate any nursing care and treatment provided, detailing all assessments, health issues, personalized care plan, actionable treatments, or evaluation. - 07/08/23 at 7:01 PM, IDON entered: Vital Signs: BP 129/70 (07/07/23 5:29 PM); Temp 97.0 (07/07/23 5:29 PM); Pulse 65 (07/07/23 5:29 PM); Resp. 18.0 (07/07/23 5:29 PM); Pain: No COGNITION, MOOD, BEHAVIOR: Resident is Alert, Oriented X 3 No Active Symptoms or Treatments effecting Level of Consciousness, Cognition, Sleep, Mood, or Behavior. GENITOURINARY and RENAL: Urine is clear and yellow No GU changes observed. GU appliance used is an indwelling catheter. The IDON did not document or indicate that she performed catheter care. Resident #1's last vital signs measured as reflected in the progress note entered by the IDON on 07/08/23 at 7:01 PM, were 07/07/23 at 5:29 PM. - 07/09/23 at 4:44 AM, LVN H entered: Vital Signs: BP 130/77 (07/09/23 4:45 AM); Temp 97.6 (07/09/23 4:45 AM); Pulse 70 (07/09/23 4:46 AM); Resp. 17.0 (07/09/23 4:47 AM); Pain: No COGNITION, MOOD, BEHAVIOR: Resident is Alert, Oriented X 3 No Active Symptoms or Treatments effecting Level of Consciousness, Cognition, Sleep, Mood, or Behavior. GENITOURINARY and RENAL: Urine is Dark Yellow Urine Present in Foley Catheter Bag 250ml no Sediment s/s of Infection Present. Catheter Care Performed No GU changes observed. GU appliance used is an indwelling catheter. Other observations and interventions include Foley Catheter Present - Draining to Gravity on Lowest Immobile Bed Rail - Emptied Drainage Bag - Patient Slept through Catheter Care - Tolerated well. - 07/10/23 4:02 AM, LVN H entered: Vital Signs: BP 132/65 (07/10/23 4:02 AM); Temp 97.8 (07/10/23 4:02 AM); Pulse 82 (07/10/23 4:02 AM); Resp. 18.0 (07/10/23 4:02 AM); Pain: No COGNITION, MOOD, BEHAVIOR: Resident is Alert, Oriented X 3 No Active Symptoms or Treatments effecting Level of Consciousness, Cognition, Sleep, Mood, or Behavior. GENITOURINARY and RENAL: Urine is Dark Yellow Urine Present in Foley Catheter Bag 250ml no Sediment s/s of Infection Present. Catheter Care Performed No GU changes observed. GU appliance used is an indwelling catheter. Other observations and interventions include Foley Catheter Present - Tolerates Catheter Care well - did not Wake A record review of hospital medical records obtained on 07/14/23, for admitted [DATE] indicated [Resident #1] presented to the ED on 07/10/23 at 11:35 AM EMS reports that patient was at [Specialty Appointment] for a follow up on foot wound care . Per EMS, aphasia (loss of ability to understand or express speech) and mild right sided facial droop was reported . face appears symmetrical to RN upon assessment, but aphasia is noted. GCS = 14 (used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients). Pt comes with Foley catheter and midline in place. Review of ED Provider Notes dated 07/10/23 at 11:59 AM indicated Resident #1 arrived confused, appears ill, and disoriented . due to continued confusion in the ED, was admitted for further workup and treatment. Review of Resident #1 UA collected in the ED at 07/10/23 at 1:43 PM, resulted (*) abnormal (AB!) lab values at 1:52 PM: URINALYSIS, ROUTINE - Abnormal; Notable for the following components: GLUCOSE, UA - Pos 1+ (AB!) | Range: Negative BLOOD UA - Pos 1+ (AB!) | Range: Negative LEUKOCYTES ESTERASE - 500 | Range: Negative URINE MICROSCOPIC - Abnormal; Notable for the following components: EPITHELIAL CELLS - Frequent (*) | Range: Few WBC, URINE - 65 (*) | Range: 0 - 5 RBC, URINE - 10 (*) | Range: 0 - 3 BACTERIA UA - Light (*) | Range: Absent MUCUS UA - Present (*) | Range: Absent YEAST - Present (*) | Range: Absent URINE MICROSCOPIC EXTENDED - Abnormal; Notable for the following components: WBC CLUMPS - Few (*) | TRANSITIONAL EPITHELIALS - Rare (*) | A review of the ED physician H & P notes dated 07/10/23 at 3:27 PM indicated [Resident #1] presented to ED with confusion . was confused and slow to respond to questions . A, A x O (to person, being [in hospital], not oriented to year and having difficulty recalling the full situation. The Assessment and Plan indicated [Resident #1] given ceftriaxone given concern for UTI . came from SNF with Foley catheter; Foley catheter removed and replaced in the ED . Admit to Inpatient. The ED physician discontinued Urine Culture on 07/10/23 at 3:30 PM due to UA consistent with UTI. [Urine cultures are not usually required with positive findings of UTIs in uncomplicated UTIs] [NAME] MJ, [NAME] SW, Reygaert WC. Urinary Tract Infection. [Updated 2022 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470195/ During a phone interview on 07/14/23 at 11:37 AM, Resident #1's family member stated that [Resident #1] went from fine to not fine in the short time at SNF. The family member said that during visitation [at SNF], [the family member] would ask nurse(s) for update and the nurses would say [Resident #1] was just sleeping and everything fine. The family member stated that concerns about [Resident #1] constant drowsiness/sleeping and confused bx when awake were brought to the nurses' attention . then stated, there is no reason [Resident #1] was escorted by ambulance to the hospital from the [VMD] follow-up appointment for confusion after nurses were told something was wrong with [Resident #1]. During an interview on 07/17/23 at 3:02 PM, LVN E stated she worked 2P - 10P, was familiar with Resident #1, and described [Resident #1] as able to feed self whenever alert enough . family member assisted with ADLs . had a Foley catheter. LVN E stated (he/ she) did not know if [Resident #1] admitted with Foley catheter but recalled a few weeks ago there was an order to perform a bladder scan and if the result was greater than (could not recall amount), to insert a Foley catheter. LVN E stated that a mobile diagnostic company performed the bladder scan but had not received results before end of shift. LVN E said that she followed up on the results on her shift the following day, after found the results on the fax machine, and sent to NP for review around 8:30 PM. LVN E said that the NP called back just as [LVN E] was leaving for home at the end of shift, so LVN E verbally told the on-shift night nurse the orders received from NP for LVN N to follow through. LVN E indicated that it was her user initials that reflected on the TAR on 07/06/23 who inserted the Foley catheter as ordered but did not actually perform the task. LVN E could not explain why she signed the TAR for a task she did not perform. LVN E stated that she had only stood by to assist with an indwelling catheter insertion and never performed on her own. LVN E verbalized the steps of procedure but stated that she would access resources on the procedure before performing because she was not comfortable with the task. LVN E stated whenever she provided catheter care to a resident she checked the entrance area, which was free from pus, discharge, and drainage; also, would check the tubing was not clogged and drained clear yellow urine. LVN E said CNAs were typically responsible for emptying the catheter drainage bag, measured urine, and informed the charge nurse of the color, any odor, and the amount. LVN E said that poor peri-/catheter care placed residents at risk of an UTI. LVN E described a change in condition as a change from the resident's day to day baseline vital signs or behavior - acting confused. LVN E stated early s/sx of UTI included confusion; urine with foul odor, sediment, or blood; and stomach pain. LVN E said that she provided direct care to Resident #1 but did not recall a change in condition, behavior, or vital signs that caused concern. LVN E said that there are orders to monitor for signs of UTI, 30 days order from day of admission to replace catheter, and to change the catheter as needed . the 10P - 6A shift change the catheter and the 6A - 2P shift performs catheter care. LVN E stated the purpose of performing catheter care and replacing the catheter at least every thirty days is to decrease risk of infection. A telephone interview was attempted on 07/17/23 at 4:34 p.m. for LVN S, but the call was not answered or returned prior to exit. During an interview on 07/17/23 at 5:38 PM, the IDON stated that she monitored 30-day catheter orders. The IDON said based on the CDC it was not required to change the catheter every 30 days. The IDON stated catheter care is used to prevent UTIs and catheter care is considered cleaning the peri area (the private areas) and performing peri care (involves cleaning the private areas). The IDON said that she ran reports to ensure there were no blanks on the MAR/TAR, then stated that ADON M was responsible for monitoring Peri-care is completed daily by monitoring the TAR. The IDON was unable to present policy, procedure, or guidelines that reflected CDC documentation that indicated changing an indwelling catheter at least every 30 days was not necessary. During an interview on 07/17/23 at 6:34 PM, ADON M stated his responsibilities included reviewing new orders, run Orders Reports to review new orders, update resident chart, follow-up on labs, and communicating with nurses. ADON M recalled Resident #1 admitted with IV abx for an UTI. ADON M stated the attending PCP ordered a bladder scan for Resident #1 . resulted urine retention . the PCP ordered placement of an indwelling catheter . and then, [Resident #1] was started on IV abx for UTI. ADON M said that he ran a report daily to monitor that scheduled tasks were incomplete/completed on the current day shift (6A - 2P). ADON M stated nurses should assess the catheter and urine output when assessed the resident during their shift. ADON M said that scheduled tasks alert nurses to perform care . if a task was not completed on a shift, it would be completed by the nurse on the next shift. ADON M stated that all nurses were trained on the risks of infections and to provide timely care. ADON M stated that he followed up with nurses to ensure catheter care was done. ADON M stated that the orders were scheduled to conduct catheter/peri care daily, to change catheter every 30 days and as needed. When asked if the reports ran revealed there were no orders entered to perform catheter care or monitor Resident #1 urine output, ADON M stated that a nurse who did not work regularly, could miss, or overlook a scheduled task. ADON M never provided an answer or explained the missing [indwelling catheter care] orders. ADON M stated the nurses were responsible for selecting all interventions related to care when entering orders and if needed clarification about incomplete or if needed additional orders, such as the need to provide catheter care/peri care, should contact the attending doctor. ADON M stated that best practice was for the CNA to communicate with the nurse . the nurse should assess concerns that the CNA told them . notify the provider, RP, and IDT to update the care plan. During an interview and record review on 07/26/23 at 9:27 AM, MDS DD stated she worked as an MDS nurse for nearly [AGE] years, but Resident #1 was not one of the resident's care plans managed [Resident #1 was assigned to MDS CC]. MDS DD reviewed Resident #1's care plan with investigator and stated that by reading the care plan it appeared that [Resident #1] had DM, HLD, PVD, was on IV abx for osteomyelitis, but did not reflect what type of IV access . Resident #1 had HTN, COPD, had the great toe AMP on Left foot . episodes of B & B incontinence, at risk for falls, on psych meds, potential for nutritional issues r/t DM, risk for PU, had a surgical wound to left great toe and left lateral heel . had a diagnosis of depression, anxiety, potential for pain r/t neuropathy and [left great toe] AMP, required assistance with ADLs, and goal was to go back home. When MDS DD was asked about the emphasis that the care plan did not reflect type of IV line, MDS DD replied it was important to identify the type of IV line to implement interventions for appropriate care of the IV access, what solution to flush with, how to monitor, dressing changes, and to include doctor specific orders. When asked if Resident #1 had other lines, tubes, or drains by reviewing the care plan, MDS DD denied. MDS DD indicated the care plan did not reflect an indwelling catheter. MDS DD stated if the indwelling catheter was placed after the ARD, the care plan was closed and the ADONs were responsible for care plan updates . that could be a reason a care plan was not developed for the catheter. MDS DD indicated if a resident discharged from the facility before the ARD, the care plan would not be updated unless the resident returned to the facility. MDS DD stated when the care plan was developed or updated, the person would ensure the care plan was updated entirely. A review of the July 2023 Infection Log revealed 7 residents with facility acquired UTIs [onset dates 07/03/23, 07/04/23, 07/05/23, 07/08/23, 07/13/23, 07/15/23, and 07/17/23] and 1 resident with a CAUTI infection [onset date 07/04/23]. Three residents were admitted to the same hall as Resident #1 with UTIs [2 residents on 07/06/23; 1 resident on 07/08/23]. Record review revealed the IDON completed The CDC Nursing Home Infection Preventionist Training Course (Web-based) on 02/28/23; and ADON D completed the course on 05/23/23. During an interview on 07/26/23 at 12:35 PM, the IDON stated expectations that MDS nurses were skilled and qualified to assess relevant care areas and were knowledgeable about the resident's status, needs, strengths, and recognized areas of decline to accurately develop care plans. The IDON said that Leadership and department heads met every morning to discuss resident status updates, changes in condition, and pertinent information to collaborate with the MDS nurses to develop and update care plans as needed. The IDON provided the Comprehensive Person-Centered Care Planning policy to investigator as requested. The IDON indicated that there was not a specific policy for peri-care or catheter care . we just follow the CDC guideline. The IDON stated that there was a protocol on how to perform peri-/catheter care and provided it to the investigator. During a phone interview on 07/26/23 at 2:06 PM, the attending PCP said that any change from baseline behavior, vital signs . from the resident's normal was considered a change in condition. The attending PCP agreed when asked if a resident presented AMS or more confused was considered a change in condition. The attending PCP said that early s/sx of UTI/CAUTI could be a fever, change in urine characteristics, or lab values. The attending PCP stated that it would be likely recommended to obtain labs or other diagnostic studies to determine if a resident had a UTI/CAUTI. The attending PCP stated instructions given were to notify MD/NP immediately of a resident's change in condition. The attending PCP indicated (he/ she) was familiar with Resident #1 but did not currently have Resident #1's chart available to review notes. When asked if Resident #1 was at risk for UTI, the attending PCP replied anyone incontinent or with an [indwelling] catheter is at risk for UTI. The attending PCP indicated lab work and follow up labs were ordered for Resident #1 and monitored for kidney function. The attending PCP stated that it was common sense to make sure a resident with a catheter had orders to monitor and provide care . the nurses could call if they needed the order to monitor and provide appropriate catheter care to Resident #1 if they had to. The attending PCP stated that Resident #1 was very complicated, and issues could occur r/t the other infections. The attending PCP said (he/she) needed to check notes and could not recall if notified about Resident #1 AMS or decline in ADLs. The attending PCP stated he/she would call the hospital, review notes, and follow up with the investigator. There was no further communication with the attending PCP before exiting the facility. On 07/26/23 at 2:30 PM, an outbound call was placed to LVN N. There was no answer. The IDON was informed that the investigator needed to speak with LVN N. The IDON acknowledged, and stated that LVN N worked nights and the night before. He/She stated LVN N was probably asleep, but would communicate with LVN N to contact the investigator. The call was not answered or returned prior to exit. During an interview on 07/27/23 at 1:04 PM, MDS CC stated she was responsible for Resident #1's care plan. MDS CC stated when the MDS assessment was completed, CAAs were triggered, and the care plan was implemented within seven days after signed by the nurse [RN/DON]. MDS CC stated she thought she had completed the care plan update but had not. In an interview on 07/27/23 at 4:45 p.m., the Admin was not able to speak to the process of care plan development/updates, FC care, MD Notification, Incontinent Care, or IV mgmt./dressing changes. The Admin stated his expectation was that all staff participated in facility in-services and trainings to maintain updated skills and follow facility protocols on resident care. The Admin indicated nursing department heads and leadership ensured nursing staff had the competency to perform their jobs appropriately and provide quality care. Review of a policy and procedure provided by the facility titled Perennial, routine procedures, revised May 2007, indicated that it is the policy of this facility to cleanse perineum, eliminate odor, prevent irritation or infection, enhance resident's self-esteem Review of a policy and procedure provided by the facility titled, Physician Orders, Pharmacy Services, revised May 2007, indicated that it is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments. The Admin was notified of an Immediate Jeopardy (IJ) on 07/26/23 at 5:04 PM due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 07/27/23 at 12:58 PM and included: 1. The Medical Director was notified of IJ on 07/26/23 at 5:45pm. 2. Review completed by DON of all residents with catheters in facility to assure appropriate monitoring and treatment orders are in place and active. 3. Review completed by DON on 07/26/23 of all residents with foley catheters and care plans updated for all residents at risk. 4. Resources, DON, ADON, and clinical leadership-initiated education with Nurses and CNAs on monitoring foley catheters, foley catheter care and UTI/CAUTI prevention. 5. CRN provided education to DON on 7/26/23 6. All licensed nurses will complete competency on foley catheter care started on 07/26/23. 7. All CNA's will complete competency on foley catheter care started on 07/26/23 8. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 9. An ad hoc meeting regarding items in the IJ template will completed on 07/26/23. Attendees will include the Medical Director, CRN, Admin, DON, ADON, Clinical Resources and will include the plan of removal items and interventions. 10. The DON, ADON or CRN will verify staff competency with 10 staff weekly using the skin check competency checklists. 11. All residents with foley catheters will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director and WCN The DON and Admin will be responsible for ensuring this meeting is held weekly and all residents with foley catheters are reviewed. 12. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring conducted on 07/27/23 of the facility's implementation of their POR included: Interview with IDON indicated she was educated by the CRN about the steps of procedure related to catheter care and completed POR entry #2 on 07/26/23. The IDON assured that appropriate monitoring and treatment orders were in place and active for all residents with catheters in the facility. Interview with IDON indicated she completed POR entry #3 on 07/26/23. The IDON indicated that she reviewed the care plans of all residents with foley catheters, and the care plans were updated. Interview with the CRN indicated she completed POR entry #5 and provided education to the IDON on 07/26/23. Interviews conducted with nursing staff scheduled 6a - 2p and 2p - 10p shift on 07/27/23 [ADON D, LVN Q, LVN O, CNA L, CNA K, MDS CC, MDS DD, CNA BB, NA AA, CNA Z, LVN C, CNA Y, CNA X, CNA W, CMA T, LVN S, LVN I, RN R, LVN E, CMA V, CNA U, and ADON M] indicated they participated in an in-service training about foley catheters. The nurses indicated they had received an in-service regarding catheter care, which included proper catheter care and continual treatment to ensure prevention of UTIs and ensure all current resident with a catheter had an order on the TAR. The CNAs and CMAs summarized the topic of training in their own words how to perform catheter care/peri-care, appropriate placement of the drainage bag, cover with privacy bag, must hang below the bladder, not rest drainage bag on floor, POC documentation, and reportable s/sx to nurse. Record Review of an in-service conducted by the CRN, dated 07/26/23, reflected the IDON signature. The summary of the in-service in a general way, covered catheter care, obtaining orders, and monitoring. Record review of in-services conducted by the CRN beginning 07/26/23 titled Foley Catheter Care reflected 10P - 6A nursing staff signatures participated in the in-service - CNA F, LVN EE, NA FF, LVN GG, CNA HH, CNA II, LVN H, CNA JJ, CNA KK, CNA LL, and CNA MM. Staff signatures from 6A - 2P and 2P - 10P shifts included, LVN S, LVN E, CMA V, LVN I, RN R, NA NN, LVN OO, RN PP, CNA AA, CNA HH, CNA QQ, CNA RR, CNA J, and CNA SS. An IJ was identified on 07/26/23. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 4 halls reviewed for infection control. 1. The facility failed to test all residents and staff when Resident #61 tested positive for COVID-19 at the facility. The facility did not test all residents until after the 6th resident tested positive. 61 residents out of 121 residents developed COVID-19. 2. The facility failed to ensure facility staff did not reuse the same cloth gowns on more than one resident. 3. The facility failed to ensure devices used by more than one resident were cleaned and sanitized between uses. 4. The facility failed to wear PPE masks properly. An Immediate Jeopardy (IJ) was identified on 07/19/2022 at 2:45 PM. While the IJ was removed on 07/22/2022 at 4:10 PM, the facility remained out of compliance at a scope of widespread and a severity of the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who had a negative COVID-19 status at risk of exposure to infection and complications of the COVID-19 virus including hospitalization and death. Findings include : 1. Review of Resident #61's Face Sheet, dated 07/21/22, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #61's Nurse Note, dated 06/30/22, reflected: 1:56 PM Reported by physical therapy that patient had not been participating well in therapy, decreased appetite, dry cough noted as well. 4:28 PM Covid rapid test completed and resulted positive, due to patient wandering and impaired memory transferred to another facility. A record review of the facility's list of COVID-19 positive residents, not dated, reflected: Resident #61 was the 1st resident to test positive on 06/30/22 and lived on Hall 1 (wander-guarded unit where all residents had memory issues and were not able to leave the unit). Her Roommate #115 tested COVID-19 positive on 07/12/22. An interview on 07/22/22 at 1:00 PM with the OTA revealed he did therapy with Resident #61 (1st COVID positive resident) on 06/30/22. The OTA said for therapy they bounced a ball and did aerobics, strength, and safety training. He said the resident did not wear a surgical mask. He said the resident was ill with lethargy a few days before she tested positive on 06/30/22. He said he told the nurse she was lethargic. He said there were four other residents he worked with around the time of 06/30/22 and all four of them tested positive for COVID-19. An interview on 07/21/22 at 12:25 PM with CNA M revealed she provided care to Resident #61 (1st COVID positive resident) on Hall 1. CNA M said the resident did not use a wheelchair, was ambulatory, and wore a wander guard. She said her roommate and her were close and did everything together. She said the resident went to the dining room for activities with other residents. CNA M said Resident #61 interacted with everyone on the hall and would pat people on the back. An interview on 07/22/22 at 11:49 AM with CNA L (first staff to test positive for COVID-19) revealed she was assigned to work on Hall 1 and Hall 2. She said she was assigned to work with Resident #61 (1st COVID positive resident) on 06/30/22 and the resident had signs and symptoms of COVID-19. She said the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #70's Face Sheet, dated 07/22/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He lived on Hall 1. Review of Resident #70's Nurse Note, dated 07/08/22, reflected: Received phone call from spouse stating she tested positive for COVID on 07/07/22 and last visited with resident on 07/04/22. Resident complained of feeling bad complaints of pain all over, no cough or congestion noted. Covid test resulted positive. A record review of the facility's list of COVID-19 positive residents, not dated, reflected: Resident #70 was the 2nd resident to test positive on 07/08/22 and lived on Hall 1. 3. Review of Resident #72's Face Sheet, dated 07/21/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #72's Nurse Note, dated 07/08/22, reflected: 4:46 PM Resident having shortness of breath upon exertion and rattling noises. Resident profusely sweating. Notified wife and Nurse Practitioner. Notified 911. Dispatcher states someone will be out shortly to send resident to hospital. A record review of the facility's list of COVID-19 positive residents, not dated, reflected: Resident #72 was the 3rd resident to test positive on 07/08/22 and lived on Hall 2. The roommate was not on the list of COVID-19 positive residents. Resident #4 and roommate Resident #3 were the 4th and 5th residents to test positive on 07/09/22 and lived on Hall 1. Resident #93 was the 6th resident to test positive on 07/10/22 and lived on Hall 2. His roommate tested positive at a later date. Resident #11 was the 7th resident to test positive on 07/11/22 and lived on Hall 1. He did not have a roommate. Resident #19 was the 8th resident to test positive on 07/12/22 and lived on Hall 2. Her roommate tested positive at a later date. Resident #17 was the 9th resident to test positive on 07/12/22 and lived on Hall 1. His roommate tested positive at a later date. Resident #39 was the 10th resident to test positive on 07/12/22 on and lived on Hall 1. His roommate tested positive at a later date. An observation on 07/19/22 at 10:40 AM -11:00 AM revealed the facility had 4 separate halls. Hall 1 was sectioned off and was identified as the Hot Unit (COVID-19 positive). Hall 2 was closed off with double doors and a pink PPE sign was on the double doors. The sign did not indicate if it was a hot unit, warm unit (COVID-19 status unknown), or a cold unit (COVID-19 negative.) Individual resident rooms on Hall 2 did not have isolation signs posted. On Hall 2 residents had their doors open and there were attached hooks on the walls next to their bathroom. There were two or more yellow, cloth gowns hanging on each hook. There were also resident rooms with hooks that had resident clothes hanging on them next to the yellow, cloth gowns. Staff were wearing N95 masks and goggles/face shields. PPE was not available next to each resident room. Hall 3 was closed off with double doors and a pink PPE sign was on the double doors. The sign did not indicate if it was a hot unit, warm unit, or a cold unit. Individual resident rooms on Hall 3 did not have isolation signs posted. PPE was not available next to each resident room. Laundry Staff O entered a resident room on Hall 3 without wearing eye protection. Hall 4 was a separate unit that was not closed off and no isolation signs were posted on resident doors. The sign did not indicate if it was a hot unit, warm unit or a cold unit. PPE was not available next to each resident room. An interview on 07/19/22 at 9:05 AM with the Clinical Market Director revealed the DON was COVID-19 positive with symptoms and was working on Hall 1, hot unit . An observation on 07/19/22 at 10:44 AM of Hall 3 revealed Speech Therapist K left Hall 3 (warm unit), with her cloth gown on, entered the supply room (cold room) wearing her cloth gown, saw the Surveyor and said, I'm not supposed to wear this (gown) out here, sorry and then walked back into Hall 3. An interview on 07/19/22 at 10:55 AM with CNA D revealed she was assigned to work on Hall 2 (warm unit). She said to work on the warm unit, she had to wear an N95 mask and a yellow, cloth gown. She said she reused the gown during her shift, and it was kept on a hook in the assigned resident's room. An observation on 07/19/22 at 11:05 AM revealed Resident #81 returned to Hall 2 (warm unit) from the dayroom (cold unit). The resident had a runny nose and was cleaning her nose with a tissue. She had her surgical mask pulled down. The Physical Therapist was with the resident, and he was wearing an N95 mask. An interview on 07/19/22 at 11:07 AM with Resident #81 revealed she was alert and confused. She said she was not feeling well, and she had her surgical mask pulled down. She said she had a runny nose, and her voice was crappy. She said she did not know when she was last tested for COVID-19 . An interview on 07/19/22 at 11:10 AM with the Physical Therapist revealed Resident #81 was not supposed to leave the warm unit to go to therapy. He said he did not know why she left Hall 2 (warm unit). An observation of the facility kitchen on 07/19/22 at 12:05 PM revealed 2 kitchen staff were placing meals in foam containers. They were both wearing KN95 masks on their chin instead of covering their nose. The Dietary Manager was also wearing her mask on her chin instead of over her nose. An interview on 07/19/22 at approximately 12:10 PM with the Dietary Manager revealed she spoke to the Surveyor, pulled her mask down, and began wiping her mouth and chin with a paper towel. The Dietary Manager said she could not stand all of the sweating that happened while wearing a mask. Interviews on 07/19/22 at 9:45 AM and 07/20/22 at 3:50 PM with the DON revealed she was working on Hall 1 the hot unit of the facility and was COVID-19 positive with symptoms. The DON said she tested COVID-19 positive on Friday, 07/15/22, and currently had a cough, congestion, and fever while working on Hall 1. The DON said on 07/01/22 (records revealed 06/30/22), Resident #61 was symptomatic with COVID-19 symptoms and tested positive on Hall 1. The DON said they transferred the resident to another facility and her roommate, Resident #115, was moved off Hall 1 and placed on quarantine in Hall 3. The DON said she made the decision at that time to do contact tracing instead of outbreak testing for the facility COVID-19 outbreak because she said both residents stayed together in their room except for dining and therapy. The DON said on 07/08/22, Resident #70 from Hall 1 was symptomatic and tested positive and was transferred to another facility. The DON said Resident #70's roommate, Resident #48, tested negative and was placed in quarantine. The DON said Resident #48 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .) The DON said at that time, all staff were tested for COVID-19, but the residents were not and contact tracing was continued for the residents. She said no staff tested positive for COVID-19. The DON said Resident #72 went to the hospital on 07/08/22 and tested COVID-19 positive but the facility did not find out until 07/11/22. The DON said on 07/10/22, Resident #94 was symptomatic, and tested positive on 07/10/22. (Per the facility COVID-19 Resident List, dated June/July 2022, Resident #94 was the 6th resident to test positive, not the 4th resident.) The DON said she made the decision to do facility-wide outbreak testing on 07/11/22 - 07/12/22 and found there were 25 COVID-19 positive residents with 6 COVID-19 positive staff. The DON said facility wide testing was completed again on 07/18/22, and an additional 23 residents tested positive. The DON said that most residents and most staff received the vaccine and first booster, but not the 2nd booster. She said for Hall 2 (warm unit) and Hall 3 (warm unit), staff were supposed to be wearing an N95/KN95 mask, eye protection, and a yellow, cloth gown to provide care to residents in quarantine. She said on Hall 1, hot hall, staff were supposed to wear a gown, N95 mask, and eye protection. The DON said she monitored to ensure staff were wearing PPE correctly. She said staff knew which yellow, cloth gown belonged to each staff member because the resident rooms had hooks to separate the gowns. She said she did not know staff were placing more than one yellow, cloth gown on each hook in the resident room. She said staff reused cloth, yellow gowns because that was the way they had always done it and she did not know disposable gowns were required. She said if she had known disposable gowns were required, she would have a stock of them to use. She said the first COVID-19 positive staff was confirmed on 07/11/22. The DON said she thought the outbreak spread so quickly because she found 3 staff were working when they were symptomatic. She said MA G was symptomatic and left work early when she tested positive on 07/12/22. The DON stated CNA H left work feeling ill and tested positive on 07/11/22. The DON stated LVN I was ill and tested positive on 07/14/22. She said for the facility decision on contact tracing instead of facility-wide outbreak testing there were a number of people involved in the decision-making process. She said in hindsight, she should have completed facility-wide outbreak testing. An interview on 07/19/22 at 12:31 PM with the Clinical Market Director revealed when the facility outbreak started, outbreak testing was not performed facility-wide because the facility decided to do contact tracing instead. Interviews on 07/20/22 at 2:07 PM and 07/22/22 02:03 PM with ADON E revealed she was assigned to Hall 1 (hot unit). She said the facility had plenty of PPE and in the hot unit, staff wore their isolation gowns without removing them for their shift. She said in hindsight, the facility could have started facility-wide outbreak testing to prevent the infection from snow-balling. ADON E said Hall 1 was a wander guard unit and the residents ate and did all activities together on Hall 1. She said about half of the residents would hang out together and all of the residents on the wander guard unit had memory issues. An interview on 07/20/22 at 2:31 PM with ADON F revealed she worked on Hall 3 and Hall 4. She said Hall 3 had residents who had developed COVID-19. She said her contact tracing revealed Hall 3 did not have any COVID-19 positive residents until they were moved from Hall 1. She said the residents who were moved to Hall 3 were placed in quarantine. She said staff on Hall 3 used N95 masks, face shields, and reusable, yellow, cloth gowns to provide care. She said staff were supposed to use one gown per resident room. She said she was not involved in the contact tracing for Hall 1 and Hall 2. She said the charge nurses were responsible for making sure staff used the cloth gowns correctly. She said staff were in-serviced about the cloth gowns when the outbreak started. ADON F said she did not complete any monitoring to make sure PPE was worn correctly. She said she did have to direct some staff to wear their masks. An observation and interview on 07/20/22 12:15 PM with CNA A revealed she was assigned to room [ROOM NUMBER] (Hall 2) on the warm unit. room [ROOM NUMBER] had several white hooks hanging on the wall next to the bathroom. The hooks had blue, disposable, isolation gowns hanging on the hooks. CNA A said she had to reuse the blue, disposable gown to provide care to the resident in the room. She said she was supposed to hang it on a CNA hook in the room after each use and dispose of it in a gray barrel in the hall at the end of her shift . Observations on 07/20/22 at 12:36 PM of the kitchen revealed Kitchen Staff B was at the sink in the kitchen with her N95 mask pulled down below her chin with her mouth and nose exposed. Kitchen Staff C was removing bread from a bread bag with her N95 mask pulled under her nose. An interview on 07/20/22 at 12:43 PM with the Dietary Manager revealed she instructed Kitchen Staff B and Kitchen Staff C to keep their N95 masks pulled up over their nose. The Dietary Supervisor said both staff were in-serviced on 07/19/22 to wear their masks appropriately . An observation and interview on 07/21/22 at 9:42 AM - 9:52 AM with MA J revealed she used the blood pressure cuff on the cart to take Resident #55's blood pressure. MA J took the blood pressure cuff back to the cart but did not clean it. MA J performed hand hygiene, donned PPE, put on gloves and took the same blood pressure cuff into a resident room to take their blood pressure. MA J said she did not have to clean the blood pressure cuff between resident uses. An interview on 07/21/22 at 10:00 AM with ADON F revealed staff were supposed to sanitize the blood pressure cuff between uses and she would address the issue with MA J. An interview on 07/21/22 at 12:40 PM with CNA N revealed she provided care to residents on Hall 2. She said staff would have one, yellow, cloth gown to use for both residents in each resident room. She said staff re-used the gown all shift. Interviews on 07/20/22 at 4:36 PM and 07/21/22 at 8:20 AM with the Administrator revealed he did not know when the last facility COVID-19 outbreak was, and the facility had plenty of disposable gowns. He said the facility used contact tracing instead of outbreak testing for the outbreak because Resident #61 who tested positive, pretty much kept to herself. He said the next resident was positive because of a COVID-19 positive family member who visited the resident. He said the facility did screen visitors for COVID-19 symptoms and staff were being tested two times a week. The Administrator said he was not sure why COVID-19 was a big deal because people were not dying, and symptoms were less severe. Review of the facility COVID Timeline/Contact Tracing, not dated, reflected: June 30, 2022 - [Resident #61 ] with decreased activity level and appetite. tested COVID positive and transferred to another facility. We did contact tracing -consistent with her [family member] who visited three to four days prior to her testing positive who is not vaccinated and non-compliant with masking determined that was the culprit of the positive. June 30th, 2022 [Resident #61's] roommate, [Resident #115] (COVID test was negative on 07/01/22) transferred to Hall 3 for contact/droplet isolation as a precaution. [Resident #61] and [Resident #115] tend to self-isolate in room and watch TV. They eat seated at a table with each other and rarely interact with other residents for more than a casual hello. Which is less than 15 minutes of contact. Staff assigned to Hall 1 tested on [DATE] and repeated on 07/07/22 and 07/14/22 to comply with county transmission rate. July 8, 2022 - [Resident #70] with c/o 'feeling bad' and 'hurting all over.' Resident tested positive for COVID. Resident transferred to another facility. We completed contact tracing and determined resident's [family member] visited on 07/04/22. [Family member] tested positive Tuesday but did not notify the facility until Friday . Staff assigned to Hall 1 already being tested . [Resident #70's] roommate, [Resident #48] tends to wander and requires redirection. [Resident #48] maintained on contact/droplet precautions. [Resident #48] tested during outbreak testing and remains negative as of 07/20/22. July 9, 2022 - [Resident #3] had episode of emesis (vomiting) and tested positive for COVID. [Resident #3's roommate [(Resident #4)] frequently helps him with tasks and also tested positive. [Residents #3 and #4] transferred to another facility. [Resident #48] and [Resident #4] share a bathroom and [Resident #48] frequently wanders into the [(Residents #3 and #4)] room and is redirected. July 11, 2022 - [Resident #11] presented with a temperature of 101.6 degrees Fahrenheit on evening shift resident tested COVID positive. Resident maintained on contact/droplet precautions and transferred to another facility on 07/12/22. The facility initially contact-traced and tested residents usually present in the Hall 1 dining room with whom [Resident #11] has interactions/sat at the table .Upon noting additional positive cases, the decision was made to test all residents of Hall 1 and Hall 2. An interview was attempted on 07/22/2022 at 2:16 PM with the Medical Director. He did not return the call of the Surveyor. Review of the Facility In-service, Personal Protective Equipment Commitment, dated 01/31/21, reflected: .wear appropriate PPE .This means an N95 mask while working, gown, and gloves each time you enter a resident's room . Review of the facility Infection Control Policy/Procedure, dated May 2007, reflected: 1. Goals. The goals of the Infection Control Program are to: A. Decrease the risk of infection to patients and personnel. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection control practices. D. Ensure compliance with state and federal regulations relating to infection control. Review of the CDC, COVID-19 Interim Infection Prevention and Control Recommendations to prevent [CONDITION(S)]-CoV-2 spread in nursing homes located in the facility COVID-19 binder, dated 02/04/22, reflected: .Testing. Create a plan for testing residents and HCP for [CONDITION(S)]-CoV-2 Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test as soon as possible .facilities should prioritize resources to test symptomatic people and all close contacts, as well as be prepared to initiate outbreak response immediately if a nursing home-onset infection is identified among residents of HCP .HCP should not work while acutely ill .Managing Residents with Suspected [CONDITION(S)]-CoV-2 Infection. HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection or equivalent . should use full PPE (gowns, gloves, eye protection, and a .N95 .New Infection in Healthcare Personnel or Residents .Because of the risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or .in a resident should be evaluated as a potential outbreak .HCP and residents with symptoms of COVID-19: Symptomatic HCP, regardless of vaccination status, should be restricted from work .Perform contact tracing .A facility-wide .approach, should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission .Broad-based approach: Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately .and if negative, again 5-7 days later. Review of the Facility Personal Protective Equipment: Conservation during Crisis or Pandemic Policy, dated 03/23/20, Isolation Gowns. Contingency Capacity (Rationing PPE): Shift to cloth isolation gown if available - single use, laundering after each use. Crisis Capacity (PPE in very limited supply) Extended use of isolation gowns (disposable or cloth) if no co-infectious diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This was determined to be an Immediate Jeopardy (IJ) on 07/19/22 at 2:25 PM. The Clinical Market Director was notified of the IJ (the Administrator and DON were not at the facility) and the IJ template was provided on 07/19/2022 at 2:45 PM. The following Plan of Removal was submitted by the facility and was accepted on 07/20/2022 at 4:45pm. It reflected: .Immediate Action Taken: 1. The Medical Director was immediately notified at roughly 3:20pm on 7/19/22. 2. DON/ED/Admission Coordinator/Designee will assure that all new admissions, exposures and positive residents are placed in designated area by following the CMS/CDC/HHSC guidelines. 3. Facility failed to perform COVID outbreak testing once a positive resident as identified by HHSC on 7/19/22. a. All residents were tested on i. 07/12/22 - 20 positive resident's [sic] identified ii. 07/18/22 - 25 positive resident's [sic] identified b. All residents will continue on outbreak testing until the current COVID outbreak has cleared: i. ED/DON/Resource/Designee are responsible to assure that this is completed per CDC, CMS, HHSC guidelines. ii. Outbreak testing will occur for staff and resident's 3-7 days until no new case are identified for at least 14 days from most recent positive test. c. Any resident displaying symptoms will immediately be tested by charge nurse and DON notified. d. Cohorting/Placement of residents i. Facility will establish designated cohorts based on resident covid status 1. Hot Unit - Resident's [sic] who are confirmed covid positive 2. Warm Unit- Resident's [sic] who are unknown covid status or exposed to covid 3. Cold Unit - Residents who have no history of covid exposure and are confirmed negative covid status. e. ED/DON/Resource/Designee will be responsible to assure that testing during out break is completed per CMS/HHSC/CDC guidelines. f. Routine testing of staff who are not up to date with COVID-19 will be completed based on county positive rate published weekly per CMS/CDC i. Resource/ED/DON/Designee will assure that staff testing is completed per listed guidelines g. Contact tracing vs Outbreak Testing per CDC guidelines i. ED/DON/Designee will initiate contact tracing if the facility has the ability to identify close contacts of the individual with COVID-19. ii. If the ED/DON/Designee is unable to complete contact tracing the ED/DON/Designee will initiate broad based testing of the facility residents and staff. h. Staff regardless of vaccine status will also be tested based on triggers upon entrance/screening to the facility i. Resource/DON/ED/Staffing coordinator/Designee will be responsible for reviewing the staff screen log daily to assure anyone who has triggered positive on the screening is tested and follow up completed. i. In the event that a newly identified covid-19 case is identified with staff or resident with close contact i. Resource/ED/DON/Designee will assure that all staff are tested regardless of vaccination status that had close contact with COVID-19 positive individual ii. Resource/ED/DON/Designee will test all residents regardless of vaccine status that had close contact with COVID-19 positive individual. j. In the event that a newly identified COVID-19 positive staff or resident in the facility that is unable to identify close contacts i. Resource/ED/DON/Designee will test all staff regardless of vaccination status facility wide or at a group level if staff are assigned to a specific location where the new case occurred (for example unit, floor or specific area of the facility) ii. Resource/ED/DON will test all residents regardless of vaccination status facility wide or at a group level (for example unit, floor or specific area of the facility). 4. The DON was on the COVID unit from 9 a.m.to 11 a.m. 7/19/22 after testing positive with signs and symptoms. a. The DON was sent home at 11 a.m. on 7/19/22 - DON upon arrival to the facility was asymptomatic, however when her symptoms developed, she went home. i. In the event that an employee becomes symptomatic while on duty they will notify the on call/DON/Designee ii. Employee will be removed from the patient care area, sent to test and wait in a secure non- patient care area for test results. b. The DON will be in-serviced on infection control and complete donning/doffing competency prior returning to work at facility, this will be completed by the Clinical Resource. 5. Staff not wearing N95 masks/eye protection a. Staff on Hot/Warm units not wearing N95 masks i. All staff provided N95 masks to wear immediately ii. All staff will have eye protection on in the warm/hot unit patient care areas iii. IDT/Resource/Designee will round to assure that staff have the appropriate mask for assigned unit. iv. HCP who are up to date with all recommended COVID-19 vaccine doses once outbreak has been cleared: 1. Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). 2. They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors) v. Donning/Doffing station has been setup at dock entrance of the COVID unit 1. ED/DON/Staffing Coordinator/Designee will assure that adequate supplies of PPE are stocked daily 2. ED/DON/Staffing Coordinator/Designee will assure that facility has adequate supplies of ppe on hand and monitor three times a week. 3. If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions while not in outbreak per CDC. a. All staff working in facilities located in counties with substantial or high transmission should also use PPE as described below i. KN95, equivalent or higher-level mask should be used for care of residents who have been identified in the cold zone. 4. If [CONDITION(S)]-CoV-2 infection is suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow contact/droplet precautions i. N95, equivalent or higher level mask for care of residents in warm zone or hot zone. ii. Face shield or eye protection iii. Isolation gown 6. Staff not wearing masks appropriately (pulling masks down in patient care area) a. IDT/Resource/Designee will round to assure that all staff are wearing masks appropriately 3 x daily for 4 weeks and results of these observations will be reviewed by the QAPI committee for recommendations. b. Resource/ED/DON/Designee will complete in-service on infection control and masking for staff starting on 07/19/22 will be completed by 07/21/22, all staff who are not present will complete training prior to first scheduled shift on return. 7. Staff not using reusable gowns appropriately. a. All reusable gowns will be removed and replaced with disposable gowns b. Warm unit ppe supplies will be stocked daily by the staffing coordinator/DON/ED or designee c. Resource/ED/DON/Designee will complete competencies to assure knowledge retention for staff Donning/Doffing will be started by 7/19/22 this will be completed by 07/21/22 - staff who were not available will complete prior to returning to work at the facility. d. DON/ED/Designee will complete 3 random staff observations weekly x 4 weeks the results of these observations will be reviewed by the QAPI committee for recommendations. Monitoring of the facility's Plan of Removal included the following: Observations, interviews, and record reviews were conducted on 07/21/22 starting at 12:05 pm and continued through 07/22/22 at 3:00 PM with 10 staff members from various shifts. The in-services, dated 07/20/22 reflected: COVID/Infection Control/Masking: Wear masks at all times. N95 masks must be worn on the Hot/Warm units and KN95 should be worn in all other areas of the facility. Warm Zone: Follow protocols - gowns, gloves, masks, goggles, face shields for quarantine rooms. Change gown and discard gloves after providing care for a resident. Perform hand hygiene after doffing. Hot Zone: Staff must wear PPE gown, gloves, mask, face shield or goggles. Gloves must be changed between each resident. Clean equipment between each resident use - glucometers, thermometers, BP cuffs, pulse oximeters, etc. Observations of resident care reflected staff were donning and doffing PPE appropriately in all 4 halls. Staff were no longer reusing yellow, cloth gowns. Staff were also wearing their N95 masks appropriately. The staff members were able to verbalize their understanding of the donning and doffing process and the importance of wearing their PPE appropriately. Staff were also able to verbalize the need to clean resident equipment between each resident. Interviewed staff members and shifts were: LVN O - worked day shift CNA M - worked all shifts CNA N - worked day shift MA J - worked all shifts LVN P - worked evening shift L

Based on interviews, observations, and record review, the facility failed to provide adequate supervision to prevent accidents to one (Resident #6249) of five residents reviewed for accidents. CNA A and CNA B failed to transfer Resident #6249 appropriately while using a Hoyer lift resulting in a fracture to the resident's left leg on 09/14/2021. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure placed residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included: Review of Resident #6249's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE]. His diagnoses included functional [CONDITION(S)] (the inability to move due to severe disability or frailty caused by another condition without physical injury or damage to the brain or spinal cord), need for assistance with personal care, muscle weakness, [CONDITION(S)] (a birth defect that occurs when the spine and spinal cord don't form properly), [CONDITION(S)] (group of disorders that affect a person's ability to move and maintain balance and posture), and other specified anxiety disorders. Review of Resident #6249's MDS assessment, dated 09/30/21, revealed a BIMS score of 14 that indicated intact cognitive response. He required extensive assistance and needed two or more persons for transfers, bed mobility, transferring, locomotion on/off unit, and dressing. Review of Resident #6249's care plan dated 10/22/2021 revealed he required assistance with ADLs and locomotion as required and Hoyer lift transfer with the assist of two related to diagnosis of functional [CONDITION(S)]. On 09/17/2021, the care plan reflected interventions to remain free of left tibia fracture complications. Review of Resident #6249's progress notes revealed the following: on 09/15/2021 at 7:00 PM RN C documented .put back in the bed around 5:30 PM by two staff members. RN C further documented that upon entering resident's room, she inspected, provided an ice pack and PRN Tylenol 3 for pain after resident complained his left knee really hurt and that it popped during the Hoyer lift transfer by two staff members. A review of the medication administration record reflected Tylenol 3 was administered on 09/15/2021 for a complaint of pain rated 10 out of 10 and was document being effective. The morning of 09/16/2021 LVN D notified the MD of the resident complaining of pain to the left knee and received an order for x-ray. Review of a progress note entered by the NP on 09/16/2021 she visited the resident that day. The resident reported that he had left knee pain at that time. The NP documented mild swelling and [CONDITION(S)] to the site and that the resident said his knee was injured and heard popping noise when transferred with Hoyer lift. The NP later documented will get an x-ray. The x-ray resulted a nondisplaced fracture of the proximal tibia and very mildly displaced fracture of the proximal fibula. Review of an incident report for Resident #6249 entered on 09/17/2021 at 4:23 PM by the ADON, revealed nursing incident description that patient c/o pain to LLE after transferred with Hoyer lift with 2 staff members present. The resident's incident description stated that his left foot was on the Hoyer lift's handle and when positioned to be lowered in bed, his body was moving but his left leg was stuck, as the aide was moving his leg to correct the position, he heard a pop and felt pain. It was further documented in the incident report that RN C took immediate action to assess, applied ice, and gave PRN pain medication. Further review of Resident #6249's progress notes revealed LVN D documented on 09/17/2021 at 1:26 PM the x-ray results showed a left knee fracture, orthopedic consult ordered by the doctor. The ADON notified NP of the inability to locate an ortho office that would accept the resident's insurance and received an order to transfer resident to the ER for further evaluation. Review of the ER discharge summary on 09/17/2021 indicated Resident #6249 was treated for a closed fracture of proximal end of left tibia (upper portion of the bone where it widens to help form the knee joint); closed fracture of proximal left fibula (located on the outer lateral side of the tibia just below the knee) with splint. Resident received a referral to an orthopedic doctor to follow up During observation and interview on 12/21/2021 at 11:54 AM, Resident #6249 was up in bed watching television. Resident #6249 recalled an incident a couple of months back when he was being transferred from wheelchair to bed by Hoyer lift when he heard a pop. His left leg became caught between the Hoyer brackets. The resident stated that he tried to tell the staff that his left foot was stuck, but they were moving so fast that he heard the pop and pain the next thing he knew. The resident further stated a nurse came in to assess his knee and gave medicine for pain. The resident pulled back covers to display a splint to the left lower extremity. Left foot uploaded with heel boot to prevent pressure. He stated an x-ray was done and followed up with an ortho doctor. The resident said that the nurses managed his pain appropriately. During the continued interview, Resident #6249 identified CNA A and CNA B as the two staff members that performed the transfer. During the review of CNA A's and CNA B's personnel files, both CNAs received new hire training, evaluation and checked off to use the Hoyer lift. An attempted interview with CNA A on 12/21/2021 at 12:15 PM was made and was unsuccessful. No further attempts to call CNA A due to her being out ill. A review of a written statement provided by CNA A on 09/17/2021 entailed .while using electric Hoyer lift to transfer the resident to bed his left foot did not appear trapped or in bad positioning, and when positioned over the bed and the other aide was guiding the sling to a position that resident yelled in pain and everyone stopped what they were doing and positioned resident over the bed and lowered him down, then call the nurse. During an interview on 12/21/2021 at 3:18 PM, CNA B stated that on the day of the incident, she remembered seeing CNA A looking for someone to assist with transferring Resident # 6249 and agreed to help. CNA B went on to state that the two secured the resident in the sling. CNA A had control of the Hoyer lift and began to raise resident out of wheelchair. CNA B went to the far side of the bed to assist with positioning resident once in bed. CNA B stated that she noticed the resident was not positioned correctly and tried to inform CNA A, but she wouldn't listen. CNA B stated that the resident cried out in pain as he was being turned and positioned over bed. CNA B stated that the they told the RN C about what happened. CNA B confirmed having a one-to-one discussion with the ADON on 09/17/2021, one-to-one training, and attending an all-staff in-service on 09/23/2021 about transferring residents safely when using a Hoyer lift. During an interview on 12/21/2021 at 1:03 PM, the ADON A confirmed Resident #6249 was a two-person Hoyer lift transfer and every CNA was responsible for reviewing the resident's Kardex before performing direct care or transferring a resident to ensure safety. The ADON stated she was not present during actual incident but conducted the follow up once learned about the resident's fracture to leg. The ADON stated that the likely cause of the fracture was related to the Hoyer lift transfer because the resident complained of pain to his left knee during and after the transfer. Hoyer lift training was provided to staff during new hire orientation, annually, and as needed. The ADON stated that she held a one-to-one with both CNAs to discuss resident safety when performing a Hoyer lift transfer, conducted a one-to one training with return demonstration skills check off, and performed an all staff in-service about Hoyer lift transfer safety on 09/23/2021, including pretest and posttest on abuse, neglect and proper transfers with return demonstration of proper transfers using a mechanical lift. The ADON further stated that the concern with staff not transferring residents properly was that they could be harmed. Review of Staff in-service regarding Hoyer lift transfer safety reflected the training was conducted on 09/23/2021. On 12/22/2021 at 11:52 AM, MA E and RA F were observed performing a Hoyer lift transfer. On 12/22/2021 at 12:27 PM, CNA G and CNA H were observed performing a Hoyer lift transfer. Each team demonstrated appropriate infection control measures, one team member using light hands-on pressure to guide patient while the other team member controlled the Hoyer lift. Verbal communication between staff members and with resident to ensure comfort was noted. Proper Hoyer lift techniques were followed as directed in Mechanical Lift and Slings policy. Individual interviews with observed staff members indicated knowledge of proper Hoyer lift procedures, safety tips, and where to locate information about a resident transfer need. Each staff member denied observing inappropriate Hoyer lift techniques and would report if seen. During an interview on 12/22/2021 at 2:16 PM, the DON stated that the facility policy required two or more assistants to perform Hoyer lift transfers. The intended purpose of the policy and procedure is to prevent harm, injury, and patient and staff safety. The DON further stated that Hoyer lift transfers were for short distances only. Any damaged slings or malfunctioning Hoyer lifts should be placed out of order and reported to her immediately. The DON stated that not performing safety checks, lack of communication or CNA B's instance did not likely guide the resident. At the same time, CNA A controlled the Hoyer Lift are ordinary circumstances that can lead to injuries. The DON said the staff was responsible for looking on the Kardex transfer list or asking the charge nurse to know the transfer capabilities of residents on their halls. The DON said the concern with staff not completing proper transfers could cause harm to residents. She stated leadership conducts daily rounds, making safety and entrapment observations to ensure appropriate steps and follow adequate procedure when using Hoyer lifts. The DON confirmed the ADON completed one-to-one and all-staff training about safety when transferring a resident using a Hoyer lift to prevent the likeliness of such an incident from occurring again. The DON stated that the incident was not reported as a facility incident because the resident could provide a statement of the incident on his own accord. Review of the facility's undated Mechanical Lift and Slings policy reflected the following: - Transfer status will be maintained on resident's care plan. - If a problem is encountered with the lift . discontinue use immediately. - If a problem is encountered while resident is being lifted, pull emergency pin, lower resident to bed or floor and notify charge nurse.