Afton Oaks Nursing And Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 residents ( Resident #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to prevent Resident #1 from falling to the floor and injuring himself during patient care on 01/09/26 and resulted in a laceration to his upper lip which required stitches. This deficiency could expose residents to harm and injury, due to not being adequately monitored. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Immobility Syndrome (Paraplegic), Muscle weakness (generalized), cognitive communication deficit, Hyperlipidemia, Unspecified, Contracture of muscle, unspecified site, Dysphagia, Oral Phase, and Need for assistance with personal care. Review of Resident #1's MDS assessment dated [DATE], section C revealed no BIMS score. Section G regarding the resident's Activities of Daily Living (ADL) Assistance revealed the resident needed supervision and two persons assisting with bed mobility, transferring, and toilet use. It also revealed the resident required two-person assistance with dressing and personal hygiene. Record review of Resident #1's care plan dated 11/12/2025 revealed Resident #1 was care planned for falls. ADL Self-Care Performance Deficit: requiring two-person assist with all ADL except for eating. Record review of CMA-A's signed statement dated 01/09/26 revealed she was providing patient care for Resident #1. The statement read in part, .Resident #1 became agitated. So, I stopped to calm him down, and after he calmed down. I started providing patient care again; however, Resident#1 became agitated again, and as I was wiping him, he fell to the floor, landing face down and on his left side. I observed blood, and I called for help. Record review of Resident #1's hospital record dated 01/09/26 revealed that Resident #1 was diagnosed with a fall, which resulted in a laceration to his upper lip. Resident #1 received stitches to treat his upper lip. Record review of Resident #1's progress note dated 01/09/26 revealed that he returned to the facility at 7:48 p.m. with one stitch to his upper lip due to sustaining a laceration from a fall. Record review of the facility's Provider Investigation Report dated 01/20/2026 and signed by the Administrator revealed, . CMA (CMA A) provided care to Resident (Resident #1) alone when his care plan called for two-person assist. He rolled out of bed on to the floor . Resident (Resident #1) sustained a laceration to his lip during the fall . Order received and carried out to send Resident (Resident #1) to (a local acute care hospital) ER for evaluation and treatment . All staff were trained (In-services on transfers, mechanical lift transfers, bed mobility, and repositioning with return demonstration) and CMA (CMA A) was terminated as it was found she failed to care for him without getting the assistance of a second staff member. Ad-hoc QAPI was held regarding fall . An audit was done on January 9-10 2026 to ensure residents care plans accurately reflected each resident's assessment needs . In an interview on 01/13/26 at 9:45 a.m., the Administrator stated CMA A was terminated because on 01/09/2026, CMA-A failed to provide appropriate patient care on Resident #1. The Administrator said CMA A should have used a two- person assist for care and because of CMA-A's failure to follow Resident #1's care plan for two-person assist, he fell out of his bed and sustained an injury to his top lip. Resident #1 was taken to the hospital, and his injury required stitches. In an interview with the ADON on 01/13/26, at 9:55 a.m., she stated that CMA A should have checked the Kardex before providing care for Resident #1. She stated the Kardex would have informed her that a two-staff member assist was the safest way to provide care for Resident#1 to prevent injury. An unsuccessful attempt to interview Resident #1 was made on 01/13/2026 at 10:35 a.m. However, observation reflected that Resident #1 did have stitches in his upper lip. In an interview with CNA-A, 10:40 a.m., CNA-B, 10:43 a.m., CMA-B,10:46 a.m., and LVN-A10:50 a.m. on 01/13/26, they stated as a result of Resident #1's incident, they were in-serviced last week on where to look to know if a resident is a two-person assist and if the resident is a Hoyer lift. An unsuccessful attempt was made to contact CMA A on 01/13/2026, at 11:26 a.m. and at 9:30 a.m. on 01/14/2026. In an interview with the MDS Nurse on 1/13/26 at 1:00 p.m., she stated that Resident #1 was a two-person assist with all ADL except eating. In an interview with the Administrator on 01/13/26 at 3:45 p.m., she stated that during her investigation, CMA A told the DON that she did not understand that she was supposed to use two people to assist. The Administrator stated that CMA A was recently in-serviced at the facility on what residents required the Hoyer lift, and where to look in the Kardex to know if a resident is a two-person assist. The Administrator stated that Resident #1 had to be taken to the hospital due to his fall from his bed during patient care with CMA A. The administrator stated that Resident #1 required stitches to his upper lip. Record review of facility in-services revealed all staff were educated on:*Hoyer lift, gait belt, and Kardex check before providing patient care on 01/09/2026.*Transfers and Safe patient handling on 01/09/26.*Abuse and Neglect on 01/09/2026*Abuse/Neglect on 01/09/2026. Record review of facility Safe Handling Policy(not dated) revealed, . The facility has a program to promote and assure safe patient handling for both the resident and the employee. Nurses will identify residents in need of transfer, repositing or movement assistance.Nurses will assess the risks associated with lifting, transferring, repositioning, or movement assistance Nurses will be educated in the identification, assessment, and control of risks of injury to residents and nurses during. Resident will be evaluated on admission and as needed for alternative means of lifting. Transferring, repositing and other movements to minimize risk of injury.patient handling. Nurses will be educated regarding correct safe handling procedures; to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to unacceptable risk or injury. 6. Facility staff will report to the supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff. 7. Nursing will request therapy disciplines to evaluate the resident ability to assist, and the amount of assistance needed with lifting, repositioning, transferring or mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the resident environment remained free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (CR #1's) reviewed for adequate supervision. -The facility failed to provide adequate supervision to prevent CR #1 from eloping from the facility at an unknown time on 9/21/25. This deficiency exposed residents living in the facility to potential harm, injury, or death due to not being adequately monitored. An Immediate Jeopardy (IJ) was identified on 11/18/25. The IJ template was provided to the facility on [DATE] at 4:41 pm. While the IJ was removed on 11/19/25, the facility remained out of compliance at a scope of with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective system. Findings included: Record review of CR#1's face sheet dated 11/18/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. CR #1 discharged on 10/07/25. His diagnosis of Parkinson's Disease with Dyskinesia (experiencing involuntary, uncontrolled movements), Cognitive Communication, Dementia with Agitation (restlessness, pacing, verbal aggression like yelling, and physical aggression such as kicking or biting). Traumatic brain injury (resulting from an external force), which may impact cognition, behavior, or functional status. Record review of CR #1's admission MDS assessment, dated 9/11/25, revealed the BIMS score was six out of fifteen, indicating he had significant cognitive impairment. Further review of MDS revealed CR #1 needs moderate assistance with supervision with one staff assistance. Record review of CR #1's care plan dated 06/16/22 revealed CR #1 has a short attention span wandering in and out of activities. Further review of the care plan revealed CR #1 was an elopement risk/wander dated 11/08/23. care plan reviewed and had interventions for risk of elopement due to wandering that included a wander guard in place that was to monitor per shift and alert staff of CR #1 attempts to leave the facility unattended. Monitor location per shift. Observing the wandering behavior and attempted the diversional interventions in behavior log. Revision dated 01/31/24. During an interview on 11/17/25 at 10:30 am, the video was requested by the ADM but the video for the incident on 9/21/25 was not provided. Record review of email on 11/17/25 at 12:31 pm. surveyor requested a video of the incident from the Regional Corporate Compliance Nurse. During interview on 11/17/15 at 2:06 p.m. Dietary-aide A, said he observed CR #1 enter the lobby, sit down, and then stand and begin pacing back and forth. He said when he left the lobby, CR #1 remained in the lobby area pacing up and down. During an interview on 11/17/25 at 2:42 pm. ADON said that CR #1 walked out with church members, but she was not present and did not know who could have opened the door. She said someone would have to unlock the door for CR #1 to be able to leave. She said whoever unlocked the door had a visual of whoever was leaving the facility. She said she did not know why the staff had not identified CR #1 before he walked out the front door. She said CR #1 was at risk and could have experienced death, been hit by a car, or been picked up by someone. During a telephone interview on 11/17/25 at 3:14 pm. RN B said LVN C came from station 3 and told her CR #1 was on the street. She said she did not know how CR #1 left the facility. She said CR #1 could have had a fall or hit by a car. During an interview on 11/17/25 at 3:33 p.m., the Social Worker said he was the manager on the day of the incident. Staff told SW that CR#1 was out of the facility. SW said he was close to the facility and was going to drive to CR #1 location. SW said the police officer was walking with CR #1. SW said he identified himself, and CR #1 recognized him and said he was ready to go home. SW said CR #1 immediately got into his car. SW said none of the staff knew which door CR #1 went out of. He said CR #1 did not have a wander guard on. He said the risk to CR #1 getting out of the facility was CR #1 could become lost and could have gotten hurt. During an interview on 11/17/25 at 4:31 pm. Regional Corporate Compliance Nurse, said CR#1 had gone out with the church group because there was a church group that morning. He said a staff member should have let the church group out and had a visual of who they were letting out of the facility. He could not give a time of how long CR#1 was out of the facility. He said they should have observed CR#1 was among the church group. He said CR#1 could have been injured, had a fall, been hit by a car, and/ or received other negative outcomes. During an interview on 11/18/25 at 8:56 am. CMA D said she saw CR #1 while she was in an Uber and called CR #1 by name. She said she exited the vehicle and called the facility and spoke with LVN C to inform her that CR #1 was no longer in the facility. She said she got out of the car and repeatedly called CR #1 by name, but CR #1 became aggressive. She stated the risk to CR #1 was significant, as CR #1 could have been hit by a car due to how fast CR #1 was moving. She said CR#1 was not paying attention to his surroundings, and she feared for his safety. She said that if CR #1 had gone one more block, CR #1 would have entered the freeway, but she was able to stop CR #1. During a telephone interview on 11/18/25 at 8:56 am. with LVN C, said she had no idea how CR #1 eloped from the building because she was helping on the floor with other residents. She said CR #1 could have been killed. LVN C said CR #1 has no sense of direction. She said CR #1 was trying to escape by crossing the street while looking backwards instead of at the cars in front of him. Telephone interview on 11/18/2025 at 10:22 am. with the facility's previous administrator stated she did not have time to answer any questions related to the elopement incident. During an interview on 11/18/2025 at 1:43 pm, the Regional Corporate Compliance Nurse said he requested access from IT for the video. Record review of the facility's policy on Elopement Prevention from Nursing Policy and Procedure Manual documented MM TIW WA 03-1.0 read in part. policy statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement . 7. If a resident is discovered to be missing, a search shall begin immediately. Environmental Modification 6. Use door alarms or monitoring devices to notify staff when residents try to leave the facility. Physical Plant 1. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Example of these devices: Wanderguard System (locking or alarming) Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record. Function of the resident's device will be verified at least daily and documented on a treatment of other flow record. Function of the alarm system will be verified each week and documented in a maintenance log. 3. All exit devices will be verified weekly and a log maintained. Record review of the facility's policy on Elopement Response from Nursing Policy and Procedure Manual documented MM TIW WA 03-1.0 read in part. policy statement Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. Policy Interpretation and Implementation 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. The Regional Corporate Compliance Nurse was notified of Immediate Jeopardy (IJ) on 11/18/2025 at 4:41 p.m., due to the above failures. The Regional Corporate Compliance Nurse was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was submitted by the facility and accepted on 11/19/2025 at 8:11 am.: Facility Immediate Actions: Resident CR#1 transferred to a facility with a secured unit on 10/7/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the Elopement Prevention policy on 11/18/25. Regional Compliance Nurse educated DON, ADON, and Interim Administrator regarding the Elopement Response policy, including referring to the Elopement Risk Binders located at each nurses' station on 11/18/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the operation of exit doors on 11/18/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the process change for residents signing out on 11/18/25. 100% audit of facility residents started and completed on 11/18/25 by DON, ADON, and Regional Compliance Nurse to identify residents at risk for elopement. Findings from that audit revealed four (4) residents with a score of 10 or greater. These residents' face sheet and pictures were added to the Elopement Risk binder that is kept at each nurse's station and at the front desk for all staff to be able to identify the facility residents at risk for elopement. Care plans were reviewed and updated for the four residents identified as at risk for elopement. 100% facility audit completed by Maintenance Director on 11/18/25 of facility entry/exit doors. The Maintenance Director identified ten (10) entry/exit doors. All 10 doors locked and alarmed, and proper function of door was tested and verified on 11/18/25 by the Maintenance Director. Signage was posted at the front door and Station 1 door on 11/18/25 to notify visitors not to open the door or allow anyone else out the door they do not know, including residents. Residents and their responsible parties were notified by Department Managers on 11/18/25 and were educated on resident sign-out procedures, including the location of the sign-out book and elopement prevention. Facility Plan to ensure compliance: 1.Residents identified as having a score of ten (10) or higher on the Elopement Risk Assessment in internal health record, the facility's electronic health record, will be added to the Elopement Risk Binder located at each nurse's station and at the front desk. 2. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the Elopement Response policy starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 3. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the Elopement Prevention policy starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 are not work until in-service completed. 4. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the operation of exit doors starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 5. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the resident sign-out process starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 6. The Medical Director was notified by the Administrator on 11/18/25 at 4:50pm by the Regional Compliance Nurse regarding the immediate jeopardy citation. 7. An Ad-hoc meeting held on 11/18/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan for removal. Monitoring Plan of Removal included the following: Record review of the training provided by Regional Corporate Nurse for the ADON, DON, Interim Administrator revealed staff were educated on the elopement policy, elopement binder, operation of the exit doors and how residents are to sign out of the facility. Record review of the facility audits of resident's assessments of elopement revealed 100 percent audit completed. Record review of the facility training provided on 11/18/2025 read in part. Topic: Exit Doors. Staff in-serviced and verified 11/20/2025 all exit doors have a 15 second delay-alarm will sound, and the door will open . Staff must respond to all alarms. Identify if a resident has exited, staff must stay with the residents and call for additional assistance. Record review of the facility training provided on 11/18/2025 read in part . Topic: Elopement Response. Staff in-serviced and verified 11/20/2025 all staff must notify the charge nurse as soon as possible of a resident missing or attempting to leave. If a resident is attempting to leave, try to redirect them. If a resident is suspected of being missing, the charge nurse will attempt to find out if a resident has signed out on a pass; it not on a pass, a search of the building and the premises will be initiated. Charge nurse will notify the Administrator and the DON, primary care provider, and the responsible party. The facility has an elopement risk binder at each nurse's station and at the front desk. This information can be used to assist search teams when looking for a resident. Record review of the facility training provided on 11/18/2025 read in part . Topic: Elopement Prevention. Staff in-serviced and verified 11/20/2025 residents are assessed by nursing to identify the risk for elopement . Wandering can indicate an unmet need. Interventions to redirect wandering include Toileting; Offering Food/Drink; Reduce Physical Discomfort (pain, toileting etc.). Residents can go into courtyards. If additional staff are needed to redirect residents, stay with the residents, stay with the resident, and call for help (charge nurse, Adon, Don, Administrator). Record review of the facility training provided on 11/19/2025 read in part. Topic: Resident sign out. Staff in-serviced and verified on 11/20/2025; the sign-out book will be located at the reception desk if present. When the receptionist leaves for the day, the sign-out book will be moved to Station 1 . All residents leaving the building are required to sign out. Record review of the facility training provided on 11/19/2025 read in part. Topic: Exit Doors. Staff in-serviced and verified on 11/20/2025 all exit doors have a 15 second delay-alarm will sound, and the door will open . Staff must respond to all alarms. Identify if a resident has exited, staff must stay with the residents and call for additional assistance. Record review of the facility training provided on 11/19/2025 read in part . Topic: Elopement Response. Staff in-serviced and verified 11/20/2025 all staff must notify the charge nurse as soon as possible of a resident missing or attempting to leave. If a resident is attempting to leave, try to redirect them. If a resident is suspected of being missing, the charge nurse will attempt to find out if a resident has signed out on a pass; it not on a pass, a search of the building and the premises will be initiated. The charge nurse will notify the Administrator, the DON, the primary care provider, and the responsible party. The facility has an elopement risk binder at each nurse's station and at the front desk. This information can be used to assist search teams when looking for a resident. Record review of the facility training provided on 11/19/2025 read in part . Topic: Elopement Prevention. Staff in-serviced and verified 11/20/2025 residents are assessed by nursing to identify the risk for elopement . Wandering can indicate an unmet need. Interventions to redirect wandering include Toileting; Offering Food/Drink; Reduce Physical Discomfort (pain, toileting etc.). Residents can go into courtyards. If additional staff are needed to redirect residents, stay with the residents, stay with the resident, and call for help (Charge Nurse, ADON, DON, Administrator). Record review of Monitoring Plan of Removal revealed signatures of meeting, which included Interim Administrator, DON, ADON, Medical Director, Social Services, Dietary, Activity Director, Regional Corporate Compliance Nurse, an unknown other: An Ad-hoc meeting held on 11/18/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan for removal. During an interview on 11/19/2025 with Interim ADM, DON, Traveling Corporate DON, ADON, SW, Maintenance Supervisor revealed staff in-person and or by telephone were in-serviced. Regional Corporate Compliance Nurse said if the employee or prn was not in serviced that staff employee cannot work their shift until all in-services were completed. During an interview on 11/19/2025 between 12:50 pm and 4:00pm with ADON, RN's ,B, E; Certified Occupational Therapy Assistant, 4-CMA's, D,F,G,H; 18-CNA's, I,J,K,L,M,N,O,P,Q,R,S,T,U,V,W,X,Y,Z; 2-Dietary Staff's, A, AA; 2-Facility Marketing Admission's, BB, CC; 1-Facility Director of Nursing, Laundry staff, LVN Charge Nurse's, DD, EE, FF, GG, HH, Social Worker indicated that employees had received training on elopement prevention and the steps to follow when a resident attempts to leave the building. Staff consistently reported that all exterior doors are equipped with a 15-second delayed-egress system that triggers an alarm when engaged. Staff stated they are expected to investigate all alarms immediately. Staff described their responsibilities when a resident approaches or exits through a monitored door. They stated they are to remain with the resident, attempt redirection when appropriate, and contact the charge nurse for assistance. Staff explained that if a resident cannot be located, nursing leadership initiates a search and determines whether the resident had signed out or otherwise been approved to leave the facility. Staff reported that the administrative staff, the DON/ADON, the residents' provider, and the responsible party are notified according to facility protocol. Staff also noted the presence of an Elopement Risk Binder at each nurse's station and the front desk. They stated this resource contains relevant information to support staff during search efforts. The staff in-services revealed interventions such as toileting, offering fluids or snacks, and addressing comfort to redirect residents. Staff stated if additional help is needed, they contact the nurse charge or nursing administration. The information provided was consistent with staff and aligned with the facility's in-service training conducted November 18, 2025, and November 19, 2025. The Regional Corporate Compliance Nurse, DON, Interim Administrator, Traveling DON, ADON were informed the immediate jeopardy was removed. While the IJ was removed on 11/19/25 at 4:33 pm. The facility remained out of compliance with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (Resident #2) reviewed for pain. -The facility failed to ensure that pain management was provided for Resident #2, who was crying in pain, during the treatment of her 14 individual wounds. -The facility failed to assess Resident #2 accurately and appropriately, for pain prior to Resident #2 receiving wound care treatments for 14 separate wounds. -The facility failed to provide timely medication interventions for Resident #2's pain management for daily wound care treatments of her 14 individual wounds. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 6:39 PM. While the Immediacy was removed on 10/19/2025 at 5:44 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures placed residents at risk of increased or unmanaged pain and actual harm. Findings Include: Resident #2 Record review of Resident #2's admission Record dated 10/22/2025 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. Record review of Section V of the MDS related to Resident #2's Care Area Assessment Summary (CAA) had no care area triggers for pain and had no care planning decision made for pain. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed no care plan for pain. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed she had the following as needed (prn) orders for pain: Acetaminophen 650 mg tablet Q 6 hours prn mild pain. Acetaminophen 650 mg tablet Q 6 hours prn pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM. Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours prn for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 PM. Record review of Resident #2's facility Order Recap dated September 2025 revealed an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. Continued record review revealed the order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's Medication Administration Record (MAR) dated September 1, 2025, through September 30,2025 revealed Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident #2's MAR dated October 1, 2025, through October 31, 2025, revealed the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. Observation and interview on 10/10/2025 at 4:59 PM with ADON A and DON of wound care performed on Resident #2. ADON A was assisted by MA E. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said yes about 30-40 minutes ago. When asked how she assessed Resident #2 for pain, ADON A said she used the PAINAD facial expression tool. The wound care treatments began with Resident #2's lower extremities. During the observation, the DON came to the bedside to also observe Resident #2's wounds for the first time since her admission on [DATE]. ADON A began removing the cling gauze wrap from Resident #2's left and right lower extremities by using wound care scissors to cut away at the tightly wrapped bandages. Resident #2 was observed by both surveyor at the bedside, wincing repeatedly each time the bandage was moved or cut which prompted this surveyor to ask ADON A if she ever used any saline or solution to moisten and loosen the adhered bandages so as to ease in the removal of the bandages so there would be less pulling, ripping or tugging at Resident #2's delicate skin. ADON A replied quickly and stated, oh yes and then began spraying a liquid solution onto the adhered bandages while still cutting. There was some brownish drainage, skin and mucous like debris observed on the inside of the bandages as ADON A continued to peel, tear, and cut the bandages away from Resident #2's right lower leg and foot. Resident #2 began to inhale and exhale deeply and became tearful, with tears brimming in her eyes. ADON A had her back to Resident #2's face and appeared focused on her wound care task, while MA A tried to speak to Resident #2 softly and reassure her, however, neither staff member stopped the procedure to reassess Resident #2 for pain. Surveyor stopped ADON A and asked what pain medication Resident #2 had been given prior to the procedure and ADON A replied Tylenol, to which surveyor replied, regular strength, to which ADON A replied, extra strength. Both surveyors requested wound care treatment be stopped immediately and DON also said they would stop the treatment, notify the physician, and get an order for a different and or stronger pain medication. Record review post observation revealed Resident #2 had received no Tylenol regular or extra strength on 10/09/2025 or 10/10/2025. Continued record review of Resident #2's MAR dated October 1, 2025, through October 31, 2025, revealed the following orders: Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet via G-Tube every 6 hours as needed for pain. Continued record review of Resident #2's, physician orders and MARs for the months of September 2025 and October 2025, revealed she had no other pain medication ordered and had not received any pain medication from her admission on [DATE] through 10/10/2025. Interview on 10/10/2025 at 5:26 pm with facility Administrator who was advised of the wound care observation of Resident #2 and the major concerns regarding the lack of any pain management for Resident #2 since her facility admission on [DATE]. The Administrator said the concerns were clinical concerns and she would have to speak with the DON to gather more information on the situation. The Administrator said she had no dealings with and did not handle anything to do with the clinical side of things, such as medication, pain management, or wound care because she was not a clinician. The Administrator said the responsibility for those things would be for the DON and she would need to follow up with the DON to determine what happened. Telephone interview on 10/10/2025 at 5:33 pm with Wound Care Doctor A who said he was notified on 10/02/2025 of Resident #2's admission and need for a wound care consultation. Wound Care Doctor A said the first time he examined or assessed Resident #2 was on 10/02/2025 and from what he could remember, she admitted with multiple extensive wounds, including her sacrum and buttocks and her toes were at risk of auto (self) amputation. Wound Care Doctor A said he did not ever see any evidence of Resident #2 being in pain during his assessments or treatments of her multiple wounds. Wound Care Doctor A said he had not prescribed anything for Resident #2's pain because he had not ever witnessed any signs or symptoms of her being in pain and had not been notified by staff that the resident ever had signs or symptoms of pain. Wound Care Doctor A said that in most instances he would defer to the resident's attending physician for any pain medication orders. When asked if he thought a person with 14 wounds could have pain, he said pain was subjective and he would not speculate. Record review of Wound Care Doctor A's progress note dated 10/2/25 for the initial assessment and treatment of Resident #2's wounds revealed the following 14 wound sites: Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon, or bone) . Site 2; Unstageable (Due to necrosis (cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function) Right, Lateral Ankle Full Thickness. Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Site 4; Arterial Wound of the Right Second Toe Full Thickness. Site 5; Arterial Wound of the Right Third Toe Full Thickness. Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Site 8; Arterial Wound of the Left Second Toe Full Thickness. Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Interview with DON on 10/11/2025 at 10:00am who said she was unaware of any issues with Resident #2's pain medication or lack of receiving pain medication for wound care. The DON said they had followed up on 10/10/205 after the observation and spoke with Resident #2's doctor and Resident #2 had a scheduled and prn order for Acetaminophen and had only prescribed Acetaminophen because she could not take NSAIDS (Non-Steroidal Anti-Inflammatory Drug) because of her hemodialysis status and history of end stage renal disease, as these drugs can cause severe kidney damage and dangerous complications. The DON said Resident #2 should have been medicated for pain prior to the treatment procedure and did not know why or how her pain management had been missed all this time. The DON said it was the responsibility of the clinical team to ensure residents are managed properly for pain. The DON said she was part of the clinical team and was partially responsible for ensuring residents had effective pain management. The DON said she was unsure if Resident #2 had been care planned for pain but said she should be. Interview on 10/11/2025 at 10:12 am with ADON A who said she believed Resident #2 had received pain medication prior to both wound care observation on 10/09/2025 and 10/10/2025. ADON A said that there was no pain medications listed for her to administer prior to wound care and only her treatments populated in the computer system for her to document on. ADON A said she was under the impression that LVN C and LVN D had premedicated Resident #2 on both 10/09/2025 and on 10/10/2025 because she told them she was going to perform wound care. When asked where the PAINAD assessments for Resident #2 could be located in the electronic medical record, ADON A said that she had looked for one and could not locate the assessment template in the facility's computerized system. ADON A said she assessed Resident #2 visually for PAINAD signs and symptoms of pain but never actually documented on an assessment form, and 10/10/2025 was the first time she ever saw Resident #2 react in pain to wound care treatments she provided. ADON A said Resident #2 should have been medicated for pain because she had a lot of wounds that could potentially be painful. ADON A said she was unsure if Resident #2 had been care planned for pain. Interview with LVN D on 10/11/2025 at 3:15 pm regarding pain medication administration for Resident #2 prior to wound care on 10/10/2025. LVN D said ADON A never asked him to premedicate Resident #2 prior to wound care. LVN D said he had never given Resident #2 any pain medication since her admission on [DATE] during his shifts. LVN D said Resident #2 only received medication from licensed nurses because of her gastrostomy tube status. LVN D said that Resident #2 never indicated she was in any pain when he provided care and that no CNA or MA staff had ever reported to him that Resident #2 was in pain. LVN D said he was unsure if Resident #2 always had pain medications ordered before, but he was sure she had orders for scheduled and prn pain medications now. LVN D said he used the PAINAD facial expression pain scale to assess Resident #2 because she was non-verbal but said he could not tell surveyor how to locate a copy of the form in the electronic medical record. Interview with LVN C on 10/13/2025 at 2:15pm regarding pain medication for Resident #2 on 10/09/2025. LVN C said she was never asked by ADON A to give Resident #2 any pain medication and had not given Resident #2 any pain medication. LVN C said Resident #2 received all her medication through her gastrostomy tube, so only the charge nurses could give pain medication. LVN C said she never observed Resident #2 having any signs or symptoms of pain but if she did, she should be medicated. LVN C said she was unsure if Resident #2 was care planned for pain. LVN C said Resident #2 had new orders for pain medications now and was unsure what the orders had been previously. LVN C said they assessed Resident #2 using a facial expression pain scale and said the assessment tool pops up in the MAR just prior to any pain medication administration but did not know how to print out the assessment tool or access it outside of the medication administration times. LVN C said the only time she had seen the tool was right before a pain medication would be given. Interview with Medical Director on 10/13/2025 at 4:00pm who said she was the attending physician for Resident #2. The Medical Director said they were contacted by the facility late Friday 10/10/2025 and Resident #2 was reassessed for pain, and she gave a new order for the Tylenol to be scheduled every 8 hours instead of just prn. The Medical Director said they conducted a virtual visit with Resident #2 on Saturday 10/11/2025 and asked the male charge nurse about the assessment. The Medical Director said initially she would only prescribe Tylenol because of Resident #2's hemodialysis dependence and potential risk of medication not being processed or excreted properly. The Medical Director said she ordered a very small trial dose of an opioid analgesic Tramadol but was starting the resident on 1/2 of the 25 mg dose for a dose of 12.5 mg so the resident could be watched and reassessed properly. When asked if she thought Resident # 2 should have had stronger and or scheduled pain medication for the daily wound care treatments, of her 14 separate wounds, the Medical Director said pain was subjective and she would not speculate, but staff should have been assessing and evaluating the resident for pain. The Medical Director said no one had notified her prior to 10/10/2025 that Resident #2 had any signs or symptoms of pain and that once she was notified Resident #2 was evaluated/re-evaluated and additional pain management interventions were ordered and implemented. Record review of facility policy procedure titled Pain Management, Assessment Scale revealed in part: Policy Complaints of pain will be assessed accordingly by the nurse and effectively managed through. prescribed medications, and comfort measures, and all available resources of the facility. Goals 5. Cognitively impaired residents will demonstrate actions of pain relief. Complaints of pain will be assessed accordingly by the nurse and effectively managed through. prescribed medications, and comfort measures, and all available resources of the facility. Procedure 1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability were included in the Admission/readmission and Weekly Nursing Summary. If a resident is non-verbal, the questions will be a PAINAD assessment. There is no QM criteria for a resident who is non-verbal. If a resident scores 7-10 on the PAINAD scale, then a (sic)PAIND SBAR will be triggered. It is directed toward residents who are non-verbal or cannot communicate. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 6:39 pm. The following Plan of Removal (POR) submitted by the facility was accepted on 10/12/2025 at 1:08 p.m. The plan of removal reflected the following: Facility Name: Date: October 12th, 2025 IJ Component: F697: Quality of care: Pain Management Facility failed to ensure that pain management was provided for Resident #2. During an observation of Resident #2's wound care on 10/10/25, Resident #2 was observed exhibiting signs/symptoms of pain. Immediate Actions: The treatment where the resident was experiencing pain on 10/10/2025 was stopped until adequate pain relief could be achieved. Primary care provider was contacted by the director of nurses on 10/11/2025 and Tylenol order changed to Extra Strength 650 mg every 8 hours scheduled and an additional dose 30 minutes prior to wound care. The Primary care provider stated that the resident was not eligible for narcotic pain relief due to renal failure. Facility Plan to ensure compliance: 100% review of residents receiving wound care for PRN pain medication orders that may be given 30 minutes prior to wound care was completed on 10/11/2025 by Regional Compliance nurse/DON/Designee. 12 of 13 residents identified requiring wound care received new orders/order clarifications to ensure adequate pain management prior to wound care from audit completed 10/11/25. 1 resident identified in the audit has an allergy to acetaminophen. Care plans for 13 of 13 facility residents with wounds were updated on 10/12/25 by Regional Compliance Nurse and DON with interventions to monitor, assess, and report pain during care, including wound care, and what to do if pain management is not effective. Regional Compliance Nurse provided in-service to DON/ADON on 10/11/2025 regarding: Pain management during care and procedures following facility's policy for enforcement, requiring no change in company policy as the policy was effective but not being followed. Communication with medical provider for any resident that is experiencing uncontrolled pain during care and/or procedures using the SBAR as communication tool. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/11/25 regarding pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. Goal for completion of this education to be completed by end of day on 10/12/25. All nurses (LVN/RNs), including PRN nurses, who are not in serviced by 10/12/25 will not be allowed to provide resident care until training has been completed. 6. The Medical Director was notified by the Administrator on 10/11/25 at 7:51pm regarding the immediate jeopardy citation. 7. An Ad-hoc QAPI meeting was held on 10/12/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will observe wound care, Mon-Fri, x 4 weeks to ensure any residents that is receiving wound care receive effective pain management during the procedure. DON/Designee will review order listing report in point click care (facility electronic medical record) daily, Mon-Fri x4 weeks to see any new wound care orders and ensure that pain management orders are in place. The Plan of Removal was confirmed for the IJ by monitoring from 10/11/2025 through 10/19/2025 as follows: On 10/10/2025 at 4:59 p.m., request was made with the DON to review the pain management and orders for Resident #2. On 10/10/2025 at 5:26 p.m., a request was made with the Administrator to review the pain management for Resident #2. The Administrator said she was not clinical and would have to discuss with the DON. During an interview with DON at 10:00 a.m. on 10/11/2025 she said she was unaware that Resident #2 had no correct orders for pain medications and had not received pain medication prior to daily wound care treatments until the shared observation of wound care on 10/10/2025. During an interview with ADON A at 10:12 am on 10/11/2025 she said she was under the impression that Resident #2 had received pain medication prior to wound care on 10/9/25 and 10/10/2025 because she had told the charge nurses to give it. ADON A could not articulate or show examples of PAINAD assessment tool she used to assess Resident #2 for pain on 10/09/2025 or 10/10/2025 and clarified that she was not the one administering pain medications. Interviews with LVN D on 10/11/2025 at 3:15 pm he said he never observed Resident #2 in pain and that ADON A had not asked him to medicate Resident #2 prior to wound care or at any other time. LVN D said he had never administered pain medication to Resident #2. In an interview on 10/12/2025 with licensed nurses who work the 6:00am-2:00pm, at 2:03 p.m., who were all knowledgeable of the step-by-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. Treatment Nurse A, ADON A, LVN B and LVN D said that for verbal residents they can assess pain on a scale of 1-10 and for non-verbal residents they can assess pain using a PAINAD scale for facial expressions. All licensed nurses gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that they should evaluate for any pain signs or symptoms prior to, during and after a procedure or treatment. All licensed staff at that time said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, they would initiate SBAR for pain and notify the MD and RP for the resident. On 10/12/2025 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the pain medication orders for Resident #2 as she had not received her pain medication as ordered that day. In an interview on 10/13/2025 at 3:18 pm with licensed nurses who worked the 2:00pm-10:00pm shift, who were all knowledgeable of the step-by-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. LVN C and LVN G said that for verbal residents they can assess pain on a scale of 1-10 and for non-verbal residents they can assess pain using a PAINAD scale for facial expressions. All licensed nurses gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that they should evaluate for any pain signs or symptoms prior to, during and after a procedure or treatment. All licensed staff at that time said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, they would initiate SBAR for pain and notify the MD and RP for the resident. In an interview on 10/13/2025 at 4:00 PM the Medical Director, who said that she was notified about the IJ being called, and she had been included on the POR. She said that all treatments and care should have orders, should be documented, and standard. On 10/13/25 at 5:07pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. In an interview on 10/14/2025 at 2:13 pm with MDS Coordinator, who said that she worked full time Monday through Friday on the day shift. She said she was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. On 10/14/25 at 6:56 pm a request was made with the Administrator, DON, Corporate and Regional staff requested staff list, wound care list and medication orders status post wound care doctor B's visit on 10/13/25, no MAR to support pain medication audits. Still pending facility audit of Resident #2's transfer to the hospital on [DATE]. In an interview on 10/15/2025 at 6pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. On 10/15/2025 at 4:44pm a request was made with the Administrator, DON, Corporate and Regional staff to review enteral feeding orders and medication orders for Resident #34 who was a new admission to the facility on [DATE]. Observations on 10/16/2025 at 6:00 a.m.- 2:00 p.m. shift of 3 out of 5 residents for wound care, Resident #11, Resident #12, and Resident #20 who did not have adequate pain management prior to or during the wound observations and wound care treatments needed to be stopped.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 4 residents (Resident #2). The facility to ensure that Resident #2 received hemodialysis as ordered on 10/03/2025, which resulted in her not receiving any hemodialysis for a total of four days. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 PM. While the Immediacy was removed on 10/16/2025 at 7:43 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure placed residents at risk for delayed treatments, and actual harm. Findings Include: Resident #2 Record review of Resident #2's admission Record dated 10/22/25 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section I for an active diagnosis of Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD). Record review of Section O of the MDS for Special Treatments, Procedures, and Programs was coded for Dialysis while a resident. Record review of Resident #2's comprehensive care plan review with a last care plan review completed date of 10/06/2025 revealed in part: .Focus.Resident #2 needs hemodialysis MWF r/t renal failure.Goal.The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date.Target Date: 10/12/2025.Interventions/Tasks.obtain vital signs and weight per protocol. Report significant changes in pulse, respiration, and B/P immediately. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed the following entry: Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2pm so she can be admitted to the facility.Tomorrow will be her dialysis today and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning. [sic] Continued record review revealed Resident #2 had a Dialysis Central Line Catheter Tunneled Right Subclavian dialysis access site. (A long flexible, hollow tube that is inserted into the large subclavian vein (a large deep vein located on each side of the body) beneath the right collar bone and then tunneled under the skin to an exit port, typically on the chest wall). Record review of Resident #2's progress note dated 10/03/2025 and created by RN A at 6:27 am revealed the following entry: .Observed in bed resting comfortably this morning. Vital signs are Temp:97.6, RR: 20, Pulse 106, B/P: 126/66, POX % is 98% on room air. No distress noted. NP A [sic]notified this morning about the situation/and the change. Resident RP. was called and notified also. Continued record review at the bottom of the entry for .Show on Shift Report, show on 24 Hour Report, Show on MD/Nursing Communication Report were unchecked and remained blank. Record review on 10/09/2025 at 11:48am of Resident #2's progress notes revealed she received in-house hemodialysis as prescribed on 10/01/2025.Record review on 10/09/2025 at 11:55 am of Resident #2's SBAR by RN A dated 10/03/2025 at 5:27 am revealed the following: I am contacting you about the following (select all that apply) .5. Cardiovascular change.14. Other.Pulse 123.5c. Describe symptoms or sign Increased pulse rate of 112.14. Other N/A.R. Request .1. I suggest or request (Check all that apply) .Monitor vital signs (box checked) .5. Provide visit (MD/NP/PA) (box was checked) .3. Date and time MD or NP notified 10/03/2025 05:50 am.1. Follow-up Orders.1. Note any new orders from the MD or NP.Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100. The document was signed and completed by RN A on 10/09/2025. Telephone interview on 10/10/2025 at 10:05 am with RN A who worked overnight shift 10 pm to 6 am and was the charge nurse assigned to Resident #2 the morning of 10/03/2025. RN A said she notified NP A that Resident #2 had not received her hemodialysis on that Friday, 10/3/25, because her HR was too high. RN A said NP A gave an order to re-evaluate Resident #2's vital signs and heart rate within an hour and call him back. When asked if RN A re-evaluated Resident #2's heart rate and called NP A back as ordered, she said it was at the end of her shift. When asked if she followed NP A's order, she said she did retake Resident #2's heart rate but it remained high, so she sent a text to NP A to notify him that Resident #2's HR remained elevated, but she did not recall if NP A ever responded or if she received any orders to administer medications to Resident #2. When asked about the Metoprolol order she documented in Resident #2's SBAR, Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100. RN A said she never administered any medication to Resident #2 because it was the end of her shift and that the Hemodialysis nurse was the one who gave Resident #2 Metoprolol prior to sending her back to the unit without dialysis. When asked if RN A could send surveyor a copy of the text message she sent to NP A, RN A said she would have to look for it. RN A again, said that she could not recall if NP A ever replied and when asked why she documented in Resident #2's SBAR dated 10/3/25 that she had spoken with NP A and received orders for medication Metoprolol, RN A did not reply or respond, she just repeated that this all happened at the end of her 10pm-6am shift and she gave report to the on-coming nurse about Resident #2's elevated HR and missed dialysis. RN A said she could not recall if she specifically asked NP A about any orders for Resident #2 to receive dialysis or an alternate intervention, RN A said she did not remember which nurse she gave report to about Resident #2 not receiving Dialysis and could not recall if she placed any of that information on the facility 24 hour communication report. RN A said she either told ADON A or LVN D about the missed dialysis and elevated HR, but she was unsure. Record review of facility 24 Hour report dated 10/03/2025 on 10/09/2025 at 3:44pm revealed no documentation of note from RN A about Resident #2's missed dialysis or change in condition/SBAR and under the Weights and Vitals section if the entry Pulse read None entered. Record review on 10/09/2025 at 2:47 pm of Resident #2's MAR dated October 1,2025 through 10/31/2025, revealed Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100, was not administered by any facility staff on 10/03/2025. Interview with DON on 10/09/2025 at 2:50 pm she said she was unaware that Resident #2 had not received dialysis on 10/03/2025. When asked if she should have known that Resident #2 had not received dialysis on 10/03/2025 the DON said that normally if a dialysis session was missed the resident would make it up on the next dialysis day. The DON said that normally the dialysis MD would order and have dialysis staff/nurse administer any medications for any altered vital signs. The DON said that there should be a clinical review each business day to address any new concerns, change in conditions, 24-hour reports, and speaking with direct care staff to ensure that residents with orders for hemodialysis receive treatments. She said that she was not aware that there were any concerns with Resident#2's receiving hemodialysis. She said that a nurse should notify a physician if a resident does not complete hemodialysis so that the physician can give interventions. The DON said Resident #2's dialysis MD would normally agree to have any IV meds administered through the dialysis port/shunt or site to save resident vasculature meaning only one access site in case of dialysis shunt failure or if the shunt site needed to be changed. Using only the dialysis shunt site would allow for a resident to have multiple sites in their arms/hands etc. The DON said she would have to look into why Resident #2 did not have any dialysis from Wed 10/01/2025 until Monday 10/06/2025. The DON said the last QAPI was last Thursday, and the facility had monthly QAPI's and weekly SOC's, (standards of care). The DON said she could not recall if she reviewed Resident #2's clinical hospital records prior to her admission but that was part of the admission process, so she most likely did. The DON said she could not recall if they discussed Resident #2 in any morning stand up or weekly SOC but since Resident #2 was admitted on [DATE] they would not have discussed any issues regarding the resident yet for QAPI. The DON said they would most likely discuss Resident #2 in this week's SOC meeting. Brief interview with ADON A on 10/10/2025 at 2:00 pm who said she did not recall speaking with RN A specifically about any orders or missed dialysis interventions for Resident #2 on that day. ADON A said she did recall discussing the resident's elevated heart rate and missed dialysis session after the fact. Interview with LVN D on 10/10/2025 at 2:13pm who said he had no memory of RN A speaking to him about Resident #2 and any missed dialysis or elevated heart rate. LVN D said he heard something about the situation later but never spoke directly with RN A or NP A about getting orders for missed dialysis intervention. Interview on 10/10/2025 at 9:38 am with Hemodialysis Nurse who said she recalled and was familiar with Resident #2. Hemodialysis Nurse said she remembered Resident #2 having a change in condition during one of her dialysis sessions and not being able to receive hemodialysis that day because of an elevated HR around 120 beats per min. The Hemodialysis nurse said that Resident #2 had an early chair time of around 4-5am and that Resident #2 was on a MWF dialysis schedule. The Hemodialysis nurse said that on 10/03/2025 Resident #2 could not get dialysis because of an elevated HR in the 120's and she called Nephrologist for orders and intervention. The Hemodialysis Nurse said she tried various interventions, including medication Metoprolol, as ordered, to get Resident #2's HR down so she could safely receive dialysis, but the interventions were unsuccessful. The Hemodialysis Nurse said she had to refer Resident #2 back to her charge nurse around 5 am because her HR remained outside of the safety parameters for her to receive dialysis. The Hemodialysis nurse said that she communicated with Resident #2's charge nurse about the medication Metoprolol that had been given to Resident #2, while she was in dialysis, per Nephrologist's order. The Hemodialysis nurse said it was not recommended for residents/patients to miss dialysis. The Hemodialysis Nurse said she would have definitely communicated the missed dialysis treatment to Resident #2's attending MD/NP because usually the doctor would send the resident to the hospital to receive dialysis, so they did not miss a treatment. The Hemodialysis nurse said she only found out that Resident #2 never went to the hospital after the fact on the following Monday, 10/06/2025, and was concerned that Resident #2 had not received dialysis for 4 days. In an interview with NP B on 10/10/2025 at 10:25 am who said he was not at work on 10/03/2025 and was not notified that Resident #2 had not received her dialysis. NP B said that the physician should be notified so they could give an order if a resident had a change in condition or anything that could affect a resident not receiving dialysis. NP B said that usually if a resident misses dialysis they wound be sent to the hospital to receive dialysis. Telephone interview with NP A on 10/10/25 at 11:33 am said he was covering NP B for one week, from 09/29/20255 through 10/03/2025, and he came to see Resident #2 on 10/01/2025 within 24 hours of her facility admission. NP A said he was notified on 10/3/25 that Resident #2 had an elevated heart rate while at dialysis and that they were unable to continue dialysis that day. NP A said he called the facility three times to provide orders but there was no answer. NP A said when he finally reached a nurse, the nurse said that an order was given to treat Resident #2's elevated heart rate, by another doctor. NP A said he was never asked what to do about Resident #2's incomplete dialysis and was under the impression the dialysis doctor/nephrologist should have made the decision of what to do if a resident did not receive dialysis. NP A said he would not speculate on if Resident #2 could or would have been sent to the hospital for dialysis, but he would expect staff to follow all orders regarding residents' treatments, medication, and care. When NP A was asked if he thought Resident #2 not receiving dialysis for four days was a concern or risk to the resident, NP A said he would not speculate about any potential risk to the resident. Attempts to contact and interview Nephrologist on 10/10/2025 at 4:13pm and on 10/11/2025 at 11:33am were unsuccessful. Record review of facility policy titled Dialysis and dated as revised November 2013 revealed in part: Dialysis is a process used to remove fluid and waste products from the body when the kidneys are unable to do so because of impaired function or when toxins or poisons must be removed immediately to prevent permanent or life-threatening damage. The purposes of dialysis are to maintain the life and well-being of the patient until kidney function is restored and to remove unwanted substances from the blood if renal function does not return. Methods of therapy include hemodialysis, hemofiltration, and peritoneal dialysis. 13. The medication regimen will be assessed by the physician and the pharmacist. When the resident is dialyzed, drug administration times may need to be changed to coincide with the dialysis schedule to prevent their removal. Medication review will be ongoing. Record review of undated facility policy titled Notifying the Physician of Change in Status, revealed in part: 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions. If the resident remains in the facility and a significant change has occurred, update the care plan accordingly. This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:14 pm. A plan of removal was requested. The following Plan of Removal (POR) submitted by the facility was accepted on 10/11/2025 at 2:39 p.m. The plan of removal reflected the following: Facility Name: Date: October 11, 2025 IJ Component: F698: Quality of care: Hemodialysis Facility failed to ensure resident #2 received hemodialysis on 10/3/25. Immediate Actions: SBAR/Change of condition assessment completed on 10/10/25 with notification of provider and responsible party. No new orders were obtained for Resident #2. Hemodialysis was resumed on next scheduled day (10/06/25) with no missed treatments since 10/06/25. Facility Plan to ensure compliance: 1. 100% review of all facility residents receiving dialysis completed by DON, ADON, and Regional Compliance Nurse on 10/10/25 to identify any other residents receiving dialysis treatments. 3 additional residents identified as receiving dialysis services. 2. 100% assessment of all facility residents ordered to receive hemodialysis treatments were audited on 10/10/25 to ensure no other residents missed hemodialysis treatments. One resident identified as unable to fully complete the session on 10/10/25, charge nurse completed SBAR and notification to MD with new monitoring orders obtained. 3. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 10/10/2025 regarding a. Change of Condition: When to Report to MD/NP/PA and follow-up communication b. Abuse/Neglect c. Dialysis: Facility's dialysis policy in-serviced for enforcement. (No revision of policy needed as policy is effective but was not being followed). 4. DON/ADON will in-service facility staff by phone and/or in person starting 10/10/2025 regarding facility policy on Abuse/Neglect. Goal for completion of this education to be completed by end of day on 10/11/25. Facility staff, including PRN staff, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/10/25 regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 6. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 10/10/25 regarding facility's dialysis policy. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 7. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). 8. The Medical Director was notified by Administrator on 10/10/25 at 8:50pm regarding the immediate jeopardy citation. 10. An Ad-hoc QAPI meeting was held on 10/10/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will monitor changes of condition x 4 weeks to ensure changes of condition have been reported to the MD and followed up. DON/Designee will monitor Dialysis residents x 4 weeks to ensure that residents did not miss any dialysis or had any incomplete dialysis session, if dialysis sessions were missed or incomplete that an SBAR was completed, and was the resident monitored. The Plan of Removal was confirmed for the IJ by monitoring from 10/12/2025 through 10/16/2025 as follows: On 10/10/2025 at 7:30 p.m., request was made with the Administrator and DON to review the dialysis communication sheet, progress note and SBAR for Resident #2 regarding her missed dialysis treatment on 10/03/2025. In an interview on 10/12/2025 with licensed nurses who worked 6:00am-2:00pm, at 2:03 p.m., Treatment Nurse A, ADON A, LVN A, LVN B, LVN C, LVN D, LVN E, LVN G, and RN B who were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate numerous examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. They were all able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). On 10/12/25 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the audits as there was no updated information to review for F798 related to Dialysis residents from Friday because their POR only indicated audits would be conducted Monday through Friday. In an interview on 10/13/2025 at 3:18 pm with licensed nurses who worked the 2:00pm-10:00pm shift, who were all knowledgeable of the step-by-step process using the SBAR as a communication tool and the facility's dialysis policy and when and how to utilize the skilled nurse's notes, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). RN B, Treatment Nurse and ADON A said they were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate various examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. In an interview on 10/13/2025 at 4:00 PM the Medical Director said that she was notified about the IJ being called, and she had been included on the POR. She said that all treatments and care should have orders, should be documented, and standard. The Medical Director said that all residents who receive dialysis should have orders, and the orders should be followed. She said that the physician should be notified if or when a resident did not receive hemodialysis as ordered. On 10/13/25 at 5:07pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. Resident #2's dialysis sheet was incorrect. In an interview on 10/14/2025 at 2:13 pm with MDS Coordinator, who said that she worked full time Monday through Friday on the day shift. She said she was able to articulate the step-to-step process for using the SBAR as a communication tool. She gave multiple examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. She was able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. She was able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). On 10/14/25 at 6:56 pm a request was made with the Administrator, DON, Corporate and Regional staff requested staff list, wound care list and medication orders status post wound care doctor, no MAR to support pain medication audits. Still pending facility audit of Resident #2's transfer to the hospital on [DATE]. Dialysis and other documentation remained incomplete. In an interview on 10/15/2025 at 6pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for using the SBAR as a communication tool. She gave multiple examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. She gave multiple examples of neglect that included isolating a resident or not changing or feeding them. She was able to explain what a change in condition was and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. She was able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). The Administrator was informed that the immediacy was removed on 10/16/2025 at 7:43 p.m. The facility remained out of compliance at a scope of pattern at a severity level of no actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #2) - The facility failed to administer Resident#2's IV antibiotic as ordered from her admission on [DATE]-[DATE]. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 pm. While the Immediacy was removed on 10/19/2025 at 5:44 pm, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure had the potential to place residents at risk for delayed treatment, and worsening infections which can lead to actual harm. Resident #2 was admitted to the hospital with critically elevated white blood cell count, sepsis and had an above the knee amputation of both of her legs. Findings Included: Resident #2 Record review of Resident #2's admission Record dated 10/22/25 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. In Section N of the MDS for Medications she was coded as having received antibiotics within the last 7 days. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed in part: Focus.Resident #2 is on antibiotic therapy r/t sepsis, r/t wounds, UTI and aspiration PNA.Goal.The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Target Date: 10/12/2025.Interventions.Administer medications as ordered. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed she had the following order: Piperacillin Tazobactam (Zosyn) 4.5 g in Sodium Chloride 0.9% 100 ml IVPB Dose: 4.5 g.Freq: every 12 hours.Route: IV.Indications of use: Cellulitis. Record review of Resident #2's physician order dated 9/30/25 at 7:15 pm revealed the following order: Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium Tazobactam Sodium) Use 100 gram intravenous every 12 hours for wound infection for 14 days, and was confirmed by LVN B. Record review of Resident #2's MAR dated September 1, 2025, through September 30, 2025, revealed Resident #2 did not receive Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium Tazobactam Sodium) Use 100 gram intravenous every 12 hours for wound infection for 14 days, as ordered. Continued record review revealed Resident #2 did not receive the medication on 9/30/25 and the order was discontinued on 10/01/25. Record review of Resident #2's Medication Administration Record (MAR) dated October 1, 2025, through October 31,2025 revealed the following: Zosyn Intravenous solution 4-0.5 GM/100 ML Piperacillin Sodium-Tazobactam Sodium in Dextrose (sugar water) Use 100 ml intravenously every 12 hours for Sepsis r/t E. Coli Continue until 10/16/2025.D/C Date: 10/04/2025 at 5:25pm. There was no administration of the medication documented on 10/01/25 for the 06:00 am dose or the 5:00pm dose. There was no documentation on 10/02/25 for the 06:00am dose and the 9=other/see nurse notes. was documented by RN A for the 5:00pm dose. Continued record review revealed no corresponding nurse notes. Record review of Resident #2's progress notes revealed Resident #2 had no IV access for antibiotic to be administered as ordered. Record review of ADON A's note dated 10/3/25 at 9:56 am revealed in part, Spoke with Hemodialysis Nurse this am.OK received to insert midline (a type of long IV catheter inserted into a large vein in the upper arm and is the middle ground between a standard peripheral (type of IV catheter inserted into a vein near the surface of the skin) IV and a central line) for IV ABT therapy. Continued record review of ADON A note dated 10/3/25 at 10:32 am Consent received from RP to insert midline for ABT use. Call placed to IV Company for insertion. Record review of Resident #2's progress notes dated 10/04/25 revealed LVN C documented the following: Note Text: Called Pharmacy A regarding Zosyn IV 4.5 gm which wrong dose (3.375gm) was dispensed to facility and altered dosage in resident's order by pharmacy; spoke with pharmacist on call who apologized for their mistake and confirmed the current dose of Zosyn 4.5 gm is no available in facility's pyxis to be administered. Medical Director notified, new order to administer Zosyn 3.375 gm IV every 8 hours until pharmacy delivers Zosyn 4.5gm and stop date changed to 10/19/25. Called Pharmacy A and Pharmacist notified. Record review of Resident #2's MAR dated October 1, 2025, through October 31,2025 revealed, Zosyn Intravenous Solution 3- 0.375 GM/50ML (Piperacillin Sodium-Tazobactam Sodium in Dextrose) Use 3.375 gram intravenously three times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED. administer every 8 hours until Zosyn 4.5gm delivered from pharmacy, was documented as administered to Resident #2 by LVN C on 10/04/25 at 8:00pm. Record review of Resident #2's MAR dated October 1, 2025, through October 31,2025 revealed her admission order for Zosyn Intravenous Solution 4-0.5 GM/100ML (Piperacillin Sodium Tazobactam Sodium in Dextrose) Use 100 ml intravenously every 12 hours for SEPSIS R/T E. COLI until 10/19/2025 was documented as administered to Resident #2 on 10/05/25 at 5 pm, by RN A. Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57 am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. In a telephone interview on 10/09/25 at 2:46 pm with the admitting nurse LVN A, she said she reviewed the hospital records of Resident #2 on 09/30/2025 to have orders to treat her wounds and infection. She said that she clarified the admission orders with NP A, entered the orders, and enlisted the help of other staff on duty to help enter the admission orders, but she failed to ensure that all the orders were entered before her shift ended. She said that Resident #2 was admitted with a wound infection, and was prescribed IV Zosyn to treat the infection, she called to clarify with NP A an order to administer the Zosyn through her pre-existing hemodialysis site, and NP A said that he would address the issue when he rounded on 10/01/2025. In a telephone interview on 10/09/2025 at 4:46 pm with Medical Director who was also the attending physician for Resident #2. The Medical Director said that she was not notified of any issues or concerns with Resident #2 receiving the IV antibiotic Zosyn as ordered. The Medical Director said she would not speculate what potential impact could result from Resident #2 not receiving the antibiotic as prescribed from her admission on [DATE] until the evening of 10/04/2025. The Medical Director said she would expect staff to follow physician orders and to notify them if or when there were any changes or issues. Interview with Hemodialysis Nurse on 10/10/2025 at 9:38 am who said she was familiar with Resident #2. Hemodialysis Nurse said that she had been contacted by facility nurse regarding a midline IV insertion for the resident but could not recall the date. Hemodialysis Nurse said Resident #2 admitted to the facility with a central line dialysis access port to her right chest and sometimes a facility will ask the Nephrologist if medications like antibiotics could be administered during dialysis through the dialysis port. The Hemodialysis Nurse said she was not asked to administer any antibiotic for Resident #2 through her dialysis port and was not aware that Resident #2 did not receive her antibiotics as ordered from her admission on 0 9/30/2025 until 10/04/2025. The Hemodialysis Nurse said that Resident #2 should have received her antibiotic as ordered because any infection she may have had could have gotten worse. Interview with the DON on 10/10/2025 at 10:18 am who said the admitting nurse should identify any skin issues at the time of admission, obtain orders from the primary physician for all medications and wound care and notify the acting wound care nurse to complete a second skin assessment within 24 hours. She said that there should be a clinical review of all new admissions on the next business day to ensure the accuracy of the admission process, that orders were entered and implemented, and she did not remember if there was a clinical review on 10/01/2025 for Resident #2. She said that there should be a clinical review each business day to address any new concerns or changes in conditions. The DON said that in the clinical review 24-hour reports, and direct care staff provide reports in the morning clinical stand-up meetings to help ensure continuity of resident care because they discuss medication orders, any obstacles, or delays in getting medications or orders. They discuss treatments that would include wound care and or hemodialysis treatments, to ensure residents with these orders receive the proper medications and treatments. She said that she was not aware that there were any concerns with Resident #2's wound care, IV antibiotics or dialysis and that the nurse at the time would be responsible for notifying the MD if Resident #2's IV antibiotic medication needed clarification of the strength or if the incorrect dose was delivered or if the resident had no other IV access except the dialysis port. The DON said the nurse at the time would be responsible for notifying the MD if Resident #2 had not completed hemodialysis so that the physician could give an intervention. The DON said she was not sure why that had not been done for Resident #2. The DON said she could not recall if she reviewed Resident #2's clinical records prior to her facility admission or facility electronic clinical records since admission. The DON said that she had not completed a physical assessment of Resident #2 since her admission on [DATE]. Interview at 10:25 am on 10/10/25 with NP B who said he had been out of town when Resident #2 admitted to the facility and NP A was covering for him and had seen Resident #2 the day after her admission on [DATE]. NP B said that Resident #2 was admitted with multiple wounds and was already being treated with IV antibiotics in the hospital and was positive for urine and wound with the same organism E. Coli. NP B said he was unaware of Resident #2 not receiving IV Abt Zosyn as ordered and would not speak to why it was or was not started from admission on [DATE]. NP B said today was the first day he saw Resident #2 and his expectation was that if a resident discharged from a hospital on medications, those medications would be continued as ordered. When asked what could happen if a resident were supposed to be on antibiotics and did not get them as ordered, NP B said the infection could get worse and he received an emergency text from the Medical Director this morning to see Resident #2. In a telephone interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident #2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records. He said that he rounded with Resident #2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia. He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day. He said that if he had been informed, he would have decided on a different treatment plan. He said that he would not speak on risk to residents, or if Resident #2 should have been sent to the hospital. He said that his expectation is that staff enter orders from the time of admission, follow orders, and make notifications to a physician when medications are not available, treatments are missing, and when there is a change in condition. Telephone interview with Wound Care Doctor A on 10/10/2025 at 5:33pm who said he had not been notified prior to 10/02/2025 of Resident #2's admission or need for a wound consultation. Wound Care Doctor A said the first time he examined/assessed Resident #2 was on 10/02/2025 and from what he could remember, she admitted with multiple extensive wounds, including her sacrum and buttocks and her toes were at risk of auto (self) amputation. Wound Care Doctor A said he did not know that the orders he wrote for recommended treatments for Resident #2 had not been implemented by facility staff until 10/04/2025. Wound Care Doctor A said that while he did not see or notice any indication of infection of Resident #2's wounds while he provided care, orders for treatments and any antibiotics should be followed. Wound Care Doctor A said he was not aware that Resident #2 had not received her IV antibiotic as ordered from admission. Record review of policy titled, Medication Administration and General Guidelines, with a date of 2025 read in part, Policy Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRx otherwise authorized personnel should refer to Drug Reference material provided by facility. Procedure. 2. Medications are administered in accordance with written orders of the attending physician. 6. All current medications and dosage schedules, except topicals used for treatments, are listed on the resident's medication administration record (MAR). This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:14pm. A plan of removal was requested. The following Plan of Removal (POR) submitted by the facility was accepted on 10/11/2025 at 2:27 p.m. PLAN OF REMOVAL Name of Facility: Date: October 11, 2025 IJ Component: F760: Significant Medication Errors Facility failed to administer Resident #2's IV antibiotic as ordered to treat UTI, wound sepsis, and Pneumonia from admission 9/30/25-10/5/25. Immediate Actions: SBAR/Change of condition assessment completed on 10/10/25 with notification of provider and responsible party regarding the missed IV antibiotics. Correct dosage of IV antibiotics have been obtained by facility and are being administered as ordered. Facility Plan to ensure compliance: 1. 100% audit completed of facility residents completed on 10/10/25 to identify any residents with IV antibiotics No additional residents identified as receiving IV antibiotics. 2. 100% audit completed on 10/10/25 of facility residents to identify any missed medications and/or treatments. Providers for residents identified as missing medications/treatments were notified and medication error documentation completed on 9 facility residents identified as missing medications/treatments. 3. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 10/10/2025 regarding: a. admission Process to include reconciling treatment and medication orders. b. Medication Administration policy in-serviced for enforcement (no revision of policy required, as policy is effective but not being followed). 4. DON/ADON will in-service facility staff by phone and/or in person starting 10/10/2025 regarding facility policy on Abuse/Neglect. Goal for completion of this education to be completed by end of day on 10/11/25. Facility staff, including PRN staff, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/10/25 regarding the admission Process to include reconciling treatment orders and medication orders. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 6. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 10/10/25 regarding Medication Administration. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 8. The Medical Director was notified by Administrator on 10/10/25 at 8:50pm regarding the immediate jeopardy citation. 9. An Ad-hoc QAPI meeting was held on 10/10/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will monitor admission Process daily, Mon-Fri, x 4 weeks to ensure any new admissions and readmissions had reconciled treatment and medication orders. Nursing administration designee will complete admission checklist audit to ensure medication reconciliation has been double checked from what was ordered versus what the facility staff enters into (EMR) the facility's electronic record. DON/Designee will monitor Medication & Treatment Administration Records daily, Mon-Fri x 4 weeks to ensure all medications & treatments were signed out, administered, and available by utilizing the Missed Med Report during morning clinical meeting. The Plan of Removal was confirmed for the IJ by monitoring from 10/11/2025 through 10/19/2025 as follows: Interview on 10/10/2025 at 4:00 p.m. with the Medical Director, who said that she was notified about the IJ being called, and she had been included on the POR. In an interview on 10/12/2025 with licensed nurses who worked 6:00am-2:00pm, at 2:03 p.m., Treatment Nurse A, ADON A, LVN A, LVN B, LVN C, LVN D, LVN E, LVN G, and RN B who were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate numerous examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. They were all able to articulate the facility's admission Process to include reconciling treatment orders and medication orders. policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). On 10/12/2025 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the audits as there was no updated information to review F760 related to medications because their POR only indicated audits would be conducted Monday through Friday. Record review of Resident #2's progress note dated 10/13/2025 at 12:33pm and completed by ADON A read in part, 12:30-Call received from Lab with critical lab value of WBC @21.1. 12:31-Call placed to NP B and informed at this time of results. NP B stated he would call back. Waiting for return call. Record Review of Resident #2's SBAR and Transfer Summary dated 10/13/2025 and completed by ADON A, did not have details as to what the change in condition was or why Resident #2 was being transferred. Interviews on 10/13/2025 with licensed nurses at 3:18pm who worked the 2:00 pm-10:00 pm shift, who were all knowledgeable of the step-by-step process using the SBAR as a communication tool and were all able to articulate the facility's admission Process to include reconciling treatment orders and medication orders, dialysis policy and when and how to utilize the skilled nurse's notes, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). LVN A, LVN C and LVN G said they were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate various examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. In an interview on 10/13/2025 at 4:00 pm the Medical Director said that she was notified about the IJ being called, and she had been included in the POR. She said that all treatments and care should have orders, should be documented, should be followed as ordered and should be standard. The Medical Director said that any resident who received hemodialysis should receive the treatments as ordered and the physician should be notified if and when a treatment or order cannot be followed so they can prescribe an alternative treatment order or intervention. On 10/13/2025 at 5:07 pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. Resident #2's dialysis sheet was incorrect. In an interview on 10/15/2025 at 9:40am with an Attending Physician at a local hospital, she said Resident #2 was admitted with a chief complaint of elevated WBC, diagnosed with sepsis, and was treated with the IV antibiotic Vancomycin. She said that there was blood culture pending to establish the cause of the infection. She said that Resident #2 admitted with extensive wounds. She said that Resident #2's wounds to her feet were necrotic with no blood flow, and has been recommended for bilateral AKA. She said that they will continue to monitor after the surgery for signs of infection because it is possible the infection has spread to the bone. She said that Resident #2 was nonverbal and not able to express if she was in pain, but she did respond to stimuli with facial cues. She said that Resident #2 had PRN morphine to manage her pain. She said that in the absence of antibiotics or wound care her infection and wounds could worsen. She said that Resident #2 needed regularly scheduled dialysis, and a physician should be consulted regarding any missed treatment to decide on an alternate treatment plan. In an interview on 10/15/2025 at 6:00 pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. In an interview on 10/16/2025 during the 6:00am-2:00pm shift with the Assistant Business Manager at 11:05am and Human Resources Director at 11:05am, both acknowledged being trained on abuse and neglected, provided types of abuse and neglect, reporting concerns with abuse and neglect to the Administrator who was the Abuse Coordinator immediately. In an interview on 10/16/2025 at 6:01pm with LVN C, she stated she has been employed at the facility since June or July of 2025. She stated she works the 10pm-6am shift on weekends. She stated her last in-service on abuse and neglect was that morning. She stated they went over skin, abuse, neglect, pain, weekly skin assessments, MARs and admission process including all documentation. She stated she knew the different types of abuse and was knowledgeable about the different types of abuse. She stated that abuse was reported to the facility Administrator who was also the Abuse Coordinator. She stated that when working with a dialysis resident, they would complete a dialysis communication sheet before and after the dialysis treatment. LVN C said the residents would be assessed for pain, and vital signs would be checked to ensure they were normal. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, she would stop the treatment or procedure, redo the assessment and check for any other orders or interventions and if interventions were ineffective, she would initiate an SBAR for pain and notify the MD and RP for the resident. LVN C stated if a resident were on dialysis, she would complete the required dialysis communication sheets before and after dialysis and notify the physician, as appropriate regarding any changes in the resident's condition. She stated once a resident had a change in condition, they were to do the change in condition-SBAR, call the physician, call the family and call the DON to notify them of the change in condition and follow the physician orders. She stated she thought the physicians came to see the residents weekly. She stated when working with any resident that was refusing care, the physician, DON, and family would be notified, and physicians' orders would be followed, and she would ensure it had all been documented. LVN C said that the physician and RP also need to be notified if a resident did not receive any medication/s so new or different orders could be implemented. In an interview on 10/16/2025 at 6:13pm with RN J, she stated she has been employed at the facility for 10 years. She stated that she worked the 10pm-6am shift. She stated her last in-service was last night for abuse and neglect. She stated they also reviewed pain and abuse and neglect, and she was knowledgeable about the different types of abuse. She stated abuse was reported to the Administrator/Abuse Coordinator. She stated she was in-serviced on the dialysis process, and that when working with a dialysis resident, she ensured the resident was clean and dry and ensured that they were stable, which included assessing their vital signs. She sta

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for physical environment. Based on observation, interviews, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for physical environment. The facility failed to ensure Hall 300 was free of odors. The facility failed to deodorize Resident #21 and Resident #31's room resulting in foul orders filling the 300 Hallway and other residents rooms on the 300 hall resulting in complaints from other residents and family members. The facility failed to ensure construction-renovations were completed in Hall 400 resulting in 2 residents (Resident #11 and Resident #22) not getting wound care, unpleasant and uncomfortable environment for the residents. The facility failed to keep the dining room door closed by propping it open with a zip tie. These failures could place residents at risk of living in an unsafe, uncomfortable environment and decreased quality of life. The findings included: Record review of Resident #21's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 (a deep wound with full-thickness tissue loss that has damaged muscle, tendon, or bone), Pressure Ulcer of Left Lower back, stage 3 (a full-thickness skin and tissue loss injury that has damaged the skin and fat layer, creating deep crater, but has not yet exposed muscle, bone, or tendon), Pressure Ulcer of Right hip, Stage 4 (a severe, full thickness wound that extends through the skin and fat to expose underlying muscle, tendon, or bone), Pressure Ulcer of Left Ankle, Unstageable, Pressure Ulcer of other site (full thickness tissue loss, but the depth cannot be determined because it is covered by eschar (dead tissue) or other slough (dead or dying tissue)), Major Depressive Disorder(a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Generalized Anxiety disorder (a common mental health condition characterized by excessive, persistent, and uncontrollable worry and anxiety about various aspects of life), and Benign Prostatic Hyperplasia without Lower Urinary Tract symptoms ( a condition where the prostate gland enlarges but does not cause any noticeable urinary problems) and Colostomy Status (refers to the condition of having a surgical procedure called colostomy). Record review of the Resident #21's Quarterly MDS revealed a BIMS score of 14, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #21 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for roll left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. Record review of Resident #21's care plan dated 09/17/25 revealed the following in part: Focus: I am Non-Complaint daily to care and refuse care (Peri-care-wound care-ADL Care) has a preference to not wear briefs, refuses nail care, shaving, haircut, showers, and grooming and wound care.Goal: Prevent New Wounds and Heal Current Wounds- I will be free of Pain or Discomfort Focus: The resident has a behavior problem refusing medications, wound care, ADL care, grooming, no sheet on bed and meals Goal: The resident will have fever episodes of refusing medications by review date Record review of Resident #31's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Unspecified Dementia (a diagnosis used when a person exhibits symptoms of dementia by the specific underlying cause cannot be determined), Local Infection of the skin and subcutaneous tissue (an infection that affects the layers of skin and underlying fat), Chronic Venous Hypertension with Ulcer of Right Lower Extremity (there is high blood pressure in the veins of the right leg, which has caused an open sore (ulcer) to form due to poor circulation), Chronic Venous Hypertension with Ulcer of Left Lower Extremity (high blood pressure in the veins of the left leg has caused a non-healing sore (ulcer) to form due to poor blood flow), Schizophrenia, Unspecified (a diagnostic category used in psychiatry when a person exhibits symptoms of schizophrenia but does not meet the full criteria for any specific subtypes of schizophrenia), Pressure Ulcer of Sacral Region, Stage 4 (a severe form of pressure injury where there is full-thickness tissue loss with exposed bone, muscle, or tendons), Pressure Ulcer of Right Heel, Stage 4 (the most severe type of pressure injury, involving deep-tissue damage with full-thickness tissue loss that exposes muscle, tendon, or bone), and Cognitive Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for roll left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Record review of Resident #31's care plan dated 09/19/25 revealed the following in part: Focus: Resident #31 is resistive to care relate to refusing incontinent care, wound treatment, weight and height management, refuses to bathe, shaving, haircuts, nail care, grooming, refuse to allow mid-line to be flushed. Goal: The resident will minimize refusal with care through next review date. Record review of Resident #11's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Atherosclerosis of Native Arteries of Extremities with Gangrene, Right Leg (Severe plaque buildup in the arteries of the right leg, blocking blood flow to the point where tissue has died), Peripheral Vascular Disease( a circular disorder where narrowed, blacked, or spasming blood vessels outside the heart and brain reduce blood flow to the limbs and organs), Atherosclerosis of native arteries of right leg with ulceration of other part of foot (refers to a serious condition where atherosclerosis, the build-up of plaque in the arteries, has severely narrowed the arteries of the right leg, leading to gangrene (tissue death) and ulceration (an open sore) on the foot), non-pressure chronic ulcer of other part of right food with fat layer exposed (a non-healing open sore on the right foot that has penetrated through the skin to the subcutaneous fat layer, but was not caused by external pressure) Hypothyroidism (an underactive thyroid condition where the gland does not produce enough thyroid hormones, causing many of the body's function to slow down), and Hyperlipidemia (high levels of lipids like cholesterol and triglycerides in the blood). Record review of the Resident #11's Quarterly MDS revealed a BIMS score of 15, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. Resident #11 requires partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs and provides less than half the effort) with Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, car transfer. Record review of Resident #11's care plan dated 09/30/25 revealed the following in part:Focus: Resident #11 has arterial ulcer related to Peripheral Arterial DiseaseRelated to third toe status post amputation secondary to gangrene. Goal: Resident #11 will be free from infection or complications related to arterial ulcer through review date. Record review of Resident #11's October 2025 Order Summary revealed an order to Cleanse right third toe arterial ulcer wound with Vashe, pat dry, apply lodosorb Gel to would bed, gauze sponge, cover with gauze border dressing dated 10/11/25. Record review of Resident #11's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. Record review of Resident #22's Electronic Health Record revealed a [AGE] year old male re-admitted to the facility 02/10/25 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-pressure chronic ulcer of left heel and midfoot with unspecified severity (long standing, non healing wound on the left heel and midfoot that was not caused by pressure), Non-pressure chronic ulcer of other part of left foot with fat layer exposed (A significant wound requiring medical attention, as it is a deeper ulcer that one limited to the skin and suggests damage has reached the subcutaneous tissue), Hereditary sideroblastic anemia (a rare genetic disorder where the body cannot produce sufficient hemoglobin due to a genetic defect) and Encounter for orthopedic aftercare following surgical amputation. Record review of Resident #22's Quarterly MDS revealed a BIMS score of 11, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #22 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer. Record review of Resident #22's care plan dated 08/08/25 revealed the following in part:Focus: Resident #22 is at risk for infection related to a site for organism invasion. Goal: Early recognition of infection to allow for prompt treatment.Focus: Resident #22 has a surgical site to LT proximal plantarGoal: Resident's surgical site will show signs of improving and remain free from s/s of infection with treatment as ordered over the next 90 days.Interventions:- Administer supplements as ordered. - Administer treatments as ordered. - Surgeon follow up as needed. Assist Resident/Responsible party with scheduling/transportation as needed. - Wound Doctor Consult. Record review of Resident #22's October 2025 Order Summary revealed an order for Wound Consult dated 10/11/25 and an order for wound care site 6 Post-Surgical Wound Left Heel every day shift for left heel wound dated 10/12/25. Record review of Resident #22's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. In an interview/observation on 10/13/25 at 2:56pm; while walking rounds the back of 400 hallway was observed that had 1 side of the hallway closed off with a closed door and on the other side of the door there was a clear plastic sheet covering the open side of the door. There were no signs posted on the closed door or plastic sheet and signs as to what type of work was being done. There were 3 men on the other side of the door and clear plastic sheet wearing N95 mask or respirator masks and actively spraying the walls and ceilings of the unit. Some residents' doors were closed and the floor was covered with slippery plastic sheeting. All of the residents' doors were covered with plastic sheets that were taped at the top and did not create a complete covering or seal over the entire door and most only partially covered the door with the bottom of at least 8 rooms uncovered and exposed to the sprayed material and dust. The 400 hallway appeared hazy with dust like material floating in the air. There were at least 2 rooms that had EBP signs posted and at least 4 rooms that had residents inside of the rooms. When staff were asked what was happening CNA B and LVN B said she did not know and that administration had not told them anything. Staff said they would like to know as well so they could wear appropriate masks because they did not know what they were breathing or what the residents were breathing. CNA B and LVN B said they had no advanced notice that the work was being done and had no way of notifying residents before the work started. The machine used to spray the cloudy material was extremely loud and sounded like a jackhammer or drill. Interviews and observations with Resident #8, Resident #9 and Resident #11 who were all in their rooms and had EBP signs posted outside their doors. Resident #8 and Resident #9 said they felt ok but were advised they could not leave their rooms while the workers were outside. They said it was loud, but they had no feelings of illness or difficulty breathing at that time. When asked how they felt about being sealed inside their rooms during the work, Resident #8 said he was ok with it and Resident #9 said it was inconvenient. All 3 of the Residents said it was too loud. All of the Residents said no one told them the work would be done that day and no one offered them masks or an option to move or change rooms. In an interview on 10/13/25 at 3:00pm with CNA-AG, she was observed with no mask on. She reported there were about 12-13 residents behind the plastic barrier on hall 400. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. In an interview/observation on 10/13/25 at 3:18pm-Notified Admin, DON and Corporate staff about immediate environmental concerns on 400 hallway and safety of residents who remained on the hallway while the substance was being sprayed. Admin said they had notified residents and family members about the renovations, and she was unsure what the substance was the workers were spraying but she could find out. She said she was unsure if anyone was required to wear any PPE or masks and said that they had signs posted on the front entry regarding the remodeling. The Admin said the facility was undergoing renovations with the new company and it was not construction. She said the workers were painting and had started renovations on 200 hall and were slowly working their way around the building. In an interview on 10/13/25 at 3:56pm with LVN B, she stated there were residents behind the plastic barriers on 400 hall. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. She stated she did not know why the workers were wearing masks. She stated she thought the workers were sanding before painting. She stated that if the workers had masks the residents and staff should have mask as well. She stated there were no residents on oxygen on the 400 hall. She stated there was one resident with COPD. She stated she did not smell any fumes but it was dusty on the hall and it was loud. She stated she was not sure if the residents were asked to move. In an interview on 10/13/25 at 3:59pm with CNA-AG, she stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barriers was needed and she did not know why the mask were needed. She stated she thought the workers were sanding prior painting the hallway. She stated that if the workers had on mask then the residents and staff should have on masks as well. She stated the renovations were loud and she was not sure if the residents were asked to move rooms or not. In an interview on 10/13/25 at 4:04pm with Contractor AO, he stated that he and the workers were spraying texturizer on the ceiling, and they would paint on 10/14/25. He stated that they were wearing the masks because it leaves dust that you should not breath in. In an interview on 10/14/25 at 11:48am with Resident #7, he stated he did not get any notice that the facility was doing any construction in the building. He stated he resides on hall 400. He stated the contractors were scraping, drilling, and painting in the hallway and it was loud. He stated everything had been flying in the air and it was affecting his sinuses, causing him to become congested and he reported he had diarrhea. In an observation on 10/14/25 at 9:38am, the dining room door was open and there was a zip tie propping the door open. There was also an extension cord running from inside of the dining room onto the outside of the dining room. The extension cord was zip tied to the hinges of the door, impeding it from closing. Surveyor attempted to close the door but it would not shut due to the extension cord being zip tied to the hinges of the door. In an interview on 10/14/25 at 9:41am with the Director of Food and Nutrition, he stated the zip tie had been on the door for about 2 months. He stated the facility did not put the tie zips there, he reported the company that had come out for their Air Conditioning had put the zip ties on the door. He stated the zip ties and extension did not stop the doors from closing. In an interview on 10/14/25 at 11:40am with Administrator-A, she stated the extension cord and zip tie was put there by the air conditioning company. She stated she would take it down and plug it somewhere else. In an interview on 10/15/25 at 12:11pm with ADON-M, she stated some of the residents on Hall 400 were not seen by the wound care doctor (Resident #11 and Resident #22). She stated she was not given a reason why the residents were not seen but she stated the wound care doctor reported that she did not want to go behind the barrier of the renovations on the 400 hall. She stated there was a barrier cutting off the hallway where renovations were being completed (painting). She stated Resident #11 and Resident #22 will not be seen until the following week (Mondays is the wound care doctors rounding days). She stated there was a barrier cutting off the hallway where they were painting. In observation rounds on 10/20/25 at 2:13pm on Hall 300, the hall smelled of urine and bowel movement. In an interview on 10/20/25 at 2:14pm with Resident #21 and Resident #31, both residents were observed lying in their beds. Upon entering Resident #21 and Resident #31's room, the smell intensified. The room smelled of urine, bowel movement, and body odor. The surveyor had on a mask but was able to smell the odor through the mask. Resident #21 stated he did not have any concerns with the smell of the room and reported that the room smelled fine. In an interview on 10/20/25 at 2:45pm with Regional Compliance Nurse-R, Regional Compliance Nurse-R was observed entering the room of Resident #21 and Resident #31. He stated the residents room did have an odor and described the smell as body odor, bowel movement and body fluid. He stated the smell was contributed to the lack of wound care. He stated Resident #21 and Resident #31 refuse wound care and stated it smells sour in the residents room. He stated he was unsure of what had been done by the administrator to address the smell. In an interview on 10/21/25 at 3:31pm with Resident #38, the resident resides on the 300 hall. He stated he did not like the smell of the 300 hall and he described the smell as different, then said it was like poop. He stated he could not smell it in his room but reported he could smell it when he goes in the hallway. He stated he would like for the hallway to smell better, because it smells that way all the time and he is sick of it. He stated this is his home and he would want it to smell better. He stated he has not spoken to anyone regarding his concern for the smell. He stated he felt as if staff knows that it smells and does not care. In an interview on 10/21/25 at 3:34pm with MA-AE, she stated there had always been an odor on the 300 hall and it was resulting from two of the resident in one of the rooms on the 300 hall. She stated the smell emits from the room into the hallway and into some of the other residents room. She stated she did not know what the facility management was doing to address the problem. She stated she did not know if the facility staff had spoken to the other residents about the concern. She stated whatever the facility management was doing about the smell was not effective. In an interview on 10/22/25 at 9:20am with Family Member #40, she stated the facility smelled horrible. She stated she was able to smell it as soon as she turns the corner to walk down hallway 300. She stated the smell hits you in the face. She stated it smelled like urine, sh**, and like something spoiled. She stated she smell was coming from one of the rooms on the 300 hall. She stated she could smell it down the hall and reported that the smell lingers into Resident #33's room. She stated she had not complained about the smell but reported Resident #33 has complained to corporate about the smell. In an interview on 10/22/25 at 9:25am with Resident #37, the resident resides on the 300 hall. He stated he did not like the way his room or the facility smelled and stated who would like the smell. He stated the smell was worse in the hallway. He stated the smell was coming from one of the rooms on the 300 hall and stated the residents in that room does not allow staff to wash their a**, change their diapers, or tend to their wounds. He stated it smells sh** and rotten flesh. He stated he felt helpless because this was his home and he could not do anything about the smell. He stated if this was his own home it would not have this smell. He stated the staff had not asked him how he felt about the smell and no one had asked him if he wanted to change halls. In an interview on 10/22/25 at 9:35am with CNA-AJ, she reported there is a concern with odor on Hall 300 because some of the residents refuse care. She stated she could not think of words to describe the smell but it was bad. She stated she did not know what the facility was doing about the smell but reported it has always smelled that way since she started working at the facility, she stated she started working at the facility in November 2024. She stated that this was the residents home and they have a right to an odor free home. In an interview on 10/22/25 at 9:40am with Housekeeper-AL, she stated she had been employed at the facility for 2 months. She stated there was an issue with odor on the 300 hall. She stated the odor was indescribable and stated it had always smelled bad ever since she started working there and the smell had gotten worse. She stated she was told the source of the smell was from residents refusals of baths and wound care. She stated she cleans each room one times a day and the rooms of concern are cleaned two times a day. She stated she spray odor neutralizer upon entering and exiting each room and she also sprays the hallways as she exits each room. She stated that she goes through 2-3 bottles of odor neutralizer a week for one hall to try to help the smell but it does not work. She stated the additional cleaning was not helping the odor. She stated that it was the residents home and they have the right to have an odor free home. In an interview on 10/22/25 at 10:20am with Resident #33, he did not have any concerns for the smell in his room or in the hallway. In an interview on 10/22/25 at 11:20am with Administrator-A, she stated she does daily observation rounds of the entire facility. She stated she had not observed a pronounced odor to any part of the facility. She stated she had only observed there to be a smell associated with incontinent care and that was normal from residents getting brief changes at every facility. She stated there had not been complaints or grievances about odors in the building. She stated housekeeping does have some targeted rooms that received additional cleaning at the back of 300 hall and 400 hall. Administrator-A sent an email to surveyors with the list of targeted rooms that get additional cleanings but she reported she did not recall the reason as to why the rooms get additional cleanings. On 10/22/2025 at 1:06pm, a policy was requested for physical environment and it was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 4 hallways, (Hall 300) and Resident #21's and Resident #31's room. The facility had live flies in areas of the facility including Halls 300, and Resident #21 and Resident #31's room. This failure could place residents at risk for decreased health, safety and quality of life. Findings included: Record review of Resident #21's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 (a deep wound with full-thickness tissue loss that has damaged muscle, tendon, or bone), Pressure Ulcer of Left Lower back, stage 3 (a full-thickness skin and tissue loss injury that has damaged the skin and fat layer, creating deep crater, but has not yet exposed muscle, bone, or tendon), Pressure Ulcer of Right hip, Stage 4 (a severe, full thickness wound that extends through the skin and fat to expose underlying muscle, tendon, or bone), Pressure Ulcer of Left Ankle, Unstageable, Pressure Ulcer of other site (full thickness tissue loss, but the depth cannot be determined because it is covered by eschar (dead tissue) or other slough (dead or dying tissue)), Major Depressive Disorder(a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Generalized Anxiety disorder (a common mental health condition characterized by excessive, persistent, and uncontrollable worry and anxiety about various aspects of life), and Benign Prostatic Hyperplasia without Lower Urinary Tract symptoms ( a condition where the prostate gland enlarges but does not cause any noticeable urinary problems) and Colostomy Status (refers to the condition of having a surgical procedure called colostomy). Record review of the Resident #21's Quarterly MDS revealed a BIMS score of 14, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #21 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. Record review of Resident #31's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Unspecified Dementia (a diagnosis used when a person exhibits symptoms of dementia by the specific underlying cause cannot be determined), Local Infection of the skin and subcutaneous tissue (an infection that affects the layers of skin and underlying fat), Chronic Venous Hypertension with Ulcer of Right Lower Extremity (there is high blood pressure in the veins of the right leg, which has caused an open sore (ulcer) to form due to poor circulation), Chronic Venous Hypertension with Ulcer of Left Lower Extremity (high blood pressure in the veins of the left leg has caused a non-healing sore (ulcer) to form due to poor blood flow), Schizophrenia, Unspecified (a diagnostic category used in psychiatry when a person exhibits symptoms of schizophrenia but does not meet the full criteria for any specific subtypes of schizophrenia), Pressure Ulcer of Sacral Region, Stage 4 (a severe form of pressure injury where there is full-thickness tissue loss with exposed bone, muscle, or tendons), Pressure Ulcer of Right Heel, Stage 4 (the most severe type of pressure injury, involving deep-tissue damage with full-thickness tissue loss that exposes muscle, tendon, or bone), and Cognitive Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #31 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. In an observation on 10/20/25 at 02:05pm, approximately 16 flies were observed on Hall 300. In an interview/observation on 10/20/25 at 2:14pm with Resident #21- The resident was observed in his room lying in bed and there was a live fly on his blanket. There were 4 live flies observed on his wall. Resident #21 stated he sees flies in his room often, he stated he thinks the flies come from the towels the staff use to wipe the tables in the rooms. In an observation on 10/20/25 at 2:17pm with Resident #31, he was observed in his room lying in bed and there were 2 live flies on his blanket and approximately 2 flies observed flying around the room. In an interview on 10/20/25 at 2:54pm with the Regional Compliance Nurse, he acknowledged that there were flies in the residents' room. He stated pest control has been called out to the facility to make additional visits. He stated they were initially coming out to the facility monthly but they now come out more often. Record review of the facility's service inspection report revealed the facility was treated 10/07/25. The facility was treated for House/Fruit/Blow/Flesh/Stable Flies, German Roaches and Fire Ants. The areas treated were the Dining-> Device Fly Light, Common Area>Device Fly Light1, Common Area->Device Fly Light2, Common Area->Device Fly Light3, Interior, Common area and Exterior; the light traps were also inspected. Prior to 10/07/25, the facility was treated on 09/30/25. The facility was treated for American Roach and Bed Bugs. The area treated was the interior. The facility was not treated for flies during this visit. Record review of the facility's pest control policy dated 2012 reflected, The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. 1. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for homelike environment.Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for homelike environment. The facility failed to ensure Hall 300 was free of odors. The facility failed to deodorize Resident #21 and Resident #31's room resulting in foul orders filling the 300 Hallway and other residents rooms on the 300 hall resulting in complaints from other residents and family members. The facility failed to ensure construction-renovations were completed in Hall 400 resulting in 2 residents (Resident #11 and Resident #22) not getting wound care and living in an unpleasant and uncomfortable environment for the residents. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, uncomfortable, and unsafe. The findings included: Record review of Resident #21's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 (a deep wound with full-thickness tissue loss that has damaged muscle, tendon, or bone), Pressure Ulcer of Left Lower back, stage 3 (a full-thickness skin and tissue loss injury that has damaged the skin and fat layer, creating deep crater, but has not yet exposed muscle, bone, or tendon), Pressure Ulcer of Right hip, Stage 4 (a severe, full thickness wound that extends through the skin and fat to expose underlying muscle, tendon, or bone), Pressure Ulcer of Left Ankle, Unstageable, Pressure Ulcer of other site (full thickness tissue loss, but the depth cannot be determined because it is covered by eschar (dead tissue) or other slough (dead or dying tissue)), Major Depressive Disorder(a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Generalized Anxiety disorder (a common mental health condition characterized by excessive, persistent, and uncontrollable worry and anxiety about various aspects of life), and Benign Prostatic Hyperplasia without Lower Urinary Tract symptoms ( a condition where the prostate gland enlarges but does not cause any noticeable urinary problems) and Colostomy Status (refers to the condition of having a surgical procedure called colostomy). Record review of the Resident #21's Quarterly MDS revealed a BIMS score of 14, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #21 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. Record review of Resident #21's care plan dated 09/17/25 revealed the following in part: Focus: I am Non-Complaint daily to care and refuse care (Peri-care-wound care-ADL Care) has a preference to not wear briefs, refuses nail care, shaving, haircut, showers, and grooming and wound care.Goal: Prevent New Wounds and Heal Current Wounds- I will be free of Pain or Discomfort Focus: The resident has a behavior problem refusing medications, wound care, ADL care, grooming, no sheet on bed and meals Goal: The resident will have fewer episodes of refusing medications by review date Record review of Resident #31's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Unspecified Dementia (a diagnosis used when a person exhibits symptoms of dementia by the specific underlying cause cannot be determined), Local Infection of the skin and subcutaneous tissue (an infection that affects the layers of skin and underlying fat), Chronic Venous Hypertension with Ulcer of Right Lower Extremity (there is high blood pressure in the veins of the right leg, which has caused an open sore (ulcer) to form due to poor circulation), Chronic Venous Hypertension with Ulcer of Left Lower Extremity (high blood pressure in the veins of the left leg has caused a non-healing sore (ulcer) to form due to poor blood flow), Schizophrenia, Unspecified (a diagnostic category used in psychiatry when a person exhibits symptoms of schizophrenia but does not meet the full criteria for any specific subtypes of schizophrenia), Pressure Ulcer of Sacral Region, Stage 4 (a severe form of pressure injury where there is full-thickness tissue loss with exposed bone, muscle, or tendons), Pressure Ulcer of Right Heel, Stage 4 (the most severe type of pressure injury, involving deep-tissue damage with full-thickness tissue loss that exposes muscle, tendon, or bone), and Cognitive Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #31 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Record review of Resident #31's care plan dated 09/19/25 revealed the following in part: Focus: Resident #31 is resistive to care relate to refusing incontinent care, wound treatment, weight and height management, refuses to bathe, shaving, haircuts, nail care, grooming, refuse to allow mid-line to be flushed.[sic] Goal: The resident will minimize refusal with care through next review date. Record review of Resident #11's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Atherosclerosis of Native Arteries of Extremities with Gangrene, Right Leg (Severe plaque buildup in the arteries of the right leg, blocking blood flow to the point where tissue has died), Peripheral Vascular Disease( a circular disorder where narrowed, blacked, or spasming blood vessels outside the heart and brain reduce blood flow to the limbs and organs), Atherosclerosis of native arteries of right leg with ulceration of other part of foot (refers to a serious condition where atherosclerosis, the build-up of plaque in the arteries, has severely narrowed the arteries of the right leg, leading to gangrene (tissue death) and ulceration (an open sore) on the foot), non-pressure chronic ulcer of other part of right food with fat layer exposed (a non-healing open sore on the right foot that has penetrated through the skin to the subcutaneous fat layer, but was not caused by external pressure) Hypothyroidism (an underactive thyroid condition where the gland does not produce enough thyroid hormones, causing many of the body's function to slow down), and Hyperlipidemia (high levels of lipids like cholesterol and triglycerides in the blood). Record review of the Resident #11's Quarterly MDS revealed a BIMS score of 15, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, rolling left and right, sit to lying, and lying to sitting on side of bed. Resident #11 requires partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs and provides less than half the effort) with Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, car transfer. Record review of Resident #11's care plan dated 09/30/25 revealed the following in part:Focus: Resident #11 has arterial ulcer related to Peripheral Arterial DiseaseRelated to third toe status post amputation secondary to gangrene. Goal: Resident #11 will be free from infection or complications related to arterial ulcer through review date. Record review of Resident #11's October 2025 Order Summary revealed an order to Cleanse right third toe arterial ulcer wound with Vashe, pat dry, apply lodosorb Gel to would bed, gauze sponge, cover with gauze border dressing dated 10/11/25. Record review of Resident #11's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. Record review of Resident #22's Electronic Health Record revealed a [AGE] year old male re-admitted to the facility 02/10/25 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-pressure chronic ulcer of left heel and midfoot with unspecified severity (long standing, non healing wound on the left heel and midfoot that was not caused by pressure), Non-pressure chronic ulcer of other part of left foot with fat layer exposed (A significant wound requiring medical attention, as it is a deeper ulcer that one limited to the skin and suggests damage has reached the subcutaneous tissue), Hereditary sideroblastic anemia (a rare genetic disorder where the body cannot produce sufficient hemoglobin due to a genetic defect) and Encounter for orthopedic aftercare following surgical amputation. Record review of Resident #22's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #22 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer. Record review of Resident #22's care plan dated 08/08/25 revealed the following in part:Focus: Resident #22 is at risk for infection related to a site for organism invasion. Goal: Early recognition of infection to allow for prompt treatment.Focus: Resident #22 has a surgical site to LT proximal plantarGoal: Resident's surgical site will show signs of improving and remain free from s/s of infection with treatment as ordered over the next 90 days.Interventions:- Administer supplements as ordered. - Administer treatments as ordered. - Surgeon follow up as needed. Assist Resident/Responsible party with scheduling/transportation as needed. - Wound Doctor Consult. Record review of Resident #22's October 2025 Order Summary revealed an order for Wound Consult dated 10/11/25 and an order for wound care site 6 Post-Surgical Wound Left Heel every day shift for left heel wound dated 10/12/25. Record review of Resident #22's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. In an interview/observation on 10/13/25 at 2:56pm; while walking rounds the back of 400 hallway was observed that had 1 side of the hallway closed off with a closed door and on the other side of the door there was a clear plastic sheet covering the open side of the door. There were no signs posted on the closed door or plastic sheet or signs as to what type of work was being done. There were 3 men on the other side of the door and clear plastic sheet wearing N95 mask or respirator masks and actively spraying the walls and ceilings of the unit. Some residents' doors were closed and the floor was covered with slippery plastic sheeting. All of the residents' doors were covered with plastic sheets that were taped at the top and did not create a complete covering or seal over the entire door and most only partially covered the door with the bottom of at least 8 rooms uncovered and exposed to the sprayed material and dust. The 400 hallway appeared hazy with dust like material floating in the air. There were at least 2 rooms that had EBP signs posted and at least 4 rooms that had residents inside of the rooms. When staff were asked what was happening CNA B and LVN B said they did not know and that administration had not told them anything. Staff said they would like to know as well so they could wear appropriate masks because they did not know what they were breathing or what the residents were breathing. CNA B and LVN B said they had no advanced notice that the work was being done and had no way of notifying residents before the work started. The machine used to spray the cloudy material was extremely loud and sounded like a jackhammer or drill. Interviews and observations with Resident #8, Resident #9 and Resident #11 who were all in their rooms and had EBP signs posted outside their doors. Resident #8 and Resident #9 said they felt ok but were advised they could not leave their rooms while the workers were outside. They said it was loud, but they had no feelings of illness or difficulty breathing at that time. When asked how they felt about being sealed inside their rooms during the work, Resident #8 said he was ok with it and Resident #9 said it was inconvenient. All 3 of the Residents said it was too loud. All of the Residents said no one told them the work would be done that day and no one offered them masks or an option to move or change rooms. In an interview on 10/13/25 at 3:00pm with CNA-AG, she was observed with no mask on. She reported there were about 12-13 residents behind the plastic barrier on hall 400. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. In an interview/observation on 10/13/25 at 3:18pm-Notified Admin, DON and Corporate staff about immediate environmental concerns on 400 hallway and safety of residents who remained on the hallway while the substance was being sprayed. Admin said they had notified residents and family members about the renovations, and she was unsure what the substance was the workers were spraying but she could find out. She said she was unsure if anyone was required to wear any PPE or masks and said that they had signs posted on the front entry regarding the remodeling. The Admin said the facility was undergoing renovations with the new company and it was not construction. She said the workers were painting and had started renovations on 200 hall and were slowly working their way around the building. In an interview on 10/13/25 at 3:56pm with LVN B, she stated there were residents behind the plastic barriers on 400 hall. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. She stated she did not know why the workers were wearing masks. She stated she thought the workers were sanding before painting. She stated that if the workers had masks the residents and staff should have masks as well. She stated there were no residents on oxygen on the 400 hall. She stated there was one resident with COPD. She stated she did not smell any fumes but it was dusty on the hall and it was loud. She stated she was not sure if the residents were asked to move. In an interview on 10/13/25 at 3:59pm with CNA-AG, she stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barriers was needed and she did not know why the masks were needed. She stated she thought the workers were sanding prior painting the hallway. She stated that if the workers had on masks then the residents and staff should have on masks as well. She stated the renovations were loud and she was not sure if the residents were asked to move rooms or not. In an interview on 10/13/25 at 4:04pm with Contractor AO, he stated that he and the workers were spraying texturizer on the ceiling, and they would paint on 10/14/25. He stated that they were wearing the masks because it leaves dust that you should not breathe in. In an interview on 10/14/25 at 11:48am with Resident #7, he stated he did not get any notice that the facility was doing any construction in the building. He stated he resides on hall 400. He stated the contractors were scraping, drilling, and painting in the hallway and it was loud. He stated everything had been flying in the air and it was affecting his sinuses, causing him to become congested and he reported he had diarrhea. In an interview on 10/15/25 at 12:11pm with ADON-M, she stated some of the residents on Hall 400 were not seen by the wound care doctor (Resident #11 and Resident #22). She stated she was not given a reason why the residents were not seen but she stated the wound care doctor reported that she did not want to go behind the barrier of the renovations on the 400 hall. She stated there was a barrier cutting off the hallway where renovations were being completed (painting). She stated Resident #11 and Resident #22 will not be seen until the following week (Mondays is the wound care doctors rounding days). She stated there was a barrier cutting off the hallway where they were painting. In observation rounds on 10/20/25 at 2:13pm on Hall 300, the hall smelled of urine and feces. In an interview on 10/20/25 at 2:14pm with Resident #21 and Resident #31, both residents were observed lying in their beds. Upon entering Resident #21 and Resident #31's room, the smell intensified. The room smelled of urine, feces, and body odor. The surveyor had on a mask but was able to smell the odor through the mask. Resident #21 stated he did not have any concerns with the smell of the room and reported that the room smelled fine. In an interview on 10/20/25 at 2:45pm with Regional Compliance Nurse-R, Regional Compliance Nurse-R was observed entering the room of Resident #21 and Resident #31. He stated the residents' room did have an odor and described the smell as body odor, feces and body fluid. He stated the smell was contributed to the lack of wound care. He stated Resident #21 and Resident #31 refuse wound care and stated it smells sour in the residents' room. He stated he was unsure of what had been done by the administrator to address the smell. In an interview on 10/21/25 at 3:31pm with Resident #38, the resident resides on the 300 hall. He stated he did not like the smell of the 300 hall and he described the smell as different then said it was like poop. He stated he could not smell it in his room but reported he could smell it when he goes in the hallway. He stated he would like for the hallway to smell better, because it smells that way all the time and he was sick of it. He stated this was his home and he would want it to smell better. He stated he has not spoken to anyone regarding his concern for the smell. He stated he felt as if staff knows that it smells and does not care. In an interview on 10/21/25 at 3:34pm with MA-AE, she stated there had always been an odor on the 300 hall and it was resulting from two of the residents (Resident #21 and Resident #31) in one of the rooms on the 300 hall. She stated the smell emits from the room into the hallway and into some of the other residents' rooms. She stated she did not know what the facility management was doing to address the problem. She stated she did not know if the facility staff had spoken to the other residents about the concern. She stated whatever the facility management was doing about the smell was not effective. In an interview on 10/22/25 at 9:20am with Family Member #40, she stated the facility smelled horrible. She stated she was able to smell it as soon as she turns the corner to walk down hallway 300. She stated the smell hits you in the face. She stated it smelled like urine, sh**, and like something spoiled. She stated she smell was coming from one of the rooms on the 300 hall. She stated she could smell it down the hall and reported that the smell lingers into Resident #33's room. She stated she had not complained about the smell but reported Resident #33 has complained to corporate about the smell. In an interview on 10/22/25 at 9:25am with Resident #37, the resident resides on the 300 hall. He stated he did not like the way his room or the facility smelled and stated who would like the smell. He stated the smell was worse in the hallway. He stated the smell was coming from one of the rooms on the 300 hall and stated the residents in that room does not allow staff to wash their a**, change their diapers, or tend to their wounds. It smells sh** and rotten flesh. He stated he felt helpless because this was his home and he could not do anything about the smell. He stated if this was his own home it would not have this smell. He stated the staff had not asked him how he felt about the smell, and no one had asked him if he wanted to change halls. In an interview on 10/22/25 at 9:35am with CNA-AJ, she reported there was a concern with odor on Hall 300 because some of the residents refuse care. She stated she could not think of words to describe the smell but it was bad. She stated she did not know what the facility was doing about the smell but reported it has always smelled that way since she started working at the facility, she stated she started working at the facility in November 2024. She stated that this was the residents' home and they have a right to an odor free home. In an interview on 10/22/25 at 9:40am with Housekeeper-AL, she stated she had been employed at the facility for 2 months. She stated there was an issue with odor on the 300 hall. She stated the odor was indescribable and stated it had always smelled bad ever since she started working there and the smell had gotten worse. She stated she was told the source of the smell was from residents refusals of baths and wound care. She stated she cleans each room one time a day and the rooms of concern are cleaned two times a day. She stated she sprays odor neutralizer upon entering and exiting each room and she also sprays the hallways as she exits each room. She stated that she goes through 2-3 bottles of odor neutralizer a week for one hall to try to help the smell but it does not work. She stated the additional cleaning was not helping the odor. She stated that it was the residents' home, and they have the right to have an odor free home. In an interview on 10/22/25 at 10:20am with Resident #33, he did not have any concerns for the smell in his room or in the hallway. In an interview on 10/22/25 at 11:20am with Administrator-A, she stated she does daily observation rounds of the entire facility. She stated she had not observed a pronounced odor to any part of the facility. She stated she had only observed there to be a smell associated with incontinent care and that was normal from residents getting brief changes at every facility. She stated there had not been complaints or grievances about odors in the building. She stated housekeeping does have some targeted rooms that received additional cleaning at the back of 300 hall and 400 hall. Administrator-A sent an email to surveyors with the list of targeted rooms that get additional cleanings, but she reported she did not recall the reason as to why the rooms get additional cleanings. On 10/22/2025 at 1:06pm, a policy was requested for homelike environment, and it was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 1 of 13 residents (Resident#2) reviewed for resident rights. 1. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 2. The facility failed to notify Resident #2's Physician when she was unable to receive Hemodialysis treatment as ordered on 10/03/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 3. The facility failed to notify Resident #2's Physician when Resident # 2 had not received all ordered treatments for all of her 14 wounds from 09/30/2025 through 10/02/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 4. The facility failed to notify Resident #2's Physician when the orders given on 10/02/2025 for wound care had not been entered into Resident #2's electronic medical records or implemented from 10/02/2025 through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 5. The facility failed to notify Resident #2's Physician when Resident #2 had only as needed, over the counter regular strength Tylenol ordered for pain medications, had not received any pain medication prior to any of the wound care treatments, or had not had pain assessments prior to wound treatments for her 14 wounds. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. An Immediate Jeopardy (IJ) was identified on 10/11/2025. The IJ template was provided to the facility on [DATE] at 12:02 PM. While the IJ was removed on 10/19/2025, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place residents at risk of delays in treatment, worsening of condition, hospitalization, and death. Findings include: Record review of Resident#2's facesheet dated 10/09/2025, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE] with a principal diagnosis of cerebral infarction, unspecified (stroke), admitting diagnosis of sepsis due to Escherichia Coli (E.Coli a bacteria) and serve sepsis with septic shock (a life-threatening condition that occurs when an infection leads to dangerously low blood pressure and organ failure, and secondary diagnosis of End Stage Renal Disease(ESRD the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment) pressure ulcer of sacral region, unstable, and UTI, site not specified. Secondary diagnosis dated 10/03/2025 for pressure ulcers of right buttock stage 4, left buttock stage 4,right ankle unstageable, left ankle unstageable, left heel unstageable, and other site unstageable. Secondary diagnosis dated 10/03/2025 for non-pressure chronic ulcer of right heel and midfoot, right foot, and left foot with fat layer exposed. Record review of Resident#2's admission assessment dated [DATE] reflected a BIMS(Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making in Section C. In Section I for active diagnosis, she was triggered for ERSD, Pneumonia, Septicemia, and UTI. In Section M for skin, she was triggered to have 2 stage 4 pressure ulcers, 6 unstageable pressure ulcers, and 5 venous and arterial ulcers present upon admission. In section M she was triggered to have infection of the foot (e.g., cellulitis, purulent drainage.) In Section N for Medications, she was triggered to have antibiotics. In Section O for Special Treatments, Procedures, and Programs, she triggered to have IV medication and hemodialysis. Record review of Resident#2's comprehensive care dated 10/06/2025 reflected:Focus: Resident#2 needs hemodialysis MWF(Monday, Wednesday, and Friday) r/t(related to) renal failure.Goal: The resident will have immediate intervention should any s/sx(sign and symptoms) of complications from dialysis occur through the review date. Intervention: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (MWF). Monitor labs and report to doctor as needed. Monitor/document report to MD (Doctor of medicine) s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report to MD PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report to MD PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report to MD PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Focus: Resident#2 has pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, Diabetes Mellitus (DM), incontinence. Present on admission: Two stage 4, Six unstageable, Five Venous/arterial ulcers, One diabetic foot ulcer. Goal: Resident#2's Pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer protein supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Administer Vitamin C as ordered. Administer Zinc as ordered. Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Focus: Resident #2 is on Antibiotic Therapy r/t sepsis r/t wounds, UTI, and aspiration PNA(Pneumonia).Goal: Resident#2 will be free of any discomfort or adverse side effects of antibiotic therapy through the review date.Intervention: Administer medication as ordered. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis. Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor q-shift (each shift) for adverse reaction. Observe for possible side effects every shift. Report pertinent lab results to MD. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed no care plan for pain Record review of Resident#2's hospital clinical record dated 09/25/2025 reflected diagnosis of sepsis with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene. Plan, Zosyn 2.25g IV every 8 hours for pansensitive E. coli wound culture plus empirical anaerobic coverage. Anticipate another 2 weeks of IV antibiotics. Record review of Resident#2's hospital clinical discharge record dated 09/29/2025 reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% SOLN(solution) 100 ml (Milliliter) with piperacillin-tazobactam (Zosyn)4.5 (4-0.5) g(gram) SOLR(Solution Reconstituted) 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty(quantity): 100 GM(gram), refills: 0. The discharge summary did not give an account of how many wounds were identified while Resident#2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident#2 discharged to treat the wounds. Record review of Resident #2's out of state hospital records, dated 09/29/2025, revealed she had the following as needed (PRN) orders for pain:Acetaminophen 650 mg tablet Q 6 hours PRN mild pain.Acetaminophen 650 mg tablet Q 6 hours PRN pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM.Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours prn for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 PM. Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part: wound care orders for her sacrum and right lateral ankle/foot. Arterial changes to RLE. Toes continue to harden, gangrenous. Right lateral leg remains purple/black. Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI. Record review of Resident #2's facility Order Recap, dated September 2025, revealed an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. The order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's MAR, dated September 1, 2025 through September 30, 2025 revealed Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident#2's facility phone medication order date 09/30/2025 at 7:15pm for piperacillin sod-tazobactam ((piperacillin sodium-tazobactam sodium) So intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident#2's MAR for the month of September 2025 no Zosyn administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's initial skin assessment dated [DATE] at 9:22pm by LVN A, read in part, .Resident #1 had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings: Pressure wound to sacral area, DTI(Deep Tissue Injury) to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle. Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of the Resident#'2 physician order summary report reflected the following orders to treat a DTI to right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of Resident #2's MAR for the month of October 2025 reflected Zosyn administered to Resident #2 on 10/04/2025 at 8:00 PM for the initial dose. Record review of the Resident#'2 physician order summary report reflected the a wound consult was not entered at resident#2's admission on [DATE] and was entered an implemented 10/02/2025. Record review of Resident #2's initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone). Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 2; Unstageable (Due to necrosis [cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function]) Right, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of physician order summary for October 2025 reflected that the orders provided initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A were not entered until 10/04/2025. Records Record review of Resident#2's progress note dated 10/03/2025 at 6:27am and completed by RN A reflected that NP A was notified of change, but there was no information detailing what the change was or orders to address the change. Records Record review of Resident#2's SBAR dated 10/03/2025 at 6:05am and completed by RN A did not reflect specific information of notifying NP A her missed hemodialysis session or orders from NP A to address the missed hemodialysis session. Record review of Resident #2's MAR, dated October 1, 2025, through October 31, 2025, revealed the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Record reviews of Resident #2's electronic medical record revealed no PAINAD assessments for Resident #2. In an observation on 10/09/2025 at 10:57 AM revealed ADON A performed Resident#2's wound care with assistance from CNA A. ADON A said at the start of the treatment Resident #2 was medicated for pain about 30-40 minutes prior. Resident #2 was observed to tolerate the wound care treatment without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed as if she were in pain. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025. She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds. She said that she reconciled the medication list and treatments for the wounds with the on call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day. She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission. She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat. She said that the her clinical impression was that some of Resident#2's wounds were infected at the time of admission, and it was apparent that she had recent debridement of the wounds prior to being discharged from the hospital. In an interview on 10/09/2025 at 4:36pm with the Medical Director, she said that she was the primary physician for Resident#2. She said that staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments. She said that she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission. She said that Resident#2 IV antibiotics should be arranged prior to a residents admission, and if it was not available orders could be arranged to switch to an oral antibiotic until it was available. She said that a wound consult should made upon admission, and the orders given after the wound consult should be entered and carried out. In a follow up interview on 10/09/2025 at 5:14pm with ADON A, she said that that the admitting nurse completes an initial skin assessment at the time of admission. She said that the treatment nurse should complete a second skin assessment on new admission with wounds identified within 24 hours of admissions. She said that the treatment nurse should review the facility clinical records and hospital clinical records. She said that the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made. She said that there should be a clinical review of all new admissions the next business day with the Administrator and clinical department heads present. She said that she worked as treatment nurse on 09/30/2025 and 10/01/2025. She said that Resident#2 admitted on [DATE] with wounds, and orders for Zosyn. She could not recall if the order for Zosyn was to treat a wound infection or UTI. She said that she did not complete the second skin assessment for Resident#2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she is not able to finish by the end of her shift. She said that ADON B would have been responsible for complete Resident#2's wound care treatment after admission. She said that she did not recall if she attended the clinical admitting on 10/01/2025. She said that LVN A was responsible for ensuring that medications and treatments were reconciled at the time of admission and entering the orders. She said that Resdient#2 did not have orders treat all her wounds or Zosyn at the time of admission. She said that a clinical review of Resident#2's admission should have caught the error. She said that the risk to Resident#2 was the worsening of wounds and infection. In an interview on 10/09/2025 at 5:30pm with ADON B, she said that she worked on 09/30/2025 and 10/01/2025 from 10:00pm -6:00am. She said that she did not assist with the admission of Resident#2, and the admission was completed by LVN A. She said that LVN A did tell her that Resident #2 admitted with wounds with treatment orders from the hospital. She said that she did complete Resident#2's wound care on 10/01/2025. She said that no one communicated to her to complete a skin assessment as the treatment nurse for Resident#2. She said that she is not the treatment nurse for the facility, but she does help with wound care. She said that she started as an ADON on 10/09/2025, prior to she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025. In an interview on 10/09/2025 with the DON, she said that she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted on [DATE]. She said that there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator present. She said that the clinical review should be to review the admission process for accuracy and correcting errors made. She said that she had not completed an assessment of Resident#2 since the time of admission. She said that she was not aware of Resident#2 to have not received antibiotics from the time of admission. She said that she was not aware that Resident#2 did not have skin assessment completed by a treatment nurse after admission. She said that it was the responsible of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse. She said that she was not aware that resident did not have orders to treat all wounds or wound consult upon admission. She said that she was not aware that Resident#2 had missed a dialysis treatment after admission. She said that she could not recall if there was a clinical review of Resident#2 after admission, and if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41pm with the Administrator, she said that she does not always stay for daily clinical meetings with the clinical department heads after the daily stand up meeting. She said that she did not believe that she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said that the DON is the clinical oversight for the facility. She said that the DON should review all new admissions, re-admission, change in conditions, and the 24 hour report for accuracy. She said that the DON should review all medical clinical records prior to a residents admission. In an observation on 10/10/2025 9:32am at the beside of Resident#2 who was non-verbal or interviewable . In an interview on 10/10/2025 at 9:38am with in-house Hemodialysis Nurse, she said that on 10/03/2025 Resident#2 could not receive hemodialysis due to a change in condition, elevated heart rate around 120 beats each minute, she contacted the Nephrologist who ordered Metoprolol to Resdient#2, and she communicated with Resident #2's nurse(name unknown) about the the order for Metoprolol. She said that Resident#2 was referred back to the facility nurse (name unknown) for further intervention and treatment. She said that when a resident does not receive hemodialysis as scheduled, they are usually sent to the hospital to receive hemodialysis. She said that she later found out that Resdient#2 was not sent to the hospital. In a phone interview on 10/10/2025 at 10:05 am with RN A who worked the 10:00pm-6:00am, said she notified NP A that Resident #2 had not received her hemodialysis on that 10/03/2025, because her hear rate was too high. RN A said NP A gave an order to re-evaluate Resident #2's vital signs and heart rate within an hour and call him back. She said that Resident#2's heart rate remain high, she sent a text message to notify NP A, NP A never responded to her text, and she did not receive any orders to administer medications to Resident #2. She said that she never administered any medication to Resident #2 because it was the end of her shift and that the Hemodialysis Nurse was the one who gave Resident #2 Metoprolol. RN A did not reply when asked why she documented in Resident #2's SBAR dated 10/03/2025 that she had spoken with NP A and received orders for medication Metoprolol. RN A said that this all happened at the end of her 10pm-6am shift, and she gave report to the on-coming nurse(LVN D) about Resident #2's elevated heart rate and missed dialysis. RN A said she could not recall if she specifically asked NP A about any orders for Resident #2 to receive dialysis and said she did tell NP A that Resident #2 had missed or was unable to get dialysis that day. RN A said she either told ADON A or LVN D about the missed dialysis and elevated HR, she was unsure if she did tell ADON A or LVN D, and unsure if she documented the information on the 24 hour report In an interview on 10/10/2025 at 11:10am with NP B, he said that he is the nurse practitioner for the facilities Medical Director. He said that Resident#2 admitted on [DATE] while he was off, NP B covered for him, and NP B saw Resident#2 on 10/01/2025. He said that Resident#2 admitted with wounds, and she was being treated with IV antibiotics, Zosyn, for UTI and Wound culture for E.Coli while in hospital, and the Zosyn was to continue for 2 weeks after discharge. He said that he was asked to see resident number today on 10/10/2025 by the Medical Director and that was his first time meeting Resident#2. He was unsure when the Resident#2 received the first dosage of the Zosyn, but it should start no later than the next day after admission. He said that his expectation would be that all medications and treatments start no later than the next day after the order is given. He said that the risk is that conditions or infections could worsen. He said that it was his expectation that a physician or nurse practitioner be notified when medications were not available to seek additional orders to treat. He said that if he had been notified that Resident#2's Zosyn was not available he would have send her back to the hospital, as there would ve no reason for her to remain in the building without the medications, and the risk to Resident#2 would have been the infection could have worsen. He said that he was not aware of Resident#2 to missed dialysis for any day or reason, but the physician should be notified if there was a change in condition that would affect a resident not receiving dialysis or any care. He said that if a resident missed dialysis, they would be sent to the hospital to get the treatment. He said that it was important for staff to notify a physician of wounds upon admission and once identified. He said that the standards were to continue with orders from the hospital until a wound care physician can take over or the primary physician makes changes to the treatment from the hospital. In an interview on 10/10/2025 at 11:10am with the DON A, she said that RN A completed the SBAR on 10/03/2025 for Resident#2, she reviewed the SBAR (Situation, Background, Assessment, and Recommendation), and there was nothing documented about a change in the residents conditions that prevented Resident#2 from receiving dialysis, that notification was made to a physician or nurse practitioner, or what a physician or nurse practitioner wanted to do about the missed dialysis. In an interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident#2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records. He said that he rounded with Resident#2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia. He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day. He said that if he had been informed, he would have decided on a different treatment plan. He said that he was not contacted to address interventions for a missed hemodialysis on 10/03/2025, he was notified of an elevated heart rate during dialysis that was addressed by another doctor. He said that he would not speak on risks to residents, or if Resident#2 should have been sent to the hospital. He said that his expectation is that staff make enter orders from the time of admission, follow orders, and make notifications to a physician when medications are not available, treatments are missed, and when there is a change in condition. In an interview and observation on 10/10/2025 4:59pm at the beside of Resident#2 of ADON B to perform Resident#2's wound care treatment with MA E, and DON present. Both ADON B and MA E said that Resident#2 were medicated prior to treatment for pain. Observation of ADON B to cut away the bandage to Resident#2 left foot that was stuck to the wound without using a saline spray to loosen the bandage. ADON B was observed not to look a Resident#2 to non verbal signs of pain. Resident#2 was observed to show facial grimace. ADON B was asked if she would use a saline spray to loosen the bandage in which she did, and continued to pull the bandage from the wound. Resident#2 was observed with tears in both eyes. ADON B was asked what medication was used to manage the pain of Resident#2, to which she replied Extra Strength Tylenol. ADON B was asked to stop the treatment. DON A told ADON B to contact the physician to see if Resident #2 could have something stronger for pain. In an interview on 10/10/25 at 5:26pm with the Administrator A, she was told of the observation made of Resident#2's wound care and concern for pain management. Administrator A said the concerns were clinical concerns and she would have to speak with the DON Ato gather more information on the sit

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on , interview and record review the facility failed to ensure the resident had the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law for 1 of 13 residents (Resident #7) reviewed for resident rights. The facility failed to establish if Resident #7 wished to designate a Responsible Party at the time of his admission on [DATE] when he was alert and oriented and able to make his wishes known. This failure could place residents at risk for a diminished quality of life, loss of dignity and loss of self-worth. Findings include: Record review of Resident #7's face sheet, dated 10/23/2025, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #7 had a principal diagnosis of Total retinal detachment, bilateral(the retina in both eyes has fully detached from the back of the eye). He was designated to be his own responsible party. Record review of Resident #7's care plan, dated 09/01/2025, reflected:Focus: Resident #7 is his own responsible party. Date Initiated: 10/16/2025Goal: Resident #7 will manage his own personal affairs such as making medical appointments, outings in the community, choice of insurance, etc. Date Initiated: 10/16/2025Interventions: Resident #7 allows 2 friends to assist him with making personal decisions regarding his medical care. Date Initiated: 10/16/2025. Focus: Resident #7 has impaired visual function r/t bilateral retinal detachment Transfer: Supervision set-up x1 with cane/walking stick.Goal: Resident #7 will have no indications of acute eye problems through the review date. Interventions: Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Tell the resident where you are placing their items. Be consistent. Record review of Resident #7's admission progress note, dated 02/20/2025, reflected he was alert and oriented times 4 at the time of his admission. Record review of Resident #7's admission MDS assessment, dated 03/19/2025, and last quarterly MDS assessment, dated 09/11/2025, reflected he had a BIMS score of 15 to indicate his cognition was intact. Record review of Resident #7's 72-hour care plan meeting progress note, dated 02/21/2025, reflected the meeting was held with Resident #7, with no information about designating a responsible party. Record review of a grievance, dated 10/03/2025, to involve Resident #7, reflected the resident was upset because his insurance was changed to PPHP and a pending appointment would be missed on 10/03/2025. The grievance was resolved after it was confirmed with PPHP the RP authorized the insurance change, although the RP denied changing the insurance. The grievance was resolved with Resident #7 being named his own responsible party, he disenrolled in PPHP insurance, re-enrolled with previous insurance provider, and his procedure was rescheduled for 11/5/2025. In an interview on 10/14/2025 at 11:48 AM, Resident #7 said he had been at the facility since February of 2025. He stated he was legally blind. He said he found out from an insurance agent with PPHP his insurance had been changed by Former RP. He said the Former RP could not have signed to change his insurance because he resided out of state. He said he called the Former RP in the presence of Administrator A and the Former RP denied signing any paperwork to change his insurance provider. In a phone interview on 10/21/2025 at 12:28pm with the previous RP, he said he always made it clear he was not Resident #7's responsible party and he was only next of kin. He said it was his understanding he would be contacted in the event of an emergency. He said Resident #7's health was not good at the time of admission but he had enough mental capacity to make his own decision then and now. He said someone called him about a special problem that would not be a charge to Resident #7, that would provide him with snacks and do his nails, but he told the person they would need to contact Resident #7 at the facility. He denied he authorized a change in Resident #7's insurance. In an interview on 10/22/2025 at 10:25 AM, Resident #7 said he was legally blind and his previous health insurance plan covered for him to have eye surgery, but when his insurance plan was changed the physician doing the surgery was no longer in network. He said the Former RP denied he changed the insurance, and he never told anyone at the facility the Former RP could make his decisions a RP. He said he was now his own RP at the facility he switched his insurance back and he was scheduled to have his eye surgery in November of 2025. He said the eye surgery was to help him regain some of not all his eyesight. He said his surgery was delayed for about one month. In an interview on 10/23/2025 at 12:12 PM with the Social Worker, he said Resident #7 filed a grievance after he went to a pre-operation appointment with an eye surgeon to discover the physician was no longer in network with his current insurance provider, PPHP. He said Resident #7 was blind, and he believed the surgery was to restore or improve his eyesight. He said while investigating the grievance Resident #7 was told his RP authorized the change in insurance. He said Resident #7 expressed wanting to be his own responsible party, he wanted to be clear his family member did not make his decisions, never made decisions on his behalf, and no one at the facility asked him if he wanted a responsible party. He said he believed the admission Coordinator and the BOM established the responsible party at the time of admission. He said there should be a conservation at the time of admission with a resident about who they wanted to be the responsible party. He said Resident #7 had always been verbal, with a BIMS of 15, alert and oriented, and able to make his wishes known. He said it would have been a violation of resident rights if he was not consulted about who he would want to be his responsible party at the time of his admission. In an interview on 10/23/2025 at 2:08 PM with Resident#7, he said no one ever asked him about his wishes at the time of admission about who he would want to be his responsible party. He said he should have been asked, his cognition was intact, and he had a high IQ. He said that because he was not his own RP at the time of admission, someone was able to change his insurance without his knowledge, and his was not able to have his eye surgery. In an interview on 10/23/2025 at 3:23 PM with admission Coordinator A, she said she started at the facility on 09/08/2025. She said if a resident was alert and oriented time 3-4, the resident should be asked about who they would want to be a responsible party. She said if relative signed a resident into the facility, the resident if alert and oriented should still be consulted on if they wanted the relative who signed them in to be the responsible party or emergency contact at the time of admission. She said if a resident was not consulted it would be a violation of the resident's rights. She said that she had not had conversations with Resident#7 because he admitted prior to her hire date. In an interview on 10/23/2025 at 4:12 PM with the BOM, she said her duties were to process admission packets, establish financial responsibility, an a payer source at the time of admission. She said the Admissions Coordinator advised her who to contact as the responsible party at the time of admission to establish financial responsibility. She said it should be determined if a resident was alert and oriented, had the cognitive ability to know what they were signing in efforts to be the responsible party and the sign admission packet at the time of admission. She said there was a 72 hour care plan with Resident #7 after his admission in which he stated he wanted his family member to be his responsible party, and it was documented in a progress note. In an interview on 10/23/2025 at 4:38 PM with the MDS Coordinator, she said the admission Coordinator and BOM worked together to establish a responsible party at the time of admission. She said if a resident was alert and oriented the resident could participate in their plan of care and make their wishes known about who should be the responsible party. She said the resident had a right to know and appointment someone to make their decisions. She said she signed off on all of Resident #7's MDS assessments from the time of admission in which he had a BIMS of 15, to indicate he was cognitively intact, and able to make his own decisions. She said she was at the 72-hour care plan, and there was never a conversations with Resident #7 about who he wanted to be his responsible party. She received the progress note, dated 02/21/2025, of the care plan and indicted there was no documentation about who would be the responsible party. She said she was under the impression Resident #7's family member was his responsible party from the time of admission, until it was changed after the resident expressed concerns about being his own responsible party, and she had a discussion with the Social Worker who said he wanted it changed to himself on 10/14/2025. In a phone interview on 10/27/2027 at 12:11 PM with Admissions Coordinator B, she worked at the facility for one year, and her last day was sometime in August 2025 or September of 2025. She said establishing who was going to be a residents RP at the time of admission and entering the information in the resident electronic medical record was part of her job duties. She said if a resident was alert and oriented, they should be consulted about who the RP would be at the time of admission, if a resident was not consulted when they were able to make their wishes known, it could be a violation of their resident rights. She said she recalled Resident #7, and he was able to make his wishes known at the time of his admission. She said Resident #7's family member was the RP at the time of admission, she was unsure why he needed an RP when he was able to make his wishes known, and she did not recall asking Resident #7 if he wanted an RP. In an interview with the Administrator, RNC B and Interim DON present, the Administrator said a resident who was alert and oriented at time of the admission, should be consulted about their wishes of who they wanted to be their responsible party. The Administrator said Resident #7 always was alert and oriented, but she was unsure of his BIMS score. The Administrator said she was not aware of conversations between Resident #7, the family and staff about Resident #7's wishes at the time of the admission about who would the responsible party. She said since corporate entities changed on 07/01/2025, she no longer had access to their policies. Both RNC B and the Interim DON said a resident who was alert and oriented at the time of the admission, should be consulted about their wishes of who they wanted to be their responsible party from the time of admission under the current cooperate entity. Record review of a witness statement, dated 10/24/2025, signed by the BOM, read in part On February 24, 2025; we have a 72 hour care plan conference regarding the admission and financial paperwork. stated, I have an [family member] we can call at this time who will be signing the required documents and his primary point of contact. Record review of the facility's, undated, policy of current corporate entity, titled Resident Rights, read in part, The resident has a right to a dignified existence, self-determination, and communication with a and access to persons and services inside and outside the facility, include those specified in this policy . Exercise of Rights - the resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. 1. The facility must ensure the resident can exercise his or her right without interference, coercion discrimination, or reprisal from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from neglect for 2 of 13 residents (CR#1 and Resident #2) reviewed for neglect.1. The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE].2. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.3. The facility failed to notify Resident #2's Physician when she was unable to receive Hemodialysis treatment as ordered on 10/03/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.4. The facility failed to notify Resident #2's Physician when Resident # 2 had not received all ordered treatments for all of her 14 wounds from 09/30/2025 through 10/02/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.5. The facility failed to notify Resident #2's Physician when the orders given on 10/02/2025 for wound care had not been entered into Resident #2's electronic medical records or implemented from 10/02/2025 through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 6. The facility failed to notify Resident #2's Physician when Resident #2 had only as needed, over the counter regular strength Tylenol ordered for pain medications, had not received any pain medication prior to any of the wound care treatments, or had not had pain assessments prior to wound treatments for her 14 wounds. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. An Immediate Jeopardy (IJ) was identified on 10/13/2025. The IJ template was provided to the facility on [DATE] at 12:13 PM. While the IJ was removed on 10/20/2025, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place residents at risk for delayed treatment, worsening of condition, increased pain, hospitalization, and death Findings include:1. Record review of CR#1's face sheet, dated 09/30/2025, reflected a [AGE] year-old male, who admitted to the facility on [DATE]. CR#1 had a diagnosis which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness resulting from a stroke). CR#1 was transferred to a local hospital on [DATE] related to a percutaneous gastrostomy endoscopic (PEG) tube replacement (feeding tube replacement). Record review of CR#1's admission MDS assessment, dated 06/03/2025, reflected a BIMS was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making. In Section M for skin, he was triggered to have 1 stage 2 pressure ulcer upon admission. Record review of CR#1's comprehensive care, dated 09/26/2025, reflected:Focus: CR#1 has a pressure ulcer to the sacrum, back (2), left ankle, left foot, left heel, Right lower legand right heel related to limited mobility, incontinence, end stage skin failure.Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer treatments as ordered and monitor for effectiveness. Record review of CR#1's hospital clinical record, dated 05/27/2025, reflected a pressure ulcer located to the buttock on 05/26/2025, with no orders identified for continued treatment upon discharge. Record review of CR#1's progress notes, dated 05/28/2025 at 9:56 PM by ADON B, read in part, .[CR#1] has dressing to sacral area and has a peg tube. No other skin issues observed to resident. Record review of CR#1's total body skin assessment, dated 05/29/2025, reflected 1 wound with no documentation of the wounds stage or size. Record review of CR#1's MAR for the month of May of 2025 reflected no wound care treatment. Record review of CR#1's May 2025 order summary reflected no orders for wound treatment or wound consult. Record review of CR#1's physician order, dated 06/03/2025, read in part, wound (1) pressure stage 2 coccyx (tailbone). Cleanse with normal saline or wound wash, pat dry, apply comfort foam border 2x (times) weekly and PRN (as needed) if soiled or dislodged. Record review of CR#1's MAR for the month of June of 2025 reflected wound care treatment for a stage 2 coccyx an initial documentation on 06/04/2025. 2. Record review of Resident #2's face sheet, dated 10/09/2025, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had a principal diagnosis which included cerebral infarction, unspecified (stroke), admitting diagnosis of sepsis due to Escherichia Coli (E.Coli a bacteria) and serve sepsis with septic shock (a life-threatening condition that occurs when an infection leads to dangerously low blood pressure and organ failure), and secondary diagnosis of End Stage Renal Disease[ESRD] the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment) pressure ulcer of sacral region, unstable, and UTI, site not specified. Secondary diagnosis, dated 10/03/2025 for pressure ulcers of right buttock stage 4, left buttock stage 4,right ankle unstageable, left ankle unstageable, left heel unstageable, and other site unstageable. Secondary diagnosis, dated 10/03/2025, for non-pressure chronic ulcer of right heel and midfoot, right foot, and left foot with fat layer exposed. Record review of Resident#2's admission assessment dated [DATE] reflected a BIMS(Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making in Section C. In Section I for active diagnosis, she was triggered for ERSD, Pneumonia, Septicemia, and UTI. In Section M for skin, she was triggered to have 2 stage 4 pressure ulcers, 6 unstageable pressure ulcers, and 5 venous and arterial ulcers present upon admission. In section M she was triggered to have infection of the foot e.g., cellulitis (a common bacterial infection of the skin and underlying tissues), purulent drainage. In Section N for Medications, she was triggered to have antibiotics. In Section O for Special Treatments, Procedures, and Programs, she triggered to have IV medication and hemodialysis. Record review of Resident #2's comprehensive care, dated 10/06/2025, reflected:Focus: Resident #2 had pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, DM, incontinence. Present on admission: Two stage 4, Six unstageable, Five Venous/arterial ulcers, One diabetic foot ulcer. Goal: Resident #2's Pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer protein supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Administer Vitamin C as ordered. Administer Zinc as ordered. Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Focus: Resident #2 is on Antibiotic Therapy r/t sepsis r/t wounds, UTI, and aspiration PNA.Goal: Resident #2 will be free of any discomfort or adverse side effects of antibiotic therapy through the review date.Intervention: Administer medication as ordered. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush ( fungal infection of the mouth), colitis (inflammation of the lining of the colon), and vaginitis (an inflammation of the vagina). Any antibiotic may cause diarrhea, nausea, vomiting, anorexia (a serious and potentially life-threatening eating disorder), and hypersensitivity/allergic reactions. Monitor q-shift for adverse reaction. Observe for possible side effects every shift. Report pertinent lab results to MD.Focus: Resident #2 needs hemodialysis MWF r/t renal failure.Goal: The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Intervention: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (MWF). Monitor labs and report to doctor as needed. Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report to MD PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report to MD PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report to MD PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Record review of Resident #2's comprehensive care plan review with a review, completed date of 10/06/2025, reflected no care plan for pain. Record review of Resident #2's hospital clinical record, dated 09/25/2025, reflected diagnosis of sepsis (a life-threatening condition where the body's extreme response to an infection damages its own tissues and organs) with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene. Plan, Zosyn 2.25g IV every 8 hours for pansensitive E. coli wound culture plus empirical anaerobic coverage. Anticipate another 2 weeks of IV antibiotics. Record review of Resident #2's hospital clinical discharge record, dated 09/29/2025, reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% SOLN100 ml with piperacillin-tazobactam (Zosyn) 4.5 (4-0.5) g SOLR 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty: 100 GM, refills: 0. The discharge summary did not give an account of how many wounds were identified while Resident #2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident #2 discharged to treat the wounds. Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part: wound care orders for her sacrum and right lateral ankle/foot. Arterial changes to RLE. Toes continue to harden, gangrenous. Right lateral leg remains purple/black. Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI. Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2PM so she can be admitted to the facility.Tomorrow will be her dialysis day and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning.Record review of Resident #2's facility phone medication order, date 09/30/2025 at 7:15 PM for piperacillin sod-tazobactam (piperacillin sodium-tazobactam sodium) So intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident #2's MAR for the month of September 2025 reflected no Zosyn was administered to Resident #2 on her admission day of 9/30/2025.Record review of Resident #2's initial skin assessment, dated 09/30/2025 at 9:22 PM, by LVN A, read in part, .[Resident #2] had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings: Pressure wound to sacral area, DTI to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle. Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of the Resident #2's physician order summary report reflected the following orders to treat a DTI to the right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of the Resident #2's physician order summary report reflected that a wound consult was not entered at Resident #2's admission on [DATE] and was entered an implemented 10/02/2025. Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's hospital records ,dated 09/29/2025, reflected she had the following as needed (PRN) orders for pain:Acetaminophen 650 mg tablet Q 6 hours PRN mild pain.Acetaminophen 650 mg tablet Q 6 hours PRN pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM.Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours PRN for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 PM. Record review of Resident #2's MAR, dated 09/01/25, through 09/30/25 reflected Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident #2's facility Order Recap, dated September 2025, reflected an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. Continued record review revealed the order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's MAR for the month of October 2025 reflected Zosyn was administered to Resident #2 on 10/04/2025 at 8:00 PM for the initial dose. Record review of Resident #2's initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone). Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 2; Unstageable (Due to necrosis [cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function]) Right, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of Resident #2's physician order summary, for October 2025, reflected the orders provided initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A were not entered until 10/04/2025. Record review of Resident #2's MAR, dated 10/01/25, through 10/31/25 reflected the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Records Record review of Resident#2's progress note dated 10/03/2025 at 6:27am and completed by RN A reflected that NP A was notified of change, but there was no information detailing what the change was or orders to address the change. Records record review of Resident#2's SBAR, dated 10/03/2025 at 6:05 AM and completed by RN A, did not reflect specific information of notifying NP A her missed hemodialysis session or orders from NP A to address the missed hemodialysis session. Record reviews of Resident #2's electronic medical record reflect no PAINAD assessments completed for Resident #2 to show that Resident#1 had been assessed for pain. In an interview on 10/08/2025 at 3:09 PM with Treatment Nurse A, she said CR#1 admitted to the facility sometime in May 2025, he had a wound, but she was not sure of the location of the wound. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said wound care was documented the MAR, without an order there would be no way to document wound care treatment, and if the standard of practice was without documentation it did not happen. She said the risk of no wound care treatment from 05/28/2025-06/03/2025 could be the wound deterioration, possible infection, and possible hospitalization. She said to go without wound care treatment from 5/28/2025-06-3-2025 was a significant amount of time. In an interview on 10/08/2025 at 4:49 PM with ADON A, she said she started at the facility on 06/30/2025. She said CR#1 was already admitted to the facility when she started so she was not sure what wounds he had at the time of admission. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented in the MAR, without an order there would be no way to document wound care treatment, and the standard of practice was without documentation it did not happen. She said the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound got worse, became infected and could lead to hospitalization. She said CR#1 did not have orders upon admission to treat the wound on the coccyx on 05/28/2025, orders were entered on 06/03/2025, and initial treatment was completed on 06/04/2025. She said CR#'1s treatment was delayed, placing him at risk of wound worsening, infection, and hospitalization. In an interview on 10/08/2025 at 5:33 PM with DON A, she said she started at the facility on 05/27/2025. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented on the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said wound care was documented in the MAR, without an order there would be no way to document wound care treatment, and the standard of practice was without documentation, it did not happen. She said she reviewed the clinical record of CR#1, he admitted with a wound to the coccyx on 05/28/2025, there were no orders to treat the wound entered until 06/03/2025, he did not receive initial treatment until 06/04/2025, his treatment was delayed, and he was placed at risk of wound worsening, infection, and hospitalization. In an interview on 10/08/2025 at 6:18 PM with Administrator A, she said residents should have orders upon admission to treat wounds. She said if a resident admitted on [DATE] and did not have orders to treat a wound until 06/03/2025, that would be a delay in treatment. She said the risk to the resident could cause the wound to worsen depending on the clinical condition of the residents and location of wound. In an interview and observation on 10/09/2025 at 10:57 AM of ADON A to perform Resident #2's wound care with assistance from CNA A. ADON A said at the start of the treatment Resident #2 had been medicated for pain about 30-40 minutes prior. Resident #2 was observed to have tolerated the wound care treatment without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle, which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed as if she were in pain. Resdient#2 was not interviewable and non-verbal. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025. She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds. She said that she reconciled the medication list and treatments for the wounds with the on call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day. She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission. She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat. She said her clinical impression was that some of Resident #2's wounds were infected at the time of admission, and it was apparent she had recent debridement (a medical procedure that involves removing dead, infected, or damaged tissue from a wound) of the wounds prior to being discharged from the hospital. In an interview on 10/09/2025 at 4:36 PM with the Medical Director, she said she was the primary physician for Resident #2. She said staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments. She said she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission. She said a wound consult should have been made upon admission, and the orders given after the wound consult should have been entered and carried out. She said that Resident#2 IV antibiotics should have been arranged prior to admission, and if it was not available orders could be arranged to switch to an oral antibiotic until it was available. In a follow up interview on 10/09/2025 at 5:14 PM with ADON A, she said the admitting nurse completed an initial skin assessment at the time of admission. She said the treatment nurse should complete a second skin assessment on new admissions with wounds identified within 24 hours of admissions. She said the treatment nurse should review the facility clinical records and hospital clinical records. She said the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made. She said there should be a clinical review of all new admissions the next business day with Administrator A and clinical department heads present. She said she worked as the treatment nurse on 09/30/2025 and 10/01/2025. She said Resident #2 admitted on [DATE] with wounds. She said she did not complete the second skin assessment for Resident #2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she was not able to finish by the end of her shift. She said ADON B would have been responsible for completing Resident #2's wound care treatment after admission. She said she did not recall if she attended the clinical admitting on 10/01/2025. She said LVN A was responsible for ensuring medications and treatments were reconciled at the time of admission and entering the orders. She said Resident #2 did not have orders to treat all her wounds at the time of admission. She said that Resdient#2 did not have orders treat infections with Zosyn at the time of admission. She said a clinical review of Resident #2's admission should have caught the error. She said the risk to Resident#2 was the worsening of wounds and infection. In an interview on 10/09/2025 at 5:30 PM with ADON B, she said she worked on 09/30/2025 and 10/01/2025 from 10:00PM -6:00AM. She said she did not assist with the admission of Resident #2, and the admission was completed by LVN A. She said LVN A told her Resident #2 admitted with wounds with treatment orders from the hospital. She said she completed Resident #2's wound care on 10/01/2025. She said no one communicated to her to complete a skin assessment as the treatment nurse for Resident #2. She said she was not the treatment nurse for the facility, but she did help with wound care. She said she started as an ADON on 10/09/2025, prior to that she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025. In a follow up interview on 10/09/2025 with the DON, she said she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted to the facility on [DATE]. She said there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator A present. She said the clinical review should be to review the admission process for accuracy and correcting errors made. She said she had not completed an assessment of Resident #2 since the time of admission. She said that she was not aware Resident #2 did not have skin assessments completed by a treatment nurse after admission. She said it was the responsibility of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse. She said she was not aware Resident #2 did not have orders to treat all wounds or wound consult upon admission She said that she was not aware of Resident#2 to have not received antibiotics from the time of admission. She said she could not recall if there was a clinical review of Resident #2 after admission, and if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41 PM with Administrator A, she said she did not always stay for daily clinical meetings with the clinical department heads after the daily stand-up meeting. She said she did not believe she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said the DON was the clinical oversight for the facility. She said the DON should review all new admissions, re-admission, change in conditions, and the 24-hour report for accuracy. She said the DON should review all medical clinical records prior to a residents admission. In an observation on 10/10/2025 at 9:32 AM at the beside of Resident #2 revealed the resident was non-verbal or not interviewable. In an interview on 10/10/2025 at 9:38 AM with the in-house Hemodialysis Nurse, she said on 10/03/2025, Resident #2 could not receive hemodialysis due to a change in condition, which was an elevated heart rate around 120 beats each minute, she contacted the Nephrologist who ordered Metoprolol to Resident #2, and she communicated with Resident #2's nurse (name unknown) about the order for Metoprolol. She said Resident #2 was referred back to the facility nurse (name unknown) for further intervention and treatment. She said when a resident did not receive hemodialysis as scheduled, they were usually sent to the hospital to receive hemodialysis. She said she later found out Resident #2 was not sent to the hospital.In a phone interview on 10/10/2025 at 10:05 AM with RN A who worked the 10:00PM-6:00AM, said she notified NP A that Resident #2 had not received her hemodialysis on 10/03/2025, because her hea

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, a residents with pressure ulcers received necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 13 residents (CR #1 and Resident #2) reviewed for pressure ulcers. -The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE]/2025. 2.--The facility failed to identify and treat the wounds of Resident #2 from admission on [DATE]-[DATE]. An Immediate Jeopardy (IJ) situation was identified on 10/11/2025. While the IJ was removed on 10/20/2025, the facility remained out of compliance, at a scope of pattern with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for delayed treatment, worsening of condition, hospitalization, and death. Resident #2 was admitted to the hospital on [DATE] with a critically elevated white blood cell count (WBC), sepsis and had an above the knee amputation of both legs due to gangrene. Findings include: 1. Record review of CR#1's face sheet dated 09/30/2025, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE] with a principal diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness resulting from a stroke). CR#1 was transferred to a local hospital on [DATE] related to a percutaneous gastrostomy endoscopic (PEG) tube replacement (feeding tube replacement). Record review of CR#1's admission MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making. In Section M for skin, he was triggered to have 1 stage 2 pressure ulcer upon admission. Record review of CR#1's comprehensive care dated 09/26/2025 reflected: Focus: CR#1 has a pressure ulcer to sacrum, back (2), left ankle, left foot, left heel, Right lower leg and right heel related to limited mobility, incontinence, end stage skin failure. Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Intervention: Administer treatments as ordered and monitor for effectiveness. Record review of CR#1's hospital clinical record dated 05/27/2025 reflected a pressure ulcer located to the buttock on 05/26/2025. Record review of CR#1's progress notes dated 05/28/2025 9:56pm by ADON B, read in part, .CR#1 has dressing to sacral area and has a peg tube. No other skin issues observed to resident. Record review of CR#1's total body skin assessment dated [DATE] reflected 1 wound. Record review of CR#1's Medication Administration Record (MAR) for the month of May of 2025 reflected no wound care treatment. Record review of CR#1's May 2025 order summary reflected no orders for wound treatment or wound consult. Record review of CR#1's physician order dated 06/03/2025 read in part, wound(1) pressure stage 2 coccyx(tailbone). Cleanse with normal saline or wound wash, pat dry, apply comfort foam border 2x(times) weekly and PRN (as needed) if soiled or dislodged. Record review of CR#1's MAR for the month of June of 2025 reflected wound care treatment for a stage 2 coccyx an initial documentation on 06/04/2025. Record review of Resident #2's admission Record dated 10/22/2025 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. Record review of Resident#2's comprehensive care plan dated 10/06/2025 reflected: Focus: Resident#2 has pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, Diabetes Mellitus (DM), incontinence. Present on admission: Two stage 4, Six unstageable (a type of pressure ulcer or wound that cannot be accurately staged due to the presence of slough [dead, yellow or gray tissue that forms in a wound] or eschar [a layer of dead, dried tissue that forms over a wound]), Five Venous (a chronic open sore that develops when blood pools in the veins of the lower legs)/arterial (a break in the skin that occurs when there is a blockage or narrowing of the arteries) ulcers, One diabetic foot ulcer. Goal: Resident#2's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer protein supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Administer Vitamin C as ordered. Administer Zinc as ordered. Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Record review of Resident#2's hospital clinical record dated 09/25/2025 reflected diagnosis of sepsis with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene. Plan, Zosyn 2.25g IV every 8 hours for pan sensitive E. coli wound culture plus empirical anaerobic coverage. Anticipate another 2 weeks of IV antibiotics. Record review of Resident#2's hospital clinical discharge record dated 09/29/2025 reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% SOLN(solution) 100 ml (Milliliter) with piperacillin-tazobactam (Zosyn)4.5 (4-0.5) g(gram) SOLR(Solution Reconstituted) 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty(quantity): 100 GM(gram), refills: 0. The discharge summary did not give an account of how many wounds were identified while Resident#2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident#2 discharged to treat the wounds. Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part: wound care orders for her sacrum and right lateral ankle/foot. Arterial changes to RLE. Toes continue to harden, gangrenous. Right lateral leg remains purple/black. Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI. Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2pm so she can be admitted to the facility.[sic]Tomorrow will be her dialysis today and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning. Record review of Resident#2's facility phone medication order date 09/30/2025 at 7:15pm for piperacillin sod-tazobactam ((piperacillin sodium-tazobactam sodium) intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident#2's MAR for the month of September 2025 revealed no Zosyn administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident#2's MAR for the month of October 2025 reflected Zosyn administered to Resident #2 on 10/04/2025 at 8:00pm for the initial dose. Record review of Resident #2's initial skin assessment dated [DATE] at 9:22pm by LVN A, read in part, .Resident #1 had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings: Pressure wound to sacral area, DTI(Deep Tissue Injury) to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle. Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of the Resident#'2 physician order summary report reflected the following orders to treat a DTI to right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of the Resident#'2 physician order summary report reflected a wound consult was not entered at resident#2's admission on [DATE] and was entered an implemented 10/02/2025. Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone). Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 2; Unstageable (Due to necrosis (cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function) Right, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days, Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm /Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days. Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days, Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days. Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of physician order summary for October 2025 reflected that the orders provided initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A were not entered until 10/04/2025. In an interview on 10/08/2025 at 3:09pm with Treatment Nurse A, she said that she started at the facility in 2022 as a floor nurse but was promoted to weekend treatment nurse in 2005. She said that CR#1 admitted to the facility sometime in May 2025, he had a wound, but she was not sure of the location of the wound. She said that residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said that the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound deterioration, possible infection, and possible hospitalization. She said that to go without wound care treatment from 5/28/2025-06/03/2025was a significant amount of time. In an interview on 10/08/2025 at 4:29pm with ADON A, she said that she started at the facility on 06/30/2025. She said that CR#1 was already admitted to the facility when she started so she was not sure what wounds he had at the time of admission. She said that residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said that the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound gets worse, becomes infected, and could lead to hospitalization. She said that CR#1 did not have orders upon admission to treat wound on the coccyx on 05/28/2025, orders were entered on 06/03/2025, and initial treatment was completed on 06/04/2025. She said that CR#'1s treatment was delayed placing him at risk. In an interview on 10/08/2025 at 5:33pm with DON A, she said that she started at the facility on 05/27/2025. She said that residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented on the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said that residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said that she reviewed clinical record of CR#1, he admitted with a wound to the coccyx on 05/28/2025, there were no orders to treat the wound entered until 06/03/2025, he did not receive initial treatment until 06/04/2025, his treatment was delayed, and he was placed at risk. In an interview on 10/08/2025 at 6:18pm with the Administrator, she said that residents should have orders upon admission to treat wounds. She said that if a resident admitted [DATE] and did not have orders to treat a wound until 06/03/2025 that would be a delay in treatment. She said that the risk to the residents could be that the wound could worsen depending on the clinical condition of the residents and location of wound. Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025. She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds. She said that she reconciled the medication list and treatments for the wounds with the on-call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day. She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission. She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat. She said that her clinical impression was that some of Resident#2's wounds were infected at the time of admission, and it was apparent that she had recent debridement of the wounds prior to being discharged from the hospital. In an interview on 10/09/2025 at 4:36pm with the Medical Director, she said that she was the primary physician for both CR#1 and Resident #2. She said that staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments. She said that she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission. She said that Resident #2 IV antibiotics should be arranged prior to a resident's admission, and if it's not available orders could be arranged to switch to an oral antibiotic until it was available. She said that a wound consult should be made upon admission, and orders should be given after the wound consult should be entered and carried out. In a follow up interview on 10/09/2025 at 5:14pm with ADON A, she said that that the admitting nurse completes an initial skin assessment at the time of admission. She said that the treatment nurse should complete a second skin assessment on new admission with wounds identified within 24 hours of admissions. She said that the treatment nurse should review the facility clinical records and hospital clinical records. She said that the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made. She said that there should be a clinical review of all new admissions the next business day with the Administrator and clinical department heads present. She said that she worked as treatment nurse on 09/30/2025 and 10/01/2025. She said that Resident #2 was admitted on [DATE] with wounds, and orders for Zosyn. She could not recall if the order for Zosyn was to treat a wound infection or UTI. She said that she did not complete the second skin assessment for Resident #2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she is not able to finish by the end of her shift. She said that ADON B would have been responsible for complete Resident #2's wound care treatment after admission. She said that she did not recall if she attended the clinical admitting on 10/01/2025. She said that LVN A was responsible for ensuring that medications and treatments were reconciled at the time of admission and entering the orders. She said that Resdient#2 did not have orders treat all her wounds or Zosyn at the time of admission. She said that a clinical review of Resident#2's admission should have caught the error. She said that the risk to Resident#2 was the worsening of wounds and infection. In an interview on 10/09/2025 at 5:30pm with ADON B, she said that she worked on 09/30/2025 and 10/01/2025 from 10:00pm -6:00am. She said that she did not assist with the admission of Resident#2, and the admission was completed by LVN A. She said that LVN A did tell her that Resident #2 was admitted with wounds with treatment orders from the hospital. She said that she did complete Resident #2's wound care on 10/01/2025. She said that no one communicated to her to complete a skin assessment as the treatment nurse for Resident #2. She said that she is not the treatment nurse for the facility, but she does help with wound care. She said that she started as an ADON on 10/09/2025, prior to she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025. In a follow up interview on 10/09/2025 with the DON, she said that she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted on [DATE]. She said that there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator present. She said that the clinical review should be to review the admission process for accuracy and correcting errors made. She said that she had not completed an assessment of Resident #2 since the time of admission. She said that she was not aware of Resident#2 having not received antibiotics from the time of admission. She said that she was not aware that Resident #2 did not have skin assessment completed by a treatment nurse after admission. She said that it was responsibility of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse. She said that she was not aware that resident did not have orders to treat all wounds or wound consult upon admission. She said that she was not aware that Resident #2 had missed a dialysis treatment after admission. She said that she could not recall if there was a clinical review of Resident #2 after admission, and if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41pm with the Administrator, she said that she does not always stay for daily clinical meetings with the clinical department heads after the daily stand-up meeting. She said that she did not believe that she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said that the DON was the clinical oversight for the facility. She said that the DON should review all new admissions, re-admission, change in conditions, and the 24-hour report for accuracy. She said that the DON should review all medical clinical records prior to a residents admission. In an interview on 10/10/2025 at 11:10am with NP B, he said that he is the nurse practitioner for the facilities Medical Director. He said that Resident#2 admitted on [DATE] while he was off, NP B covered for him, and NP B saw Resident#2 on 10/01/2025. He said that Resident#2 admitted with wounds, and she was being treated with IV antibiotics, Zosyn, for UTI and Wound culture for E. Coli while in hospital, and the Zosyn was to continue for 2 weeks after discharge. He said that he was asked to see resident number today on 10/10/2025 by the Medical Director and that was his first time meeting Resident#2. He was unsure when the Resident#2 received the first dosage of the Zosyn, but it should start no later than the next day after admission. He said that his expectation would be that all medications and treatments start no later than the next day after the order is given. He said that the risk is that conditions or infections could worsen. He said that it was his expectation that a physician or nurse practitioner be notified when medications were not available to seek additional orders to treat. He said that if he had been notified that Resident#2's Zosyn was not available he would have send her back to the hospital, as there would be no reason for her to remain in the building without the medications, and the risk to Resident#2 would have been the infection could have worsen. He said that it was important for staff to notify a physician of wounds upon admission and once identified. He said that the standards were to continue with orders from the hospital until a wound care physician can take over or the primary physician makes changes to the treatment from the hospital. In a telephone interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident #2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records. He said that he rounded with Resident #2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia. He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day. He said that if he had been informed, he would have decided on a different treatment plan. He said that he was not contacted to address interventions for a missed hemodialysis on 10/03/2025, he was notified of an elevated heart rate during dialysis that was addressed by another doctor. He said that he would not speak on risk to residents, or if Resident#2 should have been sent to the hospital. He said that his expectation is that staff make enter orders from the time of admission, follow orders, an

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 1 resident (Resident #2) reviewed for adequate supervision. The facility failed to provide adequate supervision to prevent Resident #2 from eloping from the facility at 2:05 a.m. on 5/6/25 .The noncompliance was identified as Past Non-Compliance. The IJ began on 5/6/25 and ended on 6/6/25 . The facility had corrected the noncompliance before the survey began. The failure placed residents with wander guards at risk of serious harm or death. Findings included:Record review of Resident #2's face sheet dated 7/9/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities), Muscle Wasting and Atrophy (decrease in size), and Other Abnormalities of Gait (a person's manner of walking) and Mobility. Record review of Resident #2's annual MDS dated [DATE], section C revealed a BIMS score of 6 that indicated severe cognitive impairment. Section E revealed Resident #2 had exhibited wandering daily but did not place him at significant risk of getting to a potentially dangerous place or significantly intrude on the privacy or activities of others. Section GG regarding Resident #2's Functional Abilities revealed he needed partial/moderate assistance for oral hygiene, toileting hygiene, showering/bathing, dressing, putting on/taking off footwear and substantial/maximal assistance for personal hygiene. Section V regarding Care Area Assessments revealed Resident #2 was reviewed for risks in the following areas: Cognitive Loss/Dementia (dated 4/11/2025), Communication (dated 4/11/2025), ADL Functional/Rehabilitation Potential (dated 4/11/2025), Urinary Incontinence and Indwelling Catheter (dated 4/11/2025), Behavioral Symptoms with care plan ongoing, Falls (dated 4/11/2025), and Psychotropic Drug Use (dated 4/11/2025). Record review revealed Resident #2 had an Elopement Risk Assessment completed on 2/27/25 that indicated Resident #2 was at risk of elopement. Record review of Resident #2's Care Plan revealed Resident #2 was care planned for being at risk for elopement related to wandering with date of initiation on 4/2/24. Resident #2 was also care planned regarding being noncompliant with wearing the wander guard and removing the wander guard after being applied. Interventions included wander guard with initiation date of 4/2/24with placement and function to be assessed every shift. Interventions added after the incident included Resident #2's family looking at 2 secure facilities due to noncompliance with wander guard with initiation date of 5/6/25 , and 1:1 (continuous observation) close monitoring with initiation date of 5/6/25 . Record review of Resident #2's MAR and TAR for May 2025 revealed from 5/1-5/6/25 that his wander guard was checked every shift with no documentation for night shift of 5/1/25 and sleeping was documented for night shift from 10 p.m. to 6 a.m. of 5/5/25 and 5/6/25 with no specific time documented . Wander guard was checked every four hours from 5/13/25 at 4 p.m. through 5/31/25 at 8 p.m. with no documentation for 5/21/25 at 12 p.m., 5/26 at 12 p.m. and 5/29/25 at 8 p.m. Wander guard was checked every night from 5/14-5/31/25. Safety checks were also documented every 30 minutes from 5/7-5/31/25. Record review of Resident #2's nursing progress note dated 5/6/25 at 12:01 a.m. by LVN B revealed, Resident observed not in bed during rounds. After searching around the unit and the neighborhood without finding resident. Facility management notified hence elopement protocol activated. Resident Responsible party notified. 911 called with police response. Physician also notified.Record review of statement written by CNA G on 5/6/25 revealed CNA G saw Resident #2 between 11:00 p.m. to 11:30 p.m. when CNA G took a snack to Resident #2, and he was asleep in his bed at that time and was not seen during the rest of CNA G's shift. Record review of statement written by LVN B on 5/6/25 revealed during shift report at 10:00 p.m. on 5/5/25 they were advised the door alarm in the Magnolia room (large sitting room) was going off. LVN B stated that about 12 midnight they made rounds on the unit and Resident #2 was not in his bed. LVN B stated that when they made rounds and Resident #2 was not in the center, they checked the Magnolia door, and it showed a green light (the door was operational) , and the door was secured and locked but could not recall the exact time this occurred. LVN B stated they notified CNA G at 12:15 a.m. to help look for Resident #2 and notified the other units to help search as well. Then 1 a.m. after still not being able to find Resident #2, LVN B drove to the nearby streets and neighborhood to search for him. LVN B returned to the facility at 1:45 a.m. and notified the administrator around 2 a.m. that Resident #2 was missing. LVN B notified the local Police Department and Resident #2's Responsible Party at 3:33 a.m.Record review of written statement, RN C revealed on 5/6/25 when they came on duty at 10 p.m. the alarm in the Magnolia room was going off. RN C stated that LVN B came to them at approximately 2 a.m. and told them that Resident #2 was no longer at the facility and then started a search inside and outside the facility. RN C stated the Administrator called them at 2:33 a.m. and had tried to reach LVN B but they were out looking for Resident #2. Record review of written statement, LVN C revealed there was a buzzing sound to the Magnolia door when they arrived for the 10 p.m. to 6 a.m. shift on 5/5/25. LVN C stated they checked the door at approximately 10:30 p.m. and it was secured. LVN C stated that LVN B notified them around midnight that Resident #2 was not at the facility, and they helped with an internal and external search of the facility but was unable to find Resident #2. Record review of written statement dated 5/12/25, CNA H stated they were notified that Resident #2 was missing about 1:30 a.m. but could not recall who notified them. CNA H stated they had gone to the Magnolia area and the door was unsecured. Per interview on 7/9/25 at 5:09 p.m., the Administrator said CNA H was no longer employed by the facility and was terminated for an unrelated offense and was angry. Record review of skin audit dated 5/6/25 but not timed revealed complete head to toe assessment with no wounds noted and vital signs were within normal limits. Record review of the Provider Investigation Report dated 5/12/25 regarding the elopement incident on 5/6/25 with Resident #2 revealed provider response included staff completed an audit of the elopement book for pictures and care plans to assure that all residents who were at risk had been included. Staff checked proper functioning/positioning of all Code Alert bracelets and all functioned as designed. Door checks to be conducted daily to assure proper function. Elopement drills for all three shifts on 5/6-6/7/25. In-services were immediately implemented for resident safety and Code Alerts during power loss and abuse, neglect, prevention of accidents and supervisions of residents. Ad Hoc QAPI was held with the medical director. Record review of facility's Elopement Binder revealed 1:1 logs for Resident #2 from 5/6-6/6/25 when it was documented per the log that Resident #2 was discharged [DATE]. The 1:1 logs showed documentation who was assigned to Resident #2 while he was under continuous monitoring. There was no documentation on the 1:1 logs from 10 p.m. on 5/10/25 to 6 a.m. on 5/11/25, from 2 p.m. on 5/23/25 to 6 a.m. on 5/24/25 (duplicate documentation from 2 p.m. to 6 a.m. noted on 5/23/25), from 2:10 p.m. to 5 p.m. on 5/27/25, from 6 a.m. to 8:30 a.m. on 5/28/25, from 10 p.m. on 5/28/25 to 6 a.m. on 5/29/25, from 2 p.m. to 5 p.m. on 5/30/25, from 10 p.m. on 6/4/25 to 8:30 a.m. on 6/5/25 and 6 a.m. to 7 a.m. on 6/6/25. Record review of facility's Elopement Binder revealed facility's audits for proper function and placement for code alert (wander guard) from 5/14 through 6/27/25, door checks from 4/28/25 through 7/4/25and elopement risk binders from 5/12/25 through 6/20/25 . Record review of facility's Elopement Binder revealed in services for Elopement, Response to Power Off on Exit Doors , Abuse and Neglect with objective staff will check wander guard placement every shift dated 5/6/25. The Elopement in-service included the objection to enhance staff monitoring and supervision by establishing protocols for appropriate staff supervision levels based on residents' risk assessments, encouraging regular observations and interactions. The Elopement in-service also included to implement individualized care plans. The Abuse and Neglect in-service included the objective staff will check wander guard placement every shift. All departments were included in the in-services with 130 staff members in-serviced regarding Elopement, 126 staff members in-serviced regarding Response to Power Off on Exit Doors and 136 staff members in-serviced regarding Abuse and Neglect. Record review of list of residents at risk of elopement provided during the investigation on 7/9/25 revealed there were four current residents at risk of elopement: Resident #3, Resident #4, Resident #5 and Resident #6. During interview on 7/9/25 at 11:06 a.m., LVN B said that they last saw Resident #2 between 11:00 p.m. to 12:00 a.m. and he was in bed and was wearing the wander guard. LVN B said Resident #2 was not in bed when they were making rounds around 12 a.m. but could not remember the exact time of the rounds. LVN B said they notified the administrator after searching inside and outside the facility. LVN B stated one of the doors had the alarm going off when they were searching for Resident #2 so that was when they thought he exited the building. LVN B said Resident #2 was not found before their shift ended at 6 a.m. LVN B said she had in-services regarding elopement that included to check the rooms, check the exit doors, and if the resident was missing then notify the administrator immediately. LVN B said Resident #2 had not tried to exit the facility before during their shift. During interview on 7/9/25 at 11:49 a.m., the Administrator said she was notified at 2:18 a.m. on 5/6/25 by LVN B of the elopement of Resident #2. The Administrator said that the Magnolia door was inspected on 5/6/25 after the incident and no issues were found. The Administrator said that Resident #2 was found by the Activities Director and Business Office after they started searching at 8 a.m. on 5/6/25 in addition to other staff members that were already searching for Resident #2. The Administrator said when Resident #2 was returned to the facility they replaced the wander guard and Resident #2 was placed on 1:1 supervision until he was transferred to the behavioral hospital. The Administrator said that staff should notify the Administrator and DON immediately when they realize a resident cannot be accounted for after performing a search of the facility. The Administrator said that Resident #2 had a history of removing the wander guard but was never exit seeking. The Administrator said that Resident #2 would maneuver off the wander guard. The Administrator said Resident #2 had no injuries or signs of distress when he was found. The Administrator said at the time of the incident on 5/6/25 all cameras were outside the facility and located in the Magnolia area which was the second lobby, one area of the dining room and the porch. During interview on 7/9/25 at 12:24 p.m., the Activities Director said they found Resident #2 around 9 a.m. sitting outside a car/mechanical shop at the intersection of two streets which was around a 25 minute walk from the facility per apple maps directions. The Activities Director said Resident #2 was tired and hungry when they found him but had no obvious injuries and was returned to the facility where an assessment by nursing was performed. On 7/9/25 at 12:52 p.m. all the exit doors to the facility were checked and sounded an alarm when tested. During interview on 7/9/25 at 1:20 p.m., the Administrator said Code Alert was the name for the wander guard they use. The Administrator said she did counsel LVN B who was the nurse involved in the elopement incident of Resident #2. Observation on 7/9/25 at 1:45 p.m. revealed the Administrator showing a video the Administrator stated was Resident #2 exiting the facility from the Magnolia door. An elderly man dressed in red clothing was seen walking away from the facility. The man was seen walking away from the building in the video at time stamp starting at 2:05:56 a.m. on Tuesday 5/6/25. During interview on 7/9/25 at 4:46 p.m., the Senior Maintenance said he checked the Magnolia door the day after the incident with Resident #2. The Senior Maintenance said he checked the wander guard system, keypad and everything locked down normally and everything was functioning as it should. The Senior Maintenance said that there were no prior problems with the door that he was aware of. The Senior Maintenance said the facility had done the life safety survey recently and all doors locked down with wander guard, released keypad and opened within the 15 second regulations. Observation on 7/10/25 at 9:09 a.m. revealed Resident #4's wander guard was intact on their left ankle. Observation on 7/10/25 at 9:11 a.m. revealed Resident #6's wander guard was intact on their left ankle. Observation on 7/10/25 at 9:16 a.m. revealed Resident #3's wander guard was intact on their left leg. Observation on 7/10/25 at 9:19 a.m. revealed Resident #5's wander guard was intact on their right ankle. During interview on 7/10/25 at 1:11 p.m. , CNA I stated the facility was using Code Orange for elopements. CNA I stated elopement procedures included that someone would print the census and check all the halls to make sure everyone was accounted for including to check all the rooms and doors including bathrooms and closets. CNA I said someone would also go around the premises to search. CNA I said also the Administrator and DON should be notified immediately regarding a resident elopement. During interview on 7/10/25 at 11:17 a.m. the Administrator provided documents with information regarding elopements and if residents remove wander guards. The Administrator said if she and the DON were notified that a resident removed the wander guard, they would implement the documents provided . Record review of the documents provided on 7/10/25 at 11:17 a.m. revealed an Elopement policy if there was a resident that removed their Code Alert (wander guard) the following measures would be implemented: notification by the Charge Nurse to Administrator and DNS, Notification to Family/RP, Notification to Attending Physician and/or NP, Care Plan Conference with resident and/or RP for a secure care consult (consult for a secured/locked unit), Code Alert will be reimplemented until alternative placement, Immediate placement on one-on-one until alternative placement achieved with a secure unit and Notifications to Area Director of Operations and Regional Compliance Nurse. During interview on 7/10/25 at 11:55 a.m., LVN D denied any problems with Resident #5 removing her wander guard and said she had worked with Resident #5 since Resident #5 had arrived at the facility which had been over six months. LVN D said the nurses would monitor residents who removed their wander guard and would start a 1:1 with the resident and notify the administrator. LVN D said they had training regarding this information about two months ago in May. LVN D said how they would monitor a resident who was removing their wander guard was that whoever was on a 1:1 with the resident always had eyes on the resident. LVN D said Resident #5 was the only resident with a wander guard she had at this time. During interview on 7/10/25 at 12:00 p.m., the DON said she started at the facility on 5/27/25 so she was not working at the time of the incident of Resident #2's elopement on 5/6/25. The DON said the nurses would monitor residents if they were removing the wander guard and should notify the DON and Administrator. The DON said that they only have four residents currently with wander guards and none of the four current residents with wander guards have behaviors with removing the wander guard. The DON said staff had follow up training regarding wander guards yesterday 7/9/25. During interview on 7/10/25 at 12:00 p.m., the Administrator also agreed none of the four current residents with wander guard have behaviors of removing the wander guard. The Administrator said staff was trained regarding what to do if residents remove wander guards in May.During interview on 7/10/25 at 12:08 p.m., LVN E said he usually works with Resident #3 and Resident #6 and are the only residents at his station with wander guards. LVN E said neither Resident #3 nor Resident #6 tried to remove the wander guard. LVN E said the nurses are who monitor the residents who attempt to remove the wander guards because they are supposed to be checked every shift. LVN E said that the CNAs are supposed to tell the nurses if they see the residents remove the wander guard . LVN E said if the resident was trying to remove the wander guard, then they are to notify the administrator and the DON. LVN E said that they did trainings regarding residents removing the wander guards in May and had an update 7/9/25. LVN E said residents are monitored are through 1:1 observation and this was usually done by a CNA. During interview on 7/10/25 at 12:18 p.m., LVN C said she normally works night shift at the station with Resident #3 and Resident #6. LVN C said that neither Resident #3 nor Resident #6 have problems with trying to remove the wander guards. LVN C said if residents attempted to remove the wander guard, they did 1:1 observation and redirection. LVN C said they checked for placement to make sure the wander guards were functioning correctly and in place. LVN C said that if a resident removes the wander guard, they notify the Administrator and the DON immediately. LVN C said that all staff would participate in monitoring if a resident were removing the wander guard or trying to elope. LVN C said regarding residents removing wander guards they received training a couple a months ago because they had a resident who was removing the wander guards and then a follow up 7/9/25. LVN C said the training included what to do if they hear an alarm, stand at the doors, full census sweep, 1:1 if the resident was known, make sure the wander guard is in place, safety monitoring and notify the DON/Administrator if the residents was continuing to try and exit. LVN C said the priority is the residents' safety. LVN C said she was working the night of 5/5/25 from 10 p.m. to 6 a.m. LVN C said they heard the alarm going off when she was getting report about 10:15-10:20 p.m. LVN C said she went to the Magnolia door with a couple of CNAs and checked the alarm for proper functioning. LVN C said she pushed the door open and the secondary alarm above the door went off. LVN C said she did a census and told the other nurses to do a census at that time. LVN C said that was when the nurse on Station 4 said she could not find her resident, but LVN C said she could not remember what time that occurred. LVN C said then they completed a search and notified the administrator. LVN C said that on the night of 5/5/25 there was a female resident who was sitting by the door who was wearing a wander guard and LVN C said she thought the female resident had touched the door. LVN C said that the female resident was transferred out to a secured unit and was no longer at the facility. LVN C said that after she checked the door the alarm was no longer going off and did not go off the rest of the night. During interview on 7/10/25 at 12:40 p.m., LVN B said she usually works 10 p.m. to 6 a.m. on the #400 hallway. LVN B said Resident #4 is the only resident on her hallway with a wander guard and Resident #4 has never tried to remove the wander guard. LVN B said that if a resident attempted or removed the wander guard , they initiate a 1:1. LVN B said the nurses or CNA would have to be with the resident all the time if they were attempting to remove the wander guard. LVN B said if a resident was removing the wander guard, they would notify the administrator and DON immediately if a resident was placed on a 1:1. LVN B said that they had elopement training and drill about two months ago and then updated 7/9/25. LVN B said that the training included what they are expected to do if the residents remove the wander guard which included to initiate the 1:1, someone to be with the resident all the time until they can find a long term unit to transfer the resident to. LVN B said that she was working the night shift 10 p.m. to 6 a.m. on 5/5/25 when she saw the alarm to the door was going off. LVN B said then they printed the census and checked the residents, and she said she could not remember the exact time but was after 12 midnight. LVN B said the door was alarming about this time around 12 midnight. Observation on 7/10/25 at 1:42 p.m. revealed Resident #5 with wander guard to right ankle. On 7/10/25 at 2:44 p.m., the facility administrator was notified of past noncompliance IJ. An IJ template was provided to the administrator via email at 2:48 p.m. During interview on 7/11/25 at 11:04 a.m., the Administrator stated that potential adverse effects a resident that eloped could have would include physical dangers, health complications and psychological distress. Record review of facility's policy for Elopement dated April 2017 revealed All team members will be alerted to search in the center or grounds as soon as there is an awareness of the resident missing. The policy also stated, If the resident is not quickly located in center or on grounds a point person is designated to make the following notifications: Administrator and Director of Nursing, Designated guardian or resident representative and Police (once the search of center and grounds determines the resident is not here or sooner if there is good indication they will not be located during the search). The policy also stated, Document condition notifications and times of actions deployed. Record review of the facility's undated Elopement policy if there was a resident that removed their Code Alert (wander guard) the following measures would be implemented: notification by the Charge Nurse to Administrator and DNS, Notification to Family/RP, Notification to Attending Physician and/or NP, Care Plan Conference with resident and/or RP for a secure care consult (consult for a secured/locked unit), Code Alert will be reimplemented until alternative placement, Immediate placement on one-on-one until alternative placement achieved with a secure unit and Notifications to Area Director of Operations and Regional Compliance Nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the facility must include the expiration date when applicable and were not expired for two (100 Hallway medication aide medication cart and 400 Hallway nurse medication cart) out of three medication carts reviewed for medication storage and labeling.
1. The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma and other causes of high pressure inside the eye) were labeled with expiration date for Resident #32, Resident #35, and Resident #88.
2. The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma and other causes of high pressure inside the eye) was removed from the medication cart for Resident #28 as it was past its use by recommendation.
3. The facility failed to ensure that Humalog KwikPen/insulin lispro (insulin which is a medication that lowers blood sugar) for Resident #39 was dated with open date when it was removed from the medication refrigerator and placed on the medication cart as Humalog KwikPens are only recommended to be used for 28 days once removed from the refrigerator.
This failure could place residents at risk of not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications.
Findings included:
Record Review of Resident #28's face sheet dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities) and Type 2 Diabetes Mellitus (high blood sugar).
Record review of Resident's #28's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggested cognition was intact.
Record Review of Resident #32's face sheet dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Primary Generalized (Osteo)Arthritis (breakdown of tissues of joints) and Absolute Glaucoma (eye condition that damages the optic nerve).
Record review of Resident's #32's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggested cognition was intact (13-15).
Record review of Resident #32's Care Plan printed [DATE] revealed Administer eye drops for glaucoma as ordered.
Record review of Resident #32's Order Summary Report dated [DATE] revealed Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes at bedtime.
Record Review of Resident #35's face sheet dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Anemia (low red blood cells) in Chronic Kidney Disease and Glaucoma in Diseases Classified Elsewhere (eye condition that damages the optic nerve).
Record review of Resident's #35's annual MDS dated [DATE] revealed a BIMS score of 10 that suggested moderate cognitive impairment.
Record review of Resident #35's Order Summary Report dated [DATE] revealed Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes at bedtime.
Record Review of Resident #39's face sheet dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Osteomyelitis (bone infection and Type 2 Diabetes Mellitus (high blood sugar) with Foot Ulcer (wound).
Record review of Resident's #39's quarterly MDS dated [DATE] revealed a BIMS score of 13 that suggested cognition was intact (13-15).
Record review of Resident #39's Care Plan printed [DATE] revealed Diabetes medication as ordered by doctor.
Record review of Resident #39's Order Summary Report dated [DATE] revealed Insulin Lispro Injection Solution 100 unit/milliliter with instructions to inject 8 units under the skin three times a day with meals if blood sugar is greater than 300.
Record Review of Resident #88's face sheet dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Nontraumatic Chronic Subdural Hemorrhage (brain bleed) and Unspecified Glaucoma (eye condition that damages the optic nerve).
Record review of Resident's #88's quarterly MDS dated [DATE] revealed a BIMS score of 14 that suggested cognition was intact.
Record review of Resident #88's Order Summary Reported dated [DATE] revealed Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes one time a day.
Record review of Instructions For Use Humalog KwikPen revised 7/2023 revealed unused Humalog KwikPen should be stored in the refrigerator at 36 to 46 degrees Fahrenheit. Record review also revealed to store in use Humalog KwikPen at room temperature and to throw the Humalog KwikPen away after 28 days.
Observation on [DATE] at 10:15 a.m. of 100 Hallway medication aide medication cart revealed Latanoprost 0.005% ophthalmic (eye) solution for Resident #28 was dated [DATE] and the label for the Latanoprost had instructions to discard the medications after six weeks which was [DATE]. Observation also revealed no open dates documented for two bottles of Latanoprost 0.005% ophthalmic (eye) solution for Resident #32, Latanoprost 0.005% ophthalmic (eye) solution for Resident #88, Latanoprost 0.005% ophthalmic (eye) solution for Resident #35.
Observation on [DATE] at 10:49 a.m. of 400 Hallway nurse medication cart revealed undated Humalog Kwik Pen for Resident #39.
During interview on [DATE] at 9:25 a.m., the ADON said they started at the facility on [DATE] and they were going to work on reviewing the medication carts.
During the interview on [DATE] at 11:31 a.m., the DON said that whoever used the medication cart was responsible for the medication cart and the managers should audit the medication carts as well .
During interview on [DATE] at 1:51 p.m., the Pharmacist said they look at two random medication carts at the facility. The Pharmacist said they look for expiration dates, open dates and that medications are separated by route.
Record review of facility's Storage of Medication policy with effective date of [DATE] revealed outdated, contaminated, or deteriorated mediation are immediately removed from inventory. It was also revealed When the manufacturer has specified a usable duration after opening (i.e. beyond use date), the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a Significant Change MDS assessment with 14 days after the facility determined, or should have determined, there has been a significant change in a resident's physical or mental condition for 1 of 25 residents reviewed for assessments (Resident # 31).
--the facility failed to complete a Significant Change MDS for Resident # 31 within 14 days of the resident's discharge from hospice services.
This failure placed residents who had a significant change in condition requiring an MDS assessment at risk of not receiving needed services.
Findings included:
Record review of Resident #31's face sheet revealed admission date 4/18/22 with diagnoses including Alzheimer's disease (progressive disease that destroys mental functions), dementia (loss of intellectual functioning), hypertension (high blood pressure), osteoarthritis (joint disease causing tissue breakdown), anxiety disorder (excessive worry or fear), COPD (chronic obstructive pulmonary disease caused by lung damage), Bipolar disorder (mental health condition with extreme mood swings), muscle weakness (decreased muscle strength), abnormal posture (chronic abnormal positions of the body).
Record review of documents in Resident #31's clinical chart revealed physician signed admission to hospice services dated 1/31/23.
Record review of documents in Resident #31's clinical chart revealed discharge from Hospice services on 3/7/25, due to Resident #31 being medically stable and no longer Hospice appropriate.
Interview with Rehab Director on 4/7/25 at 11:50 am revealed Resident #31 is now receiving therapy since she is not on Hospice services any longer.
Observation of resident #31 on 4/7/25 at 11:30 am revealed she was in her room in her wheelchair, alert and watching television. She said she was fine and getting ready to go to lunch in a few minutes. She said she had therapy this morning.
Record review of Resident #31's current comprehensive care plan dated 2/12/25 revealed Resident #31 receiving Hospice care, with appropriate interventions. The comprehensive care plan had not been revised to reflect discharge from Hospice services on 3/7/25.
Record review of Resident #31's Significant Change MDS dated [DATE] revealed tthe resident was not receiving Hospice services. She was discharged from Hospice services 3/7/25: the Significant Change MDS was completed more than 14 days after the significant change.
Interview with MDS nurse A on 4/7/25 at 3:15 pm revealed she just took over this job with MDS and was still learning. She said they just learned this week Resident # 31 was discharged form hospice services, and she knew the Significant Change MDS should have been done within 14 days. She said she gets information from the nurses about a resident's condition and makes the appropriate changes to MDS if needed. The risk of not having an accurate MDS provided after a significant change of condition would be incorrect information about the resident and inaccurate care provided.
Interview with interim DON on 4/7/25 at 4:00 pm revealed the care plans and MDS should be accurate and reflect the resident's true condition, and if they weren't accurate, it would affect the care provided. In further interview, he said the facility followed the RAI manual.
A policy on MDS was requested on 4/9/25, and RAI manual guidelines were provided as evidence.
Record review of the RAI manual guidelines revealed a Significant Change MDS should be completed 14 calendar days after determination of significant change in status.
Record review of the facility policy on MDS revealed dated september, 2020 revealed: .The purpose of this guideline is to provide guidance and instruction on how to complete the RAI
process. The RAI process consists of three components: The Minimum Data Set (MDS) Version
3.0, The Care Area Assessment (CAA) process and the RAI utilization guideline.
Process
The CMS Long-Term Care Facility Resident Assessment User's Manual MDS 3.0 will
provide the framework and directions to completing the RAI process
All items in the MDS are to be coded per the instructions of the CMS Long-Term Care
Facility Assessment User's Manual MDS 3.0
The center will determine who will participate in the assessment process and MDS
section responsibility
The center will determine how the process in completed ensuring that the process
includes direct observation and communication with the residents and direct care staff

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 1 of 3 residents (Resident #48) reviewed for a mental illness, intellectual disability, or developmental disability.
The facility failed to ensure Resident #48 who had a diagnosis of mental illness had a PASARR Level II (PE) screening completed.
This failure placed residents at risk of mental health needs not being met.
The findings included:
Resident #48
Record review of Resident #48's face sheet dated 04/09/25 revealed a-[AGE] year-old female admitted to the facility 06/14/23 and readmitted on [DATE]. Her diagnoses included heart diseases, bipolar disorder, schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder),
lack of coordination, Anemia, Essential hypertension, cognitive communication deficit.,
Record review of Resident #48's PASARR Level I (PL1) Screening, dated 06/13/23, indicated Resident #48 was positive for the diagnoses of mental illness.
Record review of the Resident #48's annual MDS assessment, dated 05/03/24, revealed her BIMS score was 13 out of 15 indicated she was cognitively intact. Section on active diagnosis revealed she was checked for bipolar disorder and depression and schizophrenia.
Record review of Resident #48's Care Plan dated 05/08/24 revealed Resident #48 was care planned for Self-Care Deficit related to: dx Schizophrenia and bipolar.
Goal- No functional decline and maintain maximum independence through next review date Initiated: 05/08/2024 Target Date: 01/27/2025.
Record review of Resident #48's clinical record revealed no evidence of Level 2 PASRR evaluation for mental illness.
During an interview with the facility MDS coordinator on 04/08/25 at 1:00PM, she said she was responsible for completing PASRR for all residents. She said she would look in simple if PASRR level 2 assessment was done because she was not at the facility when the Resident #48's comprehensive assessment was done.
During an interview on 04/08/25 at 2:00 PM, MDS Coordinator said PASRR level 2 assessment was not done, and she would revise the MDS and the care plan. She said an inaccurate assessment may delay or prevent Resident from getting the necessary service and care needed to improve their health.
Record review of facility provided policy on PASRR revaluation undated titled PASRR Requirements revealed:
Guidelines:
In effort of the Health Information Management Coordinator to obtain a completed record, all patients must have a Pre-admission Screening and Resident Review prior to or immediately upon admission as required by Federal and/or a patient/resident specific review process as defined by local State guidelines. The PASRR is completed to determine provision of appropriate and needed serviced to individuals who have been diagnosed with MI/MR.
Process:
1. Upon admission a PASRR must be completed timely for patients by qualified individuals. These qualified individuals may include: Physician, Nurse Practitioner, Registered Nurse, Licensed Social Worker or designee.
2. In the event a patient is discharged to a particular hospital with 'return anticipated' and readmitted from that hospital, the original PASRR that was completed at the time of the original admission may be utilized.
3. In the event a patient is discharged to a 'mental health or psychiatric hospital' and returns with a new metal health diagnosis, a new PASRR must be completed prior to or immediately upon readmission. In addition, a Level II must be completed upon or prior to readmission.
4. Each center should follow PASRR and Level II State specific requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 (Resident #362) of 7 residents reviewed for care plans.
The facility failed to develop a baseline care plan, or a comprehensive care plan in place of a baseline care plan, for Resident #362 within 48 hours of admission.
The failure could place residents at risk of not receiving effective person-centered care to achieve their highest practicable level of physical, mental, and psychosocial well-being.
Findings included:
Record review of Resident #362's face sheet dated 4/8/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Acute on Chronic Systolic Heart Failure (disorder where the heart does not pump blood as well as it should), Chronic Kidney Disease (chronic loss of kidney function) and Chronic Obstructive Pulmonary Disease (chronic lung condition causing restricted airflow).
Record review of Resident #362's Order Summary Reported dated 4/8/25 revealed order to admit to this skilled nursing facility with order date of 4/4/2025.
Record review of Resident #362's Baseline Care Plan - V 8 with effective date of 4/5/25 at 1:35 p.m. revealed no information was completed on the document.
Record review of Resident #362's Care Plan printed on 4/8/25 revealed the date initiated for all sections completed was 4/7/25 which was after 48 hours of Resident #362's admission.
During interview on 4/9/25 at 11:31 a.m., the DON said the admission nurse was responsible for opening the baseline care plan.
During interview on 4/9/25 at 2:49 p.m., LVN Z said LVNs do not open the care plans and a RN should complete the care plan. LVN Z said they did not know which RN was responsible for opening Resident #362's care plan. LVN Z said that there was an RN who came into work at 10 p.m. on 4/4/25 but did not know their name or if they were responsible for opening the care plan.
During an interview on 4/9/25 at 2:52 p.m., the DON said that any nurse, a RN or LVN, can open a resident's baseline care plan.
Record review of Resident #362's admission MDS dated [DATE] revealed the BIMS section was blank .
Record review of the facility's RAI Process Guideline policy dated September 2020 revealed the CMS Long-Term Care Facility Resident Assessment User's Manual MDS 3.0 will provide the framework and directions to completing the RAI process which included the Care Area Assessment.

Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 25 residents reviewed for care plan revision (Resident # 31).
--resident #31's comprehensive care plan was not revised to reflect discharge for hospice services.
This failure placed residents at risk of not receiving services according to their individual conditions.
Findings include:
Record review of Resident #31's face sheet revealed admission date 4/18/22 with diagnoses including Alzheimer's disease (progressive disease that destroys mental functions), dementia (loss of intellectual functioning), hypertension (high blood pressure), osteoarthritis (joint disease causing tissue breakdown), anxiety disorder (excessive worry or fear), COPD (chronic obstructive pulmonary disease caused by lung damage), Bipolar disorder (mental health condition with extreme mood swings), muscle weakness (decreased muscle strength), abnormal posture (chronic abnormal positions of the body).
Record review of documents in Resident #31's clinical chart revealed physician signed admission to hospice services dated 1/31/23.
Record review of documents in Resident #31's clinical chart revealed discharge from Hospice services on 3/7/25, due to Resident #31 being medically stable and no longer Hospice appropriate.
Interview with Rehab Director on 4/7/25 at 11:50 am revealed Resident #31 is now receiving therapy since she is not on Hospice services any longer.
Observation of resident #31 on 4/7/25 at 11:30 am revealed she was in her room in her wheelchair, alert and watching television. She said she was fine and getting ready to go to lunch in a few minutes. She said she had therapy this morning and will be having therapy every day now.
Record review of Resident #31's comprehensive care plan dated 2/12/25 revealed Resident #31 receiving Hospice care, with appropriate interventions. The comprehensive care plan had not been revised to reflect discharge from Hospice services on 3/7/25.
Interview with MDS nurse A on 4/7/25 at 3:15 pm revealed she just took over this job with MDS and was still learning. She said they did not know Resident #31 had been discharged from Hospice services until this week. She said she would get information from the nurses about a resident's condition and make the appropriate changes to care plans if needed. She said the MDS nurse would update the care plans from information from the nurses who would tell them of any changes, or at the IDT meeting. The risk of not having accurate care plans would be not the right care provided.
Interview with interim DON on 4/7/25 at 4:00 pm revealed the care plans should be accurate and reflect the resident's true condition, and if care plans weren't accurate, it would affect the care provided. In further interview, he said the facility followed the RAI manual.
A policy on care plans was requested on 4/9/25, but not supplied by the time of exit. The policy on the RAI manual was given as evidence for care plan accuracy.
Record review of the facility policy on care planning dated September 2020 revealed : .The purpose of this guideline is to provide guidance and instruction on how to complete the RAI
process. The RAI process consists of three components: The Minimum Data Set (MDS) Version
3.0, The Care Area Assessment (CAA) process and the RAI utilization guideline.
Process
? The CMS Long-Term Care Facility Resident Assessment User's Manual MDS 3.0 will
provide the framework and directions to completing the RAI process
? All items in the MDS are to be coded per the instructions of the CMS Long-Term Care
Facility Assessment User's Manual MDS 3.0
? The center will determine who will participate in the assessment process and MDS
section responsibility
? The center will determine how the process in completed ensuring that the process
includes direct observation and communication with the residents and direct care staff

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure any drug regimen irregularities were accurately reported by the Pharmacist Consultant for 1 (Resident #90) of 7 residents reviewed for pharmacy services.
The facility failed to ensure that Resident #90 did not have duplicate medication orders.
The failure could place residents at risk of receiving inaccurate administration of medications which could result in possible adverse effects or residents not receiving therapeutic benefits of medications.
Findings included:
Record Review of Resident #90's face sheet dated 4/9/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Quadriplegia (inability to move all four limbs) and Generalized Anxiety Disorder.
Record review of Resident #90's quarterly MDS dated [DATE] revealed a BIMS score of 12 that suggested moderate cognitive impairment.
Record review of Resident #90's Order Summary Report dated 4/9/2025 at 8:38 a.m. revealed order for Buspirone 5 mg with instructions to give 1 tablet by mouth two times a day with start date of 1/23/2025 with no end date. Record review also revealed an order for Buspirone 5 mg to give 1 tablet by mouth three times a day with start date of 3/1/25 with no end date.
Record review of Resident #90's March MAR printed 4/9/24 revealed Buspirone 5 mg with instructions to give 1 tablet by mouth two times a day with administrations being documented from 3/1-3/31/25 and Buspirone 5 mg with instructions to give 1 tablet by mouth three times a day with administrations being documented from 3/3-3/31/25.
Record review of Resident #90's April MAR printed 4/9/25 revealed Buspirone 5 mg with instructions give 1 tablet by mouth two times a day as being administered from 4/1-4/8/25 and Buspirone 5 mg with instructions give 1 table by mouth three times a day being administered from 4/1-4/8/25 except for 4/8/25 at 1 p.m. for which there was no documentation.
Record review of Resident #90's Care Plan printed 4/9/25 revealed intervention Administer medications as ordered.
Record review of nursing Progress Notes dated 4/9/25 at 3:46 p.m. revealed that LPN Y documented Call placed to MD to clarify buspirone orders awaiting return call.
Record review of Resident #90's electronic medication record revealed that Buspirone 5 mg with instructions give 1 table two times a day was discontinued on 4/9/2025 at 10:32 a.m. ordered by Dr. G.
Record review of Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations for Recommendation Created Between 3/1/2025 and 3/19/2025 dated 3/19/2025 revealed that Resident #90 was listed as being reviewed but did not require any recommendations.
Record review of Psychotropic & Sedative/Hypnotic Utilization by Resident For Records Updated Between 3/1/2025 And 3/19/2025 revealed Buspirone Hydrochloride (Buspirone Hcl Tab 5 mg) 1 three times a day with order date of 1/23/2025.
During an interview on 4/9/25 at 8:57 a.m., LPN Y said the doctor should have discontinued the previous Buspirone order for Resident #90 when the new order was entered.
During an interview on 4/9/25 at 9:01 a.m., MA L said the Buspirone order for Resident #90 was a duplicate. MA L said Resident #90 received Buspirone in the morning, at 1 p.m. and at night. MA L said that she usually worked the 400 hallway where the resident was located and has worked at the facility since October of 2023. MA L said she received in-services from the facility especially regarding medication errors and that she received in-services at least monthly and maybe every two weeks. MA L said that the pharmacist came to the facility on Thursdays and did trainings as well. MA L said that a negative effect if a resident received a medication that was not accurate that it would be a medication error and the resident could have received a double dose.
During observation and interview on 4/9/25 at 9:10 a.m. revealed that Resident #90 was lying in hospital bed. Resident #90 was alert and no signs of distress noted. Resident #90 did not mention any concerns regarding his Buspirone when he was asked if he had any issues regarding his medications.
During interview on 4/9/25 at 9:19 a.m., LPN Y said they notified Dr. G regarding the Buspirone order, and that Dr. G said that they would fix the order. LPN Y said they had worked at the facility for six months and had not received any ongoing training from the facility regarding medications. LPN Y said that an adverse reaction if a resident received a medication that was not accurate would be the resident would need to be monitored and would be a medication error.
During interview on 4/9/25 at 9:25 a.m., the ADON said they started at the facility on 4/7/25. The ADON said they were not familiar with the facility's process of reviewing new orders. The ADON said that the process they were familiar with was that the managers have morning meetings to review orders and if this was not the current process then they would recommend this. The ADON said an adverse effect a resident could have if not given the accurate dosage of medication was adverse side effects depending on the medication.
During interview on 4/9/25 at 9:31 a.m., the DON said previous orders should be discontinued when new orders are put in. Regarding the Buspirone order for Resident #90 with start date of 3/1/25, the DON said that it looked like the doctor put a new order in but did not discontinue the previous order. The DON said the pharmacy reviewed the medications monthly for residents and had not yet reviewed medications for April. The DON said an adverse effect a resident could experience receiving a medication incorrectly would depend on the medication, but the resident could have an adverse reaction.
During interview on 4/9/25 at 9:46 a.m., the Administrator said orders should be reviewed daily for accuracy. The Administrator said that there was a daily clinical startup which was a clinical meeting in the mornings that the DON, unit managers and reimbursement nurses attended and reviewed new orders.
Message left by surveyor for Dr. G on 4/9/25 at 11:23 a.m. with request to call surveyor but no call back received prior to survey exit.
During interview on 4/9/25 at 1:51 p.m., the Pharmacist said they only had Buspirone three times a day documented for Resident #90 in her notes which was separate from the facility's electronic medical record and denied having any notes regarding Resident #90 taking Buspirone twice a day. The Pharmacist said that she looks for duplicate medication entries when reviewing medication orders. The Pharmacist said that they review the medications a few days before they come to the facility.
Record review of facility's Clinical Start-Up Guide: A Qualitative Audit policy revealed that during the Clinical Start-Up that new physician orders are viewed for accuracy of transcription of physician's orders into the electronic medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure any medications were not given in excessive doses for 1 (Resident #90) of 7 residents reviewed for medication orders.
The facility failed to ensure that Resident #90 did not recieve incorrect doses of medication.
The failure could place residents at risk of receiving inaccurate administration of medications which could result in possible adverse effects or residents not receiving therapeutic benefits of medications.
Findings included:
Record Review of Resident #90's face sheet dated 4/9/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Quadriplegia (inability to move all four limbs) and Generalized Anxiety Disorder.
Record review of Resident #90's quarterly MDS dated [DATE] revealed a BIMS score of 12 that suggested moderate cognitive impairment.
Record review of Resident #90's Order Summary Report dated 4/9/2025 at 8:38 a.m. revealed order for Buspirone 5 mg with instructions to give 1 tablet by mouth two times a day with start date of 1/23/2025 with no end date. Record review also revealed an order for Buspirone 5 mg to give 1 tablet by mouth three times a day with start date of 3/1/25 with no end date.
Record review of Resident #90's March MAR printed 4/9/24 revealed Buspirone 5 mg with instructions to give 1 tablet by mouth two times a day with administrations being documented from 3/1-3/31/25 and Buspirone 5 mg with instructions to give 1 tablet by mouth three times a day with administrations being documented from 3/3-3/31/25.
Record review of Resident #90's April MAR printed 4/9/25 revealed Buspirone 5 mg with instructions give 1 tablet by mouth two times a day as being administered from 4/1-4/8/25 and Buspirone 5 mg with instructions give 1 table by mouth three times a day being administered from 4/1-4/8/25 except for 4/8/25 at 1 p.m. for which there was no documentation.
Record review of Resident #90's Care Plan printed 4/9/25 revealed intervention Administer medications as ordered.
Record review of nursing Progress Notes dated 4/9/25 at 3:46 p.m. revealed that LPN Y documented Call placed to MD to clarify buspirone orders awaiting return call.
Record review of Resident #90's electronic medication record revealed that Buspirone 5 mg with instructions give 1 table two times a day was discontinued on 4/9/2025 at 10:32 a.m. ordered by Dr. G.
Record review of Psychotropic & Sedative/Hypnotic Utilization by Resident For Records Updated Between 3/1/2025 And 3/19/2025 revealed Buspirone Hydrochloride (Buspirone Hcl Tab 5 mg) 1 three times a day with order date of 1/23/2025.
During an interview on 4/9/25 at 8:57 a.m., LPN Y said the doctor should have discontinued the previous Buspirone order for Resident #90 when the new order was entered.
During an interview on 4/9/25 at 9:01 a.m., MA L said the Buspirone order for Resident #90 was a duplicate. MA L said Resident #90 received Buspirone in the morning, at 1 p.m. and at night. MA L said that she usually worked the 400 hallway where the resident was located and has worked at the facility since October of 2023. MA L said she received in-services from the facility especially regarding medication errors and that she received in-services at least monthly and maybe every two weeks. MA L said that a negative effect if a resident received a medication that was not accurate that it would be a medication error and the resident could have received a double dose.
During observation and interview on 4/9/25 at 9:10 a.m. revealed that Resident #90 was lying in hospital bed. Resident #90 was alert and no signs of distress noted. Resident #90 did not mention any concerns regarding his Buspirone when he was asked if he had any issues regarding his medications.
During interview on 4/9/25 at 9:25 a.m., the ADON said they started at the facility on 4/7/25. The ADON said they were not familiar with the facility's process of reviewing new orders. The ADON said that the process they were familiar with was that the managers have morning meetings to review orders and if this was not the current process then they would recommend this. The ADON said an adverse effect a resident could have if not given the accurate dosage of medication was adverse side effects depending on the medication.
During interview on 4/9/25 at 9:31 a.m., the DON said previous orders should be discontinued when new orders are put in. Regarding the Buspirone order for Resident #90 with start date of 3/1/25, the DON said that it looked like the doctor put a new order in but did not discontinue the previous order. The DON said an adverse effect a resident could experience receiving a medication incorrectly would depend on the medication, but the resident could have an adverse reaction.
During interview on 4/9/25 at 9:46 a.m., the Administrator said orders should be reviewed daily for accuracy. The Administrator said that there was a daily clinical startup which was a clinical meeting in the mornings that the DON, unit managers and reimbursement nurses attended and reviewed new orders.
Message left by surveyor for Dr. G on 4/9/25 at 11:23 a.m. with request to call surveyor but no call back received prior to survey exit.
Record review of facility's Clinical Start-Up Guide: A Qualitative Audit policy revealed that during the Clinical Start-Up that new physician orders are viewed for accuracy of transcription of physician's orders into the electronic medical record.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that:
1.The facility failed to keep the dining room clean and free of dirty dishes with leftover food overnight
2.The facility failed to ensure that the rails along the vent hood was free of grease.
3. The facility failed to store and date foods stored in the refrigerator one of two refrigerator in the kitchen.
3. The facility failed to ensure that the dry good pantry was free from expired food product.
These failures could place residents at risk for food borne illness.
The findings included:
Observation of the dining room on 04/07/25 at 6:50 AM revealed-
-Observation of the dining room revealed there were 5 Resident sitting in the dining room waiting for their coffee. Observation of the door by the dish washing machine, revealed a small cart in the dining room with leftover food, and gnats flying around the dishes.
-Observation and interview on 04/07/25 beginning at 6:50AM, revealed there were grease build up along the vent hood rails.
Observation of one of 2 freezer in the kitchen (Freezer #2) in the main kitchen, revealed the following-
-large bowl of salad undated and unlabeled (no identifying information). [NAME] K said that was left over from Yesterday 04/06/25.
-Fruit (Peaches) out of original container in a plastic container unlabeled and undated
-Tuna salad in a large bowl covered with plastic wrap dated 03\30\25 to use by 04\06\25.
-Observation of one of two freezers at the back revealed 6 individual cookies in plastic -wrap dated 11/25/24. [NAME] K took them out and said, what are these and toss them in a trash container.
-observation of the dry goods area revealed 5Ibs container of creamy peanut butter dated best used by 03\23\23.
All unlabeled and undated food items were identified by [NAME] K.
During an interview with [NAME] K on 04/07/25 at 7:15AM, she said she was off over the weekend. She said the vent hood was supposed to have been cleaned and all food in the freezer and the refrigerator should be labeled and dated with date opened and used by date.
During an interview with the Dietary Manager on 04/07/25 at 7:30AM, he said the vent hood was supposed to have been cleaned. He said he will get it done. He looked at the dirty dishes in the dining room by the dishwashing room and said they might have been brought to the dining room after the kitchen was closed. He said all food items out of the original container are supposed to be dated and labeled with the date opened and used by date. He said all staff are responsible for cleaning after themselves and whoever put leftover food items in the refrigerator\freezer was supposed to have date when opened\left over date and use by date.
Record review of facility police dated 05/2014 revised 09/2017 titled Food: Preparation revealed in part Policy Statement: Policy Statement
All foods are prepared in accordance with the FDA Food Code
Food Storage: Dry Goods Policy Statement
All dry goods will be appropriately stored will be appropriately stored in accordance with the FDA Food Code.
Environment: Policy Statement
All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to thoroughly investigate and report an incident for 1 (Resident #1) of 6 reviewed for abuse and neglect.
The facility failed to report Neglect after Resident #1 drank hand sanitizer.
The facility failed to thoroughly investigate after Resident #1 got a hold of a bottle of hand sanitizer and drank it and was hospitalized on [DATE].
This failure could have placed residents at risk of abuse and neglect.
Findings included:
Record review of Resident #1's face sheet revealed she was a [AGE] year-old female with diagnosis of Alzheimer Disease with late onset(a progressive disease that destroys memory and important mental functions), Type 2 Diabetes, Mellitus (a chronic disease in which the body has trouble controlling blood sugar) Acute kidney failure (a condition in which the kidneys cannot filter waste), and bi-polar disorder(a disorder associated with episodes of mood swings ranging from depressive lows and manic highs).
Record review of Resident #1's MDS quarterly dated 12/25/2025 revealed BIMS Summary score of 03.
Section E0900- Wandering Presence and Frequency was coded as O. Behavior not exhibited.
Section P0200- Restraints and Alarms revealed E. Wander/Elopement alarm was used.
Record review of Resident #1's care plan dated 11/20/2019 and target date of 2/21/2025 revealed:
Focus: Resident #1 is at risk for elopement related to wandering. Resident requires a wander guard for safety.
Goal: Patient was not to have no incidence of elopement.
Interventions: check placement and function of wander guard, evaluate effect og cognitive impairment upon resident's ability to understand changes in surroundings.
Focus: Resident #1 have little or no awareness of safety, or boundaries related to other's personal space. Going into other resident's rooms, not always aware if areas are okay for her to be in, rummaging through items that are not hers. Wandering about her living space. Resident #1 wander aimlessly into other residents' rooms. Staff redirects me. Date initiated 1/19/2025 revised on 2/20/2025.
Goal: Resident #1 will be able to maintain a meaningful life.
Interventions: If Resident #1 was wandering into other residents' rooms gently re-direct her by taking her hand and lead me into other parts of open space that offers me activities that may be engaging.
Record review of elopement Risk evaluation dated 2/27/2025 revealed that Resident #1 was at risk for wandering due to her cognitive impairment and poor decision making.
Record review of Resident #1's nursing progress note dated 3/17/2025 at 3:00pm, stated Resident #1 was found sipping ethyl alcohol 70% from a hand sanitizer container. The resident appeared alert. No immediate signs of distress were noted at the time of observation. Nurse immediately intervened and took the container from resident. Resident #1 was assessed for any signs of alcohol poisoning or adverse reactions, including vital signs and level of consciousness and any complaints of discomfort. The attending physician was notified. Resident #1 was monitored closely for any potential effects of alcohol poisoning. Poison Control was contacted, and a case number assigned. Nurse was told to continue to monitor.
Record review of nursing progress note dated 3/17/2025 at 4:50pm, revealed that the receptionist called the charge nurse because Resident #1 was in the lobby and hard to awaken. Nurse stated that when she arrived at the scene, the resident was having shakes of upper extremities with her eyes opened. She was offered candy, and she asked, where was the candy?. Physician was contacted and vitals taken. Blood sugar was 201. Physician A stated to send her out to the ER.
Record review of Resident #1's hospital record dated 3/17/2025 revealed chief complaint for visit was said to be drug overdose. Report stated resident #1 admitted with dementia unknown baseline who was found drinking hand sanitizer at the nursing home. EMS states unknown amount. Labs including etoh level ordered. Etoh (ethanol) wa negative. Resident #1 will require admission to the IMU for close monitoring. Lab ordered stat: Ethanol Level Value <5.0
Comment: The pharmacological responses to blood alcohol levels may vary from individual to individual. The fatal concentration had been reported to be greater than 400.0mg/dl. Ethanol % <0.005.
Record review of in-service training revealed RN A had conducted an in-service on 3.17.2025 it covered: Identify and labeling of all hazardous material according to safety guidelines, ensuring all hazardous materials are stored properly in locked cabinets or areas inaccessible to residents, and if residents get hazardous material notify DON, Administrator, Physician, family and poison control.
Record review of typed statements pertaining to the incident of Resident #1 drinking hand sanitizer were not signed. Further review of information provided by the Administrator were Resident #1's face sheet, medication review and care plan all had print dates of 4/1/2025 (exit date).
An interview with RP on 3/31/2025 @ 12:28pm, stated that she had been called about the incident when Resident #1 drank hand sanitizer. She stated that she was told that the hand sanitizer came from one of the medication carts. She said she did not recall the name of the nurse that called her. She said Resident #1 did not have a history of seizures. She stated she was aware that she had been wandering at the facility and had a wander guard. She stated that wander guard was used so she would not leave out of the door. She walked in circles both day and night. She had late-stage Alzheimer disease. She had gone into other resident's rooms a few times. She had no history of leaving the building. She said she was not a fall risk. She stated that she had been told by hospital staff that the labs showed she had a small amount of the hand sanitizer in her system, not enough to harm her.
An interview with RN A on 3/31/2025 at 3:48pm stated that she had been employed for two to three weeks, and worked the 8a-5pm shift M-F. She stated that she was the unit manager. She said the charge nurse (LVN A) told her that Resident #1 had drank hand sanitizer or at least that hand sanitizer was all over her shirt. She said she called Poison Control and was provided a case number. LVN A worked Hall 4 and was familiar with the residents' behavior. She stated when she spoke with the doctor, she was told to monitor and if her vitals changed to call him back. She said LVN A called the doctor the second time to let him know she was hard to awaken and that her blood sugar was higher than normal. She said drinking ethyl alcohol could have had the resident inebriated, or it could have gotten in her eyes and that would have been bad, death if someone were to drink a whole lot of it. She was not sure what sized bottle the resident had. She stated she had conducted an in-service on 3/17/2025 about patient safety and hazardous material storage.
An interview on 3/31/2025 at 4:05pm, Physician A stated that he was notified about Resident #1 drinking the hand sanitizer. He said at the time no one told him how much. He said they called poison control, and they told the nurse to just monitor. He said when they called him back about her being hard to awaken, he told them to send her out to the hospital for precaution. He said hand sanitizer could affect the liver. He said the hospital said she did not have much and was not deemed harmful at least, he repeated her labs, and they were pretty good. It is unknown how much she drank. No long-term effects from it. Labs were not abnormal from drinking the hand sanitizer. She was at her baseline. He said the only recommendation for her wandering and seeking items that might be harmful is supervising her. He said they need to monitor her closely. He said everyone knows her. Everyone was watching out for her. He said she wander ed but mostly sit in the lobby. He said the key was monitoring her.
An interview with LVNA on 4/1/2025 at 10:36am, she said she had been a nurse for 40 years. She had been an employee for about 6 months. She worked here from 2000-2005 and she just came back. She stated that CMA A alerted her that Resident #1 had drank hand sanitizer. She had it on her shirt. She talked with the unit manager (RN A); she called poison control and the doctor. She was told to monitoring her. She watched her for a change in condition. She said Resident #1 went to the front lobby to sit as she usually does then she was alerted by the receptionist that she could not awake her. She said the Resident had been in the lobby about 30-40 minutes. She said she took her vitals and blood sugar was out of baseline (200was not usually more than 140. She was taken to the room, and she called Physician A and he said to send her out 911. She said the hand sanitizer was usually in the locked cart. She was walking on the hall when CMA A saw Resident #1 with the bottle in her hand and it was on her chest. They assumed that she drank it. It looks like a brand-new bottle. No hand sanitizer was on her face, and she did not smell it on her breathe. When EMS arrived, she wanted to eat, and her tray was already on the tray table. She began to fight as she wanted to eat. She said she got a report from the DON that Resident #1';s sodium was high and no trace of the hand sanitizer from the blood test. Sodium level was 160 when she got to the hospital. She does have a diagnosis of renal disease. One intervention they put in place was to give her a bottled water. She walked around with it in her hand all day drinking along the way.
An interview with Receptionist B on 4/1/2025 at 11:25am revealed she had been employed at the facility since January 2025. She normally worked from 3p-8p in the evening. She stated that Resident #1 normally sit in the front lobby and walk around too. She stated that she had been sitting there for 30-40 minutes on 3/17/2025. She attempted to wake her. Her eyes were opened but she was not responding. A CNA came they tried to get her up. She told the CNA to go get a nurse. LVN A came, and they got her in the chair, and she was taken to the station. They called 911 and she asked what happened because she not normally like that she normally walked a lot, sat in the lobby and then walked some more all day. She said to herself, something happened because that was not like her. She sometimes pass and get a candy from her desk. If she sat in the lobby too long, she would call the station and ask them to come get her.
Interview with CMA A on 4/1/2025 at 11:56am, she said she had been employed 1.5 years and worked Hall 400 (where Resident #1) resided. She said on 3/17/2025 she saw Resident #1 coming from the back side of 400. She said the bottle of hand sanitizer was up against her mouth and turned upside down in the air (as someone drinking a beverage). She said she saw hand sanitizer on her shirt. She said that she immediately took the bottle, but Resident would not hand her the top. She said she called for the charge nurse (LVN A) to come to help her as the resident began to get aggressive with her. She said then the nurse took her into her room and took her vitals. She said as far as she was aware her vitals were normal. She said she was not aware that she was found in the lobby hard to awaken. She said she heard that later in the day. She said the hand sanitizer did not come from her medication cart as hers was still on the cart. She said the hand sanitizer was usually kept on top of the medication cart for use before passing medications. She said they had an in-service and now they must keep it inside of their carts. She said hand sanitizer is hazardous for anyone with dementia or with any ailments.
Observation and Interview on 4/1/2025 at 12:12pm CMA B said she had been employed since October 2024. She worked 7a-7pm shift. She said she worked on Hall 300. She stated that she hid her hand sanitizer behind her pill crusher. Observation of a 2 oz. bottle of hand sanitizer on top of the medication cart near the pill crusher. She said she recall an in-service about keeping the hand sanitizer in the draw, but she needed to use it so often when passing medications, she just hid it. They usually have a big bottle that was kept in the side pocket on the cart. She said although there is hand sanitizer on the wall they are too far apart for her to use before passing medications. She sanitizer hands before and after passing medications.
A telephone interview with the DON on 4//1/2025 at 2:25pm she stated no one saw Resident #1 drink the hand sanitizer to her knowledge. Then, she was told that she had a change in condition and got orders from physician A to send her out. The nurse reported to EMS that she was hard to arouse. She said hypernatremia was her diagnosis. She had been hydrated her with IV fluids and they monitored her labs when she returned. She said the hospital report indicated that she did not have any alcohol in her system. She said no staff admitted to giving Resident #1 the hand sanitizer. She said she did an investigation, and they immediately started an in-service immediately and made sure there was no hand sanitizer. What could have happened to her had she drunk the hand sanitizer- could cause disoriented, she is not sure about any amount of alcohol, impaired vision, and cognitive impairment or inebriated. She said she did not call in this incident to State agency due to the fact she was not harmed.
An interview with the Administrator on 4/1/2025 at 3:04pm, revealed she had been employed since September 2023. She said she found out Resident #1 had drunk hand sanitizer during their in daily clinical morning meeting the next day. She said she talked to the DON after she interviewed staff and she said staff did not see her drink hand sanitizer. She said Resident #1 was in the lobby, and she was unresponsive. She was sent out to the hospital. She said she saw the hospital record today and it indicated that she had 0.005% ethyl alcohol in her system. When she talked to Physician A, he was not alarmed. They also did an ad hoc qapi with their medical director. She said it reconfirmed that the resident was accessed, and the nurse had immediately called the poison control. She said Resident #1 was not symptomatic. She said most staff use the dispensers affixed on the walls. She said she understood it was a small maybe 2 oz bottle, so there is not that much in the bottle. She said she was not a nurse or a doctor, so she did not know what could have happened if she had drunk more of the hand sanitizer. She said the nurse called poison control, and they took necessary measures. She said in the past she would often over report to State office as her reason for not reporting this incident.
Record review of TULIP on 4/1/2025 revealed no incident was found.
Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose was to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good hygiene for 1 of 6 residents (Resident #2) reviewed for Activities of Daily Living.
1.
Resident #2 had not been showered as scheduled on 3/10, 3/24, or 3/28/2025.
These failures could place residents at risk of embarrassment, discomfort, and skin breakdown.
Findings included:
Record review Resident #2's face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with chronic obstructive pulmonary disease(lung disease that block airflow and make it difficult to breathe), unspecified sequelae of cerebral infarction(another term for stroke), Type 2 diabetes mellitus(a chronic disease in which the body has trouble controlling blood sugar), hemiplegia and hemiparesis (partial paralysis on one side of the body), and muscle weakness (decreased strength in the muscles).
Record review Resident #2 quarterly MDS date 1/7/2025 revealed Section C-0500- BIM summary score of 12 which meant he had moderate cognitive impairment.
Section GG-0115- functionality limitation in range of motion revealed Resident #2 had impairment on one side both upper and lower extremities.
Section GG- Mobility devices revealed a wheelchair was used for mobility.
Section GG0130- E. Shower/bathe was coded as 02-which meant substantial/maximal assistance - helper does more than half the effort.
Record review of Resident #2's care plan dated 12/20/2024 revised on 2/18/2025 revealed the resident has an ADL self-care performance deficit r/t activity intolerance, limited mobility. Goal: The resident will maintain current level of function through the review date. Interventions: Body odor prefers to use Arm and Hammer. Encourage the resident to participate to the fullest extent possible with each interaction. Monitor /document report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Resident #2's plan of care revealed Resident #2 shower days were on Mondays, Wednesdays and Fridays on the 6a-2pm shift.
Review of care staff plan of care revealed there were no documentation of showers for Resident #2 on 3/10/2025 (M ), 3/24/2025(M) and 3/28/2025(F) when his shower days were scheduled on Mondays, Wednesdays and Fridays.
During an interview with Resident #2 on 3/29/2025 at 10:09am, revealed him to state thatthat the resident he does not refuse showers. He stated that if staff said he refused showers they were not telling the truth. He stated he was often told by the CNAs that they are short because of call ins. He said his shower days were on Mondays, Wednesdays, and Fridays. He said he had not denied showers. He said he would not because he enjoyed have a clean body. He said staff told him the next shift would do his shower. He said he preferred showers before lunch.
During an interview with CNA C on 3/29/2025 at 10:21am, she said she had been employed for 32 years. She said she worked stations 1 and 2(located on Halls 100 and 200) on first shift (6a-2pm). She said Resident #2 had not refused showers with her. She stated that she always got her showers completed. CNA A said sometimes the CMAs, or the nurse helps with other things so she could shower residents. She stated that she input all ADLs assisted with in PCC from the kiosk on the wall. She stated she would tell the charge nurse if Resident #2 refused showers.
During an interview with RN B on 3/29/2025 at 11:08am, she said she had been employed here for 9 ½ years. She said she worked the 10am-6pm. She normally worked Station 1 (Hall 100). She stated Resident #2 had not refused showers as far as she was aware. She stated she assisted with showers sometimes. She stated when she assisted with showers, she also did her skin checks. She said when a resident missed a shower, they would not have good hygiene, could get infections and that would not be a good thing.
A telephone interview with the DON on 4/1/2025 at 2:25pm she said she had been off from the facility since 3/25/2025. She said prior to her leave, she required staff bring her daily shower sheets at the end of the shift. But CNAs are supposed to let their nurse know if there were refusals as soon as possible. She said she had received some complaints about residents not getting showers. She said anytime she received this as a complaint she would check with staff about why residents did not get their shower. She said if showers are refused, they are care planned for refusals of ADLs. She said even if a resident refused on one shift, they would sometimes allow a different staff or next shift to shower them. She said she could not recall if Resident #2 had refused showers. She said if a resident does not get showers as scheduled, this could cause body odor, embarrassment, and infections.
An interview with the Administrator on 4/1/2025 at 3:04pm, she said she had been employed at the facility since September 2023. She stated that she was not aware of residents were not getting showers. She said the DON typically have a schedule in place and they are supposed to follow-up with the CNAs if they do not complate any of the Resident ADLs. She said she would bring the shower schedule for Resident #2. She stated if a resident does not get a shower as scheduled, they could have bad hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision.
The facility failed to ensure Resident #1 was adequately supervised as a result she drank hand sanitizer and was hospitalized from [DATE]-[DATE].
This failure could place residents at risk of severe injuries, require hospitalization, or death due to lack of supervision by facility staff.
Findings iIncluded:
Record review of Resident #1's face sheet revealed she was a [AGE] year-old female with diagnosis of Alzheimer Disease with late onset (a progressive disease that destroys memory and important mental functions), Type 2 Diabetes, Mellitus (a chronic disease in which the body has trouble controlling blood sugar) Acute kidney failure (a condition in which the kidneys cannot filter waste), and bpolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs).
Record review of Resident #1's MDS quarterly dated 12/25/2025 revealed BIMS Summary score of 03.
Section E0900- Wandering Presence and Frequency was coded as O. Behavior not exhibited.
Section P0200- Restraints and Alarms revealed E. Wander/Elopement alarm was used.
Record review of Resident #1's care plan dated 11/20/2019 and target date of 2/21/2025 revealed:
Focus: Resident #1 was at risk for elopement related to wandering. Resident requires a wander guard for safety.
Goal: Patient was not to have no incidence of elopement.
Interventions: check placement and function of wander guard, evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings.
Focus: Resident #1 have little or no awareness of safety, or boundaries related to other's personal space. Going into other resident's rooms, not always aware if areas are okay for her to be in, rummaging through items that are not hers. Wandering about her living space. I wander aimlessly into other residents' rooms. Staff redirects me. Date initiated 1/19/2025 revised on 2/20/2025.
Goal: Resident #1 will be able to maintain a meaningful life.
Interventions: If Resident #1 was wandering into other residents' rooms gently re-direct her by taking her hand and lead me into other parts of open space that offers me activities that may be engaging.
Record review of elopement Risk evaluation dated 2/27/2025 revealed that Resident #1 was at risk for wandering due to her cognitive impairment and poor decision making.
Record review of Resident #1's nursing progress note dated 3/17/2025 at 3:00pm, stated Resident #1 was found sipping ethyl alcohol 70% from a hand sanitizer container. The resident appeared alert. No immediate signs of distress were noted at the time of observation. Nurse immediately intervened and took the container from resident. Resident #1 was assessed fr any signs of alcohol poisoning or adverse reactions, including vital signs and level of consciousness and any complaints of discomfort. The attending physician was notified. Resident #1 was monitored closely for any potential effects of alcohol poisoning. Poison Control was contacted, and a case number assigned. Nurse was told to continue to monitor.
Record review of nursing progress note dated 3/17/2025 at 4:50pm, revealed that the receptionist called the charge nurse because Resident #1 was in the lobby and hard to awaken. Nurse stated that when she arrived at the scene, the resident was having the shakes of upper extremities with her eyes opened. She was offered candy, and she asked, where was the candy?. Physician was contacted and vitals taken. Blood sugar was 201. Physician A stated to send her out to the ER.
Record review of Resident #1's hospital record dated 3/17/2025 revealed chief complaint for visit was said to be drug overdose. Report stated resident #1 admitted with dementia unknown baseline who was found drinking hand sanitizer at the nursing home. EMS states unknown amount. Labs including etoh level ordered. Etoh (ethanol) is negative. Resident #1 will require admission to the IMU for close monitoring. Lab ordered stat: Ethanol Level Value <5.0
Comment: The pharmacological responses to blood alcohol levels may vary from individual to individual. The fatal concentration has been reported to be greater than 400.0mg/dl. Ethanol % <0.005
An interview with RP on 3/31/2025 @ 12:28pm, stated that she had been called about the incident when Resident #1 drank hand sanitizer. She stated that she was told that the hand sanitizer came from one of the medication carts. She said she did not recall the name of the nurse that called her. She said Resident #1 did not have a history of seizures. She stated she was aware that she had been wandering at the facility and had a wander guard. She stated that wander guard was used so she would not leave out of the door. She walked in circles both day and night. She had late-stage Alzheimer disease. She had gone into other resident's rooms a few times. She had no history of leaving the building. She said she was not a fall risk. She stated that she had been told by hospital staff that the labs showed she had a small amount of the hand sanitizer in her system, not enough to harm her.
An interview with RN A on 3/31/2025 at 3:48pm stated that she had been employed for two to three weeks, and worked the 8a-5pm shift M-F. She stated that she was the unit manager. She said the charge nurse (LVN A) told her that Resident #1 had drank hand sanitizer or at least that hand sanitizer was all over her shirt. She said she called Poison Control and was provided a case number. LVN A worked Hall 4 and was familiar with the residents' behavior. She stated when she spoke with the doctor, she was told to monitor and if her vitals changed to call him back. She said LVN A called the doctor the second time to let him know she was hard to awaken and that her blood sugar was higher than normal. She said drinking ethyl alcohol could have had the resident inebriated, or it could have gotten in her eyes and that would have been bad, death if someone were to drink a whole lot of it. She was not sure what sized bottle the resident had. She stated she had conducted an in-service on 3/17/2025 about patient safety and hazardous material storage.
An interview on 3/31/2025 at 4:05pm, Physician A stated that he was notified about Resident #1 drinking the hand sanitizer. He said at the time no one told him how much. He said they called poison control, and they told the nurse to just monitor. He said when they called him back about her being hard to awaken, he told them to send her out to the hospital for precaution. He said hand sanitizer could affect the liver. He said the hospital said she did not have much and was not deemed harmful at least, he repeated her labs, and they were pretty good. It is unknown how much she drank. No long-term effects from it. Labs were not abnormal from drinking the hand sanitizer. She was at her baseline. He said the only recommendation for her wandering and seeking items that might be harmful was supervising her. He said they need to monitor her closely. He said everyone knows her. Everyone was watching out for her. He said she wandered but mostly sit in the lobby. He said the key was monitoring her.
An interview with LVNA on 4/1/2025 at 10:36am, she said she had been a nurse for 40 years. She had been an employee for about 6 months. She worked here from 2000-2005 and she just came back. She stated that CMA A alerted her that Resident #1 had drank hand sanitizer. She had it on her shirt. She talked with the unit manager (RN A); she called poison control and the doctor. She was told to monitoring her. She watched her for a change in condition. She said Resident #1 went to the front lobby to sit as she usually does then she was alerted by the receptionist that she could not awake her. She said the Resident had been in the lobby about 30-40 minutes. She said she took her vitals and blood sugar was out of baseline (200) it is not usually more than 140. She was taken to the room, and she called Physician A and he said to send her out 911. She said the hand sanitizer is usually in the locked cart. She was walking on the hall when CMA A saw Resident #1 with the bottle in her hand and it was on her chest. They assumed that she drank it. It looks like a brand-new bottle. No hand sanitizer was on her face, and she did not smell it on her breathe. When EMS arrived, she wanted to eat, and her tray was already on the tray table. She began to fight as she wanted to eat. She said she got a report from the DON that Resident #1'; s sodium was high and no trace of the hand sanitizer from the blood test. Sodium level was 160 when she got to the hospital. She does have a diagnosis of renal disease. One intervention they put in place was to give her a bottled water. She walked around with it in her hand all day drinking along the way.
An interview with receptionist B on 4/1/2025 at 11:25am revealed she had been employed at the facility since January 2025. She normally worked from 3p-8p in the evening. She stated that Resident #1 normally sit in the front lobby and walk around too. She stated that she had been sitting there for 30-40 minutes on 3/17/2025. She attempted to wake her. Her eyes were opened but she was not responding. A CNA came they tried to get her up. She told the CNA to go get a nurse. LVN A came, and they got her in the chair, and she was taken to the station. They called 911 and she asked what happened because she not normally like that she normally walked a lot, sat in the lobby and then walked some more all day. She said to herself, something happened because that was not like her. She sometimes passed and got a candy from her desk. If she sat in the lobby too long, she would call the station and ask them to come get her.
Interview with CMA A on 4/1/2025 at 11:56am, she said she had been employed 1.5 years and worked Hall 400 (where Resident #1) resided. She said on 3/17/2025 she saw Resident #1 coming from the back side of 400. She said the bottle of hand sanitizer was up against her mouth and turned upside down in the air (as someone drinking a beverage). She said she saw hand sanitizer on her shirt. She said that she immediately took the bottle, but Resident would not hand her the top. She said she called for the charge nurse (LVN A) to come to help her as the resident began to get aggressive with her. She said then the nurse took her into her room and took her vitals. She said as far as she was aware her vitals were normal. She said she was not aware that she was found in the lobby hard to awaken. She said she heard that later in the day. She said the hand sanitizer did not come from her medication cart as hers was still on the cart. She said the hand sanitizer was usually kept on top of the medication cart for use before passing medications. She said they had an in-service and now they must keep it inside of their carts. She said hand sanitizer is hazardous for anyone with dementia or with any ailments.
Observation and Interview on 4/1/2025 at 12:12pm CMA B said she had been employed since October 2024. She worked 7a-7pm shift. She said she worked on Hall 300. She stated that she hid her hand sanitizer behind her pill crusher. Observation of a 2 oz. bottle of hand sanitizer on top of the medication cart near the pill crusher. She said she recall an in-service about keeping the hand sanitizer in the draw, but she needed to use it so often when passing medications, she just hid it. They usually have a big bottle that was kept in the side pocket on the cart. She said although there was hand sanitizer on the wall they are too far apart for her to use before passing medications. She said she did sanitizer hands before and after passing medications.
An interview on 4/1/2025 at 12:25pm with Interview with NP state that he had been fat the facility for about 2 years. He stated that he had about 90 residents at the facility. He stated that Resident #1 have had recent medications changed due to the pacing/wandering. He stated that Resident #1 had bi-polar and late-stage Dementia and was on a low dosage of Zyprexa. He said a recent GDR was done for her to help with the anxiety and pacing. He stated he had not been informed about her drinking hand sanitizer. He said that if any resident drinks enough hand sanitizer it could be harmful. He said he could not speak on outcomes because he would need all the details.
A telephone interview with the DON on 4//1/2025 at 2:25pm she stated no one saw Resident #1 drink the hand sanitizer to her knowledge. Then, she was told that she had a change in condition and got orders from physician A to send her out. The nurse reported to EMS that she was hard to arouse. She said hypernatremia was her diagnosis. She had been hydrated her with IV fluids and they monitored her labs when she returned. She said the hospital report indicated that she did not have any alcohol in her system. She said no staff admitted to giving Resident #1 the hand sanitizer. She did an investigation, and they immediately started an in-service immediately and made sure there was no hand sanitizer. What could have happened to her had she drunk the hand sanitizer- could cause disoriented, she is not sure about any amount of alcohol, impaired vision and cognitive impairment or inebriated.
An interview with the Administrator on 4/1/2025 at 3:04pm, revealed she had been employed since September 2023. She said she found out Resident #1 had drunk hand sanitizer during their in daily clinical morning meeting the next day. She said she talked to the DON after she interviewed staff, and she said staff did not see her drink hand sanitizer. She was in the lobby, and she was unresponsive. She was sent out to the hospital. She said she saw the hospital record today and it indicated that she had 0.005% ethyl alcohol in her system. When she talked to Physician A, he was not alarmed. They also did an ad hoc qapi with their medical director. She said it reconfirmed that the resident was accessed, and the nurse had immediately called the poison control. She said Resident #1 was not symptomaticnot symptomatic. She said they never found out where the resident got the hand sanitizer. She said most staff use the dispensers affixed on the walls. She said she understood it was a small maybe 2 oz bottle, so there was not that much in the bottle. She said she was not a nurse or a doctor, so she did not know what could have happened if she had drunk more of the hand sanitizer. She said the nurse called poison control, and they took necessary measures. She said the verbal report from the DON was that she had no alcohol in her system. She said the hospital records showed that alcohol was negative. She said the DON also did in-services with staff and she will provide a copy of the in-service.
A copy of the facility's Accident and supervision policy for review was requested but not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for comprehensive care plans.
1. The facility failed to ensure Resident #3's had a care plan to reflect the residents' weight loss.
2. The facility failed to ensure Resident #3's had a care plan to reflect his medication Ozempic that was prescribed from November 2024 through February 2025.
These failures could place residents at risk of not receiving adequate care and services to improve their quality of life.
Findings include:
Record review of Resident #3's face sheet, dated 11/04/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), cerebrovascular disease (a condition that affects the brain's blood supply and blood vessels), chronic pain (persistent pain), gastro esophageal reflux disease (A digestive disease in which the stomach acid or bile irritates the food pipe lining), muscle weakness (decrease strength in the muscle), diabetes (high blood sugar), anxiety (persistent worry or fear) depression (a common mental health characterized persistent low mood, loss of interest and other symptoms that interferes with daily life) and hemiplegia (paralysis or weakness on one side).
Record review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 12, which indicated he was cognitively aware. For ADL's Resident #3 required partial/ moderate assistance in the areas of oral hygiene, toileting hygiene, upper body dressing, and lower body dressing, was substantial/maximal assistance in shower/bathe self and putting on/taking off footwear. For weight loss, he had a 15 pounds weight loss in two months.
Record review of Resident #3's care plan, dated 11/12/2024, reflected Resident #3 was care planned for the following:
Focus: The resident has nutritional problems or potential nutritional problem r/t Diet restrictions: mechanically altered diet
Goals: o The resident will maintain adequate nutritional status as evidenced by maintaining weight
, no s/sx of malnutrition, and consuming at least 50% of at least 2 meals daily through review date.
Intervention o Explain and reinforce to the resident the importance of maintaining the diet ordered.
Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors.
o Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking,
Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing
to eat, appears concerned during meals.
o Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow. up as indicated.
Record review of Resident #3's weight log, dated November 2024 to March 2025, reflected the following:
Admit weight on 11/04/2024: 216 lbs., 12/10/2024; 210 LBS., 01/03/2025: 201 lbs., 02/12/2025: 190:00lbs and 03/03/2025: 190.2 lbs.
Record review of Dietitian's documentation in the nurse's progress notes, dated 3/3/2025, revealed a weigh of 190.2 lbs., with a -7.5% change [Comparison Weight on 12/10/2024, 210.3 Lbs,-9.6% , -20.1 Lbs ] MDS: -5.0% change over 30 day(s) [Comparison Weight 1/3/2025, 202 Lbs,-5.9% , -12 Lbs. ] -3.0% change from last weight [ Comparison Weight 1/3/2025, 201.5Lbs, -5.7% , -11.5 Lbs. ] -7.5% change [Comparison Weight 12/10/2024, 210.3 Lbs,-97% , -20.3 Lbs.
Record review of Resident #3's physician's order, dated 11/08/2024, reflected an order for Ozempic 0.25 or 0.5mg subcutaneous, solution pen injection. Inject 0.5 subcutaneously one time a day every Friday.
Record review of Resident #3's MAR, dated November 2024 to February 2025, reflected the medication was given as ordered every Friday. Fingerstick blood sugar was hyperglycemia or hypoglycemia notify the MD or NP if blood sugar is < 70 or >400.
Record review of Resident #3's care plan reflected the care plan was not developed to address actual weight loss that took place between January and February. The care plan did not address Ozempic and it's side effects
Record review of the medication guide for use of Ozempic revealed it decreases appetite.
Observation on 03/13/2025 at 11:25 am, revealed the resident was in bed and appeared to be asleep. He was clean and groomed with no offensive urine or feces odor. Resident #3 did not respond when his name was called at first, but responded the second time when his name was called. He was alert and oriented and could make his needs known.
During an interview on 03/13/2025 at 11:25 am, Resident #3 said when he was on Ozempic he had some weight loss. He said he had no appetite. He said he was now getting another medication to treat his diabetes, and it was working. He said he was aware that one of the side effects of the Ozempic was weight loss. He said he was no longer getting Ozempic, he was getting a different medication to treat his diabetes.
During an interview with LVN C on 03/13/2025 at 4:10 pm, she said the resident was on Ozempic and he was no longer getting Ozempic. She said he had some weight loss, but he was now getting another medication to treat his diabetes.
During an interview via telephone with the MDS Coordinator on 03/13/2025 at 4:20 pm, the MDS Coordinator said she was responsible for updating resident's MDS and care plans. She said she and the other MDS coordinator were new to the MDS position. She said she usually looked at nurse's notes and CNA documentation to do the MDS and care plans. She said she could not remember if she was the one who was responsible for doing Resident #3's care plan. The MDS coordinator stated she was going to look at Resident #3's care plan and modify it. She said she would educate the other MDS nurse to look at the nurse's notes regarding activities in the last 7 days, interview staff and residents and update care plans. She said if care plans or the MDS were not accurate residents may not receive the appropriate care.
During an interview with the DON on 03/13/2025 at 5:40 pm, the DON stated Resident #3 had some weight loss because he was on Ozempic. She said his care plan should be updated to reflect his weight loss. She said both MDS nurses were new in the position and she was going to ensure that they get some more training on MDS and care plans.
Interview with the Administrator on 03/13/2025 at 6:05 pm, revealed they did not have a policy for care planning. She said they used the RAI manual for MDS and care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Resident #3 and Resident #5) reviewed for pharmacy services.
1. The facility failed to ensure Resident #3 was administered his inhaler and supplement as ordered by his physician.
2. The facility failed to ensure Resident #5 was administered his Carvedilol oral tablet as ordered by his physician.
These failures could place residents at risk of not being provided their medications as ordered which could result in dimishing quality of life.
Findings include:
1. Record review of Resident #3's face sheet, dated 11/04/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), cerebrovascular disease (a condition that affects the brain's blood supply and blood vessels), chronic pain (persistent pain), gastro esophageal disease (A digestive disease in which the stomach acid or bile irritates the food pipe lining), muscle weakness (decrease strength in the muscle), diabetes (high blood sugar), anxiety (persistent worry or fear) depression (a common mental health characterized persistent low mood, loss of interest and other symptoms that interferes with daily life) and hemiplegia (paralysis or weakness on one side).
Record review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 12, reflected he was cognitively aware. For ADL's Resident #3's required partial/moderate assistance in the areas of oral hygiene, toileting hygiene, upper body dressing, and lower body dressing, was substantial/maximal assistance in shower/bathe self and putting on/taking off footwear. For weight loss, he had a 15 pounds weight loss in two months.
Record review of Resident #3 physician's order reflected:
Order dated 11/4/2024 for Proair inhaler Aerosol solution 108 mcg/act 2 puffs every 6 hrs. at 6:00 am, 12:00 pm and 6:00 pm.
Order dated 01/08/2024 for House supplement 90 ml 3 times a day at 7:00 am, 1:00 pm and 10:00 pm.
Record review of Resident #3's MAR, dated February and March 2025, reflected:
Proair inhaler Aerosol solution 108 mcg/act 2 puffs every 6 hrs. reflected blank on the MAR for 02/07/2025, 02/14/2025 and 02/15/2025 at 6:00 am.
House supplement 90 ml 3 times a day reflected blanks on the MAR for 03/6/2025, 3/07/2025, 3/11/2025, 2/5/2025, 2/19/2025 and 2/27/2025 at 10:00 pm
Record review of the nurse's notes for February and March 2025 revealed no reasons why the medications were not documented as given or not given
Observation on 03/13/2025 at 11:25 am revealed Resident #3 was in bed, and appeared to be asleep. He was clean and groomed with no offensive urine or feces odor. Resident #3's did not respond when his name was called at first but responded the second time when his name was called. He was alert and oriented and could make his needs known.
During an interview on 03/13/2025 at 11:25 am with Resident #3, he said when he was not getting his Clonazepam medications as ordered. He said the physician had changed his Clonazepam and the nurse had just started giving him his medications as ordered on 3/12/2025.
2. Record review of Resident #5's admission record reflected an [AGE] year old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses .which included chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), chronic pain (persistent pain), hypertension (high blood pressure), heart failure (a condition where the heart doesn't pump blood as well as it should), muscle weakness (decrease strength in the muscle), asthma (a condition where the airways become inflamed and swell making it difficult to breathe), depression (a common mental health characterized persistent low mood, loss of interest and other symptoms that interferes with daily life) and hyperlipidemia (level of high fat in the blood).
Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. For ADL's the resident needed supervision for oral hygiene, eating, for upper and lower body dressing and putting on and taking off footwear. He needed substantial/maximal assistance for shower/bathe self. He was coded as continent of bowel and occasionally incontinent of bladder.
Record review of Resident #5's care plan, initiated 05/22/2020 and revised 4/17/2024, read in part:
Focus: has hypertension r/t, lifestyle choices, Smoking.
Goal: o The resident will maintain a blood pressure within the normal parameters through the review date.
o The resident will remain free of complications related to hypertension through review date.
o Avoid taking the blood pressure reading after physical activity or emotion distress.
Intervention: o Give anti-hypertensive medications as ordered. Monitor for side effects such as
orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness.
o Observe abnormalities for urinary output. Report significant changes to the MD.
o Observe for any edema. Notify MD if abnormal reading noted.
o Observe/report PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (Dyspnea).
o Obtain blood pressure readings daily per orders. Take blood pressure readings. under the same conditions each time.
o The resident needs BP taken with a medium size cuff.
Record review of Resident #5's Consolidated orders for March 2025 reflected an order for Carvedilol oral tablet 20 mg, give 1 tablet by mouth every 12 hours for high blood pressure. Medications to be given at 8:00 am and 8:00 pm.
Record review of Resident #5's MAR, dated March 2025, reflected blank on the MAR for 03/11/2025 for the 8:00 pm dose of Carvedilol 20mg.
Further record review of Resident #5's progress note, dated March 2025, reflected no documentation as to why the medication was withheld or not given.
During interview on 3/13/2025 at 4:10 PM with LVN C, she stated there should be no blanks on the MARs. She said blanks on the MARs would indicate the medication/medications were not given. She said when medications were given it should be documented and if not given it should be documented and the reason why it was not given. She said residents not getting their medication could cause them to get sick.
During interview on 3/13/2025 at 5:25 pm, LVN D said there should be no blanks on the MARs. She said if medications were given or not given they should be documented on the MARs. She said if medications were not given the reason should also be documented.
During interview on 03/13/2025 at 5:45 pm, the DON stated there should be no blanks on the MARs. She said if medications were given it should be documented on the MARs, if they were not given it should be documented with the reasons why tthey were not given. She said if there were blanks on the MARs it could cause the resident to get too much medication or the resident not getting his/her medications. The resident not getting their medication could cause them to take longer to get well. She said her expectation of the nurses and medication aides were to document whether medications were given or not given. She said she was going to in-service the staff.
Record review of the facility's, undated, policy and procedure on Standard of Practice read in part .
The expectation set forth by the facility's management is that the nurses comply with current standards of practice in terms of following physician's orders for medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 resident (Resident #1) reviewed for incontinent care.
-The facility failed to ensure CNA A and CNA B properly cleaned Resident #1 during incontinent care.
This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life.
Findings included:
Record review of the admission sheet (undated) for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cognitive communication deficit (a communication difficulty caused by a cognitive impairment), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and weakness (reduced strength in one or more muscles).
Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the BIMS score was 09 out of 15, which indicated moderately impaired cognitively. The MDS revealed Resident required substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. Further review of MDS section H0300: Urinary Incontinence was coded (3) always incontinent. section H0400: Bowel Incontinence was coded (3) always incontinent.
Record review of Resident #1's care plan, initiated 04/16/2021 and revised on 01/24/2024 revealed the following:
Focus: (Resident #1) has bowel and bladder incontinence.
Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date.
Interventions: Clean peri-area with each incontinence episode.
Observation on 11/27/24 at 9:24a.m., revealed CNA A and CNA B provided Resident #1 with incontinence care.
CNA A unfasten the resident's brief and tucked it under the resident's buttocks. CNA A did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus (the opening at the end of the urethra, the tube that carries urine from the bladder out of the body).
In an interview on 11/27/24 at 9: 42a.m., with CNA A, she said she had been working at the facility since January 2024 as a full-time employee. CNA A said she did not spread Resident's labia and clean the resident's meatus during incontinent care because I was nervous. She said the failure placed the resident at risk for infections. She said she did not recall doing CNA competency checks for incontinent care at this facility.
In an interview on 11/27/24 at 9:47 a.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care, following peri care guidelines to keep level of UTIs down. She said CNAs were provided in- service/ check offs in a classroom setting on a manikin once a month on peri care and hand hygiene by the Unit Manager.
In an interview on 11/27/24 at 10:12 a.m., with the Unit Manager, she said she provided CNAs/nurses in-service alternating between hand hygiene one month and peri-care the next in a classroom on a manikin or at bedside.
On 11/27/24 at 12:02pm policy on perineal care was requested from the Administrator.
No policy on Perineal Care was provided on exit.
Record review of facility's In-service Training Record dated: 10/23/2024 Presented by Unit Manager, Program Content/ Title: Peri-Care. The in-service was not signed by CNA A.
Record review of facility's Peri Care Audit Tool (undated) revealed read in part: .3. Remove soiled brief, wash front to back, changes side of cloth or disposable wipe with each swipe. 4. Female-front, washes middle first, then the sides .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 infection for 1 of 4 residents (Resident #1) reviewed for infection.
CNA A failed to performed hand hygiene after removing soiled gloves before leaving Resident#1's room.
This failure could place residents at risk for the spread of infection.
Findings included:
Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cognitive communication deficit (a communication difficulty caused by a cognitive impairment), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and weakness (reduced strength in one or more muscles).
Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the BIMS score was 09 out of 15, which indicated moderately impaired cognitively. The MDS revealed Resident required substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. Further review of MDS section H0300: Urinary Incontinence was coded (3) always incontinent. section H0400: Bowel Incontinence was coded (3) always incontinent.
Record review of Resident #1's care plan, initiated 04/16/2021 and revised on 01/24/2024 revealed the following:
Focus: (Resident #1) has bowel and bladder incontinence.
Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date.
Interventions: Clean peri-area with each incontinence episode.
Observation on 11/27/24 at 9:24a.m., revealed CNA A and CNA B provided Resident #1 with incontinence care.
CNA A unfasten the resident's brief and tucked it under the resident's buttocks. CNA B assisted Resident #1 turn onto her right side to clean her buttocks. CNA A said, I need to go and get fitted sheet. CNA A removed soiled gloves and without sanitizing/washing her hands left the room. CNA A returned after few minutes with a clean fitted sheet in a clear trash bag.
In an interview on 11/27/24 at 9: 42a.m., CNA A said she needed to get fitted sheet and forgot to sanitize her hands before leaving the room. She said not performing hand hygiene could result in cross contamination. She said she had completed in-services on infection two weeks ago.
In an interview on 11/27/24 at 9:47 a.m., with the DON, she said she expected staff to sanitize their hands before entering the room using the sanitizer on the hallway, after touching a dirty area prior to moving to a clean area and in between glove change when performing incontinent care. She said these failures were risk for infection control. She said CNAs were provided in service/ check offs in a classroom setting on a manikin once a month on peri care and hand hygiene by the Unit Manager.
In an interview on 11/27/24 at 10:12 a.m., with the Unit Manager, she said she provided CNAs/nurses in-service alternating between hand hygiene one month and peri-care the next in a classroom on a manikin or at bedside.
Record review of facility's Hand Hygiene Care Audit signed by CNA A and Unit Manager dated 11/19/24 revealed read in part: .3. Hand washing is done every time you remove gloves.9. washes hands every time gloves are removed .
Record review of facility's Infection control policy (dated November 1, 2017) revealed read in part: . Policy statement: This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy interpretation and implementation: 1. This center's infection control policies and practices apply equally to all team member. 2. The objectives of our infection control policies and practices are to: a. prevent, identify, detect, investigate, report and control infections in the center .
Record review of facility's Handwashing/Hand Hygiene policy (dated November 1, 2017) revealed read in part: .Policy: This center considers hand hygiene the primary means to prevent the spread of infections. 5. Use an alcohol-based hand rub or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: k. After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to make prompt efforts by the facility to resolve grievances the resident may have, for 1 (Resident #30) of 16 residents reviewed for grievances.
-1. The facility failed to follow-up and ensured Resident #30's missing property had been found or replaced.
2. The facility failed to complete the grievance process by following up with Resident #30 to see if his missing items were replaced, and the facility did not assist him with replacing his missing items. Resident #30 was missing his wallet that had his social security card, green card, cash app card, bank card, $10.00 and food stamp card.
These failures could place residents at risk for missing property, emotional distress, and lack of resources needed to function and thrive at the facility.
Findings include:
Record review of Resident #30's face sheet reflected a [AGE] year-old male who was admitted into the facility on 6/19/24. He had diagnoses which included hyperlipidemia (a condition in which there are abnormally high levels of lipids in the blood), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduced blood flow in the limbs), cognitive communication deficit, dysphagia oropharyngeal (a swallowing difficulty that occurs during oropharyngeal phase, when food or liquid is moved from the mouth to the upper esophageal sphincter), and acquired absence of left leg above knee.
Record review of Resident #30's Comprehensive MDS assessment dated [DATE], reflected he had a BIMs score of 12 out of 15, which indicated he was moderately cognitively impaired. He required setup or cleanup assistance for eating and oral hygiene. He required partial/moderate assistance for toilet hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene. Resident #30 could not attempt to perform toilet transfer or tub/shower transfer due to medical conditions and safety concerns. Resident #30 used a wheelchair for mobility.
Record review of Resident #30's comprehensive Care Plan dated 8/2/2024 revealed, I have no interest in hobbies. I'm not used to having a lot of free time. Goal, try to find new things to help me find new interest. Intervention, invite me to sit in during activities programs and let me join in at my own comfort level.
Record review of Customer Concern Log dated 6/23/2024recorded by the Administrator revealed, Received: Nature of Concern, Resident #30 alleged content of wallet missing included cash app card, food stamp card, green card, social security card, and 10.00 cash. Resolved: Resolution, Alert and oriented to person, place, and time. Reported to HHSC. PD notified and investigation. During rounds on 6/21/2024, Resident #30 refused to allow DNS to assist with placement of belongings inventory. Social services followed-up with Resident #30 and he called to replace items from wallet. There was no assistance needed.
Interview on 11/14/2024 at 3:35p.m., Administrator said DON went to Resident #30's room on 6/21/24 and tried to complete an inventory regarding his items and to help him put away his personal belongings but he refused to have the inventory done. She said when she was informed that Resident #30's wallet was missing, she reported it to the state, searched for items, and reported it to the police. She said staff were also Interviewed. She said she did not look further into Resident #30's missing items because he had two friends that would go to the store for him. She said Resident #30 was able to make phone calls to replace the items. She said to her knowledge Resident #30 was able to replace all his missing items. She said if surveyor needed copies of his identifiable information, she could speak with the Business Office
Interview on 11/14/2024 at 3:48p.m., Social Worker said the facility did not follow up with Resident #30 regarding his missing items. He said they took Resident #30's word regarding him taking the initiative to replace his own items. The Social Worker said the grievance process could have been better. He said if there had been a more thorough investigation, the facility could have made sure Resident #30 received the things that he needed while at the facility.
Interview on 11/14/2024 at 3:54p.m., Resident #30 said he was not able to replace all his items. He said the facility did not assist him with replacing the items. He said his family member helped him replace all his items except for his social security and green card. He said he was having a hard time renewing his Citizenship because he was still working on replacing his missing green card. He said there were no cameras in his room. He said all those items were in his wallet because he lived at the facility, and he did not think someone would steal from him. He said he also left a lift stick on the van and the facility never delivered it to him.
Interview on 11/14/2024 at 4:17p.m., Business Office Manager said she was required to meet with residents within 72 hours to go over insurance, and who will pay for room and board upon their admission to the facility. She said Resident #30 came to the facility with his social security card, green card, electric express card. She said he would give his identification information if he had it. She said she made copies of the items and uploaded it to his files and to PCC for his documents.
On 11/14/2024 at 4:25p.m., surveyor went to the business office to obtain copies of Resident #30's documentation that was supposedly scanned upon his admission at the facility, that the Business Office Manager said she would provide. When the Surveyor arrived at the Administrator's office to obtain those items, she refused to give a copy of the inventory and identifiable documentation for the resident such as his social security card, green card, and bank card. Surveyor requested the items from the
Administrator, and she said she did not have the items and eventually shut the door.
Record Review of the facility's policy titled Filing Grievances/Complaints, revised on 09/2005 reflected in part . our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc. without fear of discrimination, threat, or reprisal in any form. Grievances and/or complaints may be submitted orally or in writing. The Grievance Official will oversee the grieving process, receiving and tracking through conclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 8 residents (Resident #2 and Resident #3) reviewed for Activities of Daily Living.
1.
The facility failed to ensure Resident #2's received incontinent care since the previous day which resulted in his adult brief, sheets and bed soaked with urine.
2.
The facility failed to ensure Resident # 2 was given scheduled showers.
3.
The facility failed to ensure Resident #3's adult brief was clean and dry.
These failures could place residents at risk of embarrassment, discomfort, and skin breakdown.
Findings included:
Resident #2
Record review of Resident #2 face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: dementia, hypertension, hemiplegia and hemiparesis following cerebral infarction (stroke-occurs when there is a disrupted blood flow to the brain) affecting left side, contracture of left wrist, pain in left shoulder, and Type 2 diabetes (condition that affects the way your body uses sugar).
Record review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE], section C500 BIM summary score of 11 (means moderately impaired). Section G0110 Activities of Daily Living assistance revealed (A) Bed mobility - Limited assistance needed with one person physically assisting. G0120- Bathing required physical help in part of bathing activity with one staff. Section G0300- Moving on and off toilet (8) for activity did not occur. Section H0300- Urinary Incontinence (3) Always incontinent.
Record review of resident care plan, revised of 5/12/23, revealed Resident #2 had an ADL self-care deficit due to previous CVA with residual left side hemiparesis and contracture in left hand. Interventions would be to anticipate and meet the resident's needs.
Observation of Resident #2 on 8/13 at 2:46 p.m., revealed he had a urine odor and soiled brief.
Observation of Resident #2 on 8/16/23 at 11:11 a.m., revealed he had a soiled brief, sheets and the bed was soaked with urine.
Interview with Resident #2 on 8/13/23 at 2:46 p.m., revealed his brief was wet and no one was in to change him since about 5am. He stated that he was told by an unknown CNA that she would be back. However, she did not come back.
Interview with Resident #2 on 8/16/23 at 11:11 a.m. revealed staff did not check on him often nor changed his brief as needed. He stated despite him pressing the call light, staff usually told him they would come back and never return. He stated he had not had a shower since the previous week on Thursday (8/10/23). He said he should have a shower every Tuesday, Thursday and Saturday. He stated it was very embarrassing that he smelled due to staff not changing him and not getting showers on the days he was supposed to get them. He said he wanted to leave the facility because they were not providing services he was paying for.
Interview with the Charge Nurse A on 8/16/23 at 11:17 a.m., revealed she would check to see what staff were responsible for residents on the hall (Hall 300). She stated, This does not make any sense that he was this soaked with urine. She removed the sheets off him and requested Nurse C come to observe. She stated CNA E was responsible for caring for the resident today and did not provide incontinent care for Resident #2. She said she would ensure Resident #2 received a shower and linen was changed because there was no excuse for him not being changed or showered. She said the resident required assistance with incontinent care and showers. CNA's are responsible for bathing and incontinent care of the residents. She said keeping the residents' briefs dry lowered their risk of skin breakdown.
Interview with CNA D on 8/16/23 at 12:07 p.m., revealed CNA E was responsible for Resident #2's room.
Interview with CNA E on 8/16/23 at 1:18 p.m., revealed someone called in and no one told him to cover Resident #2's room. He stated he had not been in Resident #2's room at all during his shift which was 6AM-2PM. He said that the schedule usually had what rooms each staff were responsible for daily.
Resident #3
Record review of Resident #3 face sheet revealed an 85- year-old female that was admitted to the facility on [DATE] with diagnoses which included Alzheimer Disease (a progressive disease that destroys memory), Dementia (a thinking and social symptoms that interferes with daily functioning), Dysphagia (impairment in the production of speech from brain disease), and severe cognitive communication deficit.
Record review of Resident #3's annual MDS revealed in section C500-BIM score was 0. Section H0300- Urinary Incontinence (3)- Always incontinent.
Record review of the care plan dated 5/24/22 and revised date of 4/13/23 revealed Resident #3 had an ADL self-care deficit due to Alzheimer's disease and abnormality of gait and mobility. Bed mobility: The resident required assistance by 1 staff to turn and reposition. Bathing and showering- The resident required physical help by 2 staff with bathing.
Observation on 8/16/23 at 11:19 a.m of Resident #3 revealed she had a strong urine odor. There were no sheets on the bed.
Interview with Resident #3 on 8/16/23 at 11:19 a.m., revealed she was not interview able.
Interview with Charge Nurse on 8/16/23 at 11:22 a.m., revealed her to state the resident was sometimes combative, but she should still receive incontinent care as needed. She removed the sheet off the resident and stated she was wet, and she would get staff to change her.
Interview with the ADON on 8/16/23 at 1:17 p.m., revealed she was unaware two residents were found in wet soiled briefs and that Resident #2 had not had a shower in 3 days. She said that she would look into it and find out why they had not been changed as needed and why Resident #2 had not been showered according to his care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to thoroughly investigate and report an injury of unknown origin for 1 (CR #1) of 8 reviewed for abuse and neglect.
The facility failed to thoroughly investigate CR #1 injury of unknown origin which was suspicious due him being a total care resident with an impacted acute or subacute fracture of the supracondylar distal femur and a diagnosis of Quadriplegia.
The facility failed to implement interventions to ensure CR #1 was safe after learning that his knee was swollen and was total dependent on staff for care.
The facility failed to report the results of all investigations to officials in accordance with state law, including to State agency within 5 working days of the incident.
An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system.
This failure could have placed residents at risk of abuse and neglect.
Finding Included:
Record review of census provided on 8/4/2023, revealed a census of 101 residents.
Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain).
Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition.
Record review of progress note #1, dated 8/1/23 at 6:37 PM, revealed CNA A reported CR #1's knee was swollen to LVN A.
Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status.
Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur.
Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room.
Record review of progress note dated 8/2/23 at 10:16p.m., CR#1 was transported to a local hospital via ambulance.
Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease.
Record review of the schedule dated 8/1/23 and 8/2/23, revealed that LVN A was scheduled as the nurse for Hall 100, CNA B worked 6a-2pm shift on Hall 100, CNA A was scheduled to work Hall 100 (2pm-10pm shift).
Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA B all worked on 8/1/23, 8/2/23 and 8/3/23 and had access to CR#1 for over 24 hours.
Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23).
Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused.
Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way.
Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation.
Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency.
Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency.
Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures.
Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma.
Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture.
Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended due to no staff admitting any falls or trauma. She said that it is also believed that if CR#1 had fallen he would have other injuries.
Interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she started the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin to State agency because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She stated that no staff had been suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating.
Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do.
Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that her investigation revealed that no one saw anything. She said no one was suspended because she did not find that anyone intentionally hurt CR#1. When asked how did she protect CR#1 during her investigation, she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVN A, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a on 7/31/23, CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires.
Subsequent interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious though and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately.
Interview with HR on 9/11/23 at 2:25 p.m. revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023.
Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting.
Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation.
Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin.
The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template, and a Plan of Removal (POR) was requested.
The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm
Immediate action to ensure residents were not in jeopardy and threat of harm:
On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome.
On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able.
On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23.
On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23.
If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings.
On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23.
Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training.
Facilities Plan to ensure compliance quickly by the following actions:
All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23.
On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23.
On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary.
On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly.
On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained.
On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23.
The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project.
On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project.
Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent.
Monitoring of the plan of removal included the following:
Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted.
Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on.
Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, reporting incidents, professionalism, transfers, smoking policy.
Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON.
Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility.
Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator.
The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement policies and procedures for ensuring the reporting of reasonable suspicion of a crime for 1 (CR #1) of 8 residents who was total care and sustained a femur fracture.
1. The facility failed to thoroughly investigate and report to State Survey agency that CR #1, who was a total care resident, sustained a supra condylar femur fracture and required surgical procedure.On 8/2/23 the resident was sent to the hospital and it was confirmed to be a supracondylar acute or subacute fracture. This suspicious injury of unknown origin should have been reported to the Administrator immediately. Interim Administrator A was not made aware of the incident until 8/3/23 a day later. Meanwhile the staff that had assisted CR#1 continued to work and no investigation was started. Interim Administrator A did not conduct an investigation.
2. The facility failed to ensure all allegations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown origin were reported to State Agency for 1 (CR #1) of 8 reviewed for abuse and neglect.
This failure could have placed 101 residents at risk of abuse and neglect.
An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system.
Findings Included:
Record review of census provided on 8/4/2023, revealed a census of 101 residents.
Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain).
Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following:
Section B0600- Speech clarity- (2) no speech
B0700- Ability to make self-understood (3)-Rarely or never.
B0800- Ability to understand others (3)-Rarely or never
Section C500- Brief Interview of Mental Status was unscored.
Section G0110- Activities of Daily Living (ADL's) included: bathing, toileting, grooming and hygiene) revealed the following:
A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist),
B. Transfer (4-total dependence) support (3) (two-person assist),
C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist)
Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear.
Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns.
Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder.
Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition.
Record review of progress note #1, dated 8/1/23 at 6:37 p.m. LVN A wrote: CNA A reported CR #1's knee was swollen, assessed and contracted physician.
Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status.
Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur.
Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room.
Record review of progress note dated 8/2/23 at 10:16p.m., CR#1 was transported to a local hospital via ambulance.
Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease.
Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation.
Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA Z all worked on 8/1, 8/2 and 8/3 and had access to CR#1 for over 24 hours.
Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation.
Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency.
Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency.
Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma.
Interview with Interim Administrator B on 9/8/23 at 5:47 p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended.
Subsequent interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she did start the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She denied staff being suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating.
Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do.
Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that she started an investigation on 8/2/23, she learned that nobody saw anything and CNA A reported the swelling on 8/1/23. She said no one was suspended. What did she do to protect CR#1 during her investigation she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVNA, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a (7/31/23), CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires.
Subsequent interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately.
Interview with HR on 9/11/23 at 2:25 p.m. revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023.
Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting.
Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin.The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template, and a Plan of Removal (POR) was requested.
The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm
Immediate action to ensure residents were not in jeopardy and threat of harm:
On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome.
On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able.
On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23.
On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23.
If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings.
On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23.
Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training.
Facilities Plan to ensure compliance quickly by the following actions:
All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23.
On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23.
On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary.
On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly.
On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained.
On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23.
The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project.
On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project.
Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent.
Monitoring of the plan of removal included the following:
Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted.
Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on.
Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, reporting incidents, professionalism, transfers, smoking policy.
Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON.
Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility.
Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator.
The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
The facility failed to ensure that residents were free from accidents and injuries for 1 (CR#1) of 8 reviewed for accident and injuries.
The facility failed to follow their policy and procedure for investigating injuries of unknown origin after both Interim Administrator A and the DON became aware that CR#1 sustained an impacted acute or subacute fracture of the supracondylar distal femur.
The facility failed to thoroughly investigate CR#1 injury of unknown origin which was suspicious due him being a total care resident with an impacted fracture of the distal metaphysis of the right femur and a diagnosis of Quadriplegia.
The facility failed to implement interventions to ensure CR#1 was safe after learning that his knee was swollen and was totally dependent on staff for care.
The facility failed to report the results of all investigations to officials in accordance with state law, including to State agency within 5 working days of the incident.
An Immediate Jeopardy (IJ) situation was identified on 9/9/23 at 10:19 a.m. While the IJ was removed on 9/13/2023, the facility remained out of compliance at a scope of isolated with no actual harm due to the facility's need to evaluate the effectiveness of the corrective system.
Findings Included:
Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain).
Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition.
Record review of progress note #1, dated 8/1/23 at 6:37 p.m., LVN A wrote: CNA A reported CR #1's knee was swollen assessed and contacted physician.
Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status.
Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur.
Record review of progress note dated 8/2/23 at 9:34 p.m., LVN A wrote: The results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room.
Record review of CR #1's hospital record revealed CR#1 was admitted on [DATE] at 10:48 PM. Chief complaint was at baseline nonverbal patient with possible fracture of the right femur and swollen right knee. A pre-operative evaluation was conducted and surgical procedure to take place on 8/3/23.
Observation of CR#1 on 8/4/23 at 2:40 p.m. at the local hospital revealed the resident was asleep. His right leg was wrapped with bandages from his thigh to just passed his knee.
Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23).
Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 p.m., revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused.
Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way.
Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation.
Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and this could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency.
Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency.
Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures.
Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma.
Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture.
Interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she started the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin to State agency because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She stated that no staff had been suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating.
Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said documented the progress note as they are required to do.
Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that her investigation revealed that no one saw anything. She said no one was suspended because she did not find that anyone intentionally hurt CR#1. When asked how did she protect CR#1 during her investigation, she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVN A, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a on 7/31/23, CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires.
Interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious though and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately.
Record review of the schedule dated 8/1/23 and 8/2/23, revealed that LVN A was scheduled as the nurse for Hall 100, CNA B worked 6a-2pm shift on Hall 100, CNA A was scheduled to work Hall 100 (2pm-10pm shift).
Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA B all worked on 8/1/23, 8/2/23 and 8/3/23 and had access to CR#1 for over 24 hours.
Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting.
Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation.
Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin.
Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin.
The Interim Administrator B was notified of an Immediate Jeopardy (IJ) on 9/9/2023 at 10:19p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template and a Plan of Removal (POR) was requested.
The following Plan of Removal submitted by the facility was accepted on 9/13/23 at 1:56pm
Facilities Plan to ensure compliance quickly by the following actions:
The center initiated an investigation immediately upon the knowledge of the incident on 8/2/2023, concerning the fracture of the right knee for resident. After the IJ was given on 9/9/23 the interim Administrator reviewed the findings and agreed that the etiology of the fracture was inconclusive. Based on interviews with staff, residents, observation of other residents, medical record review and medical record review by the Medical Director, there was lack of evidence to support abuse and neglect. Based on the investigation, and the review, the facility is unable to substantiate abuse and neglect.
Immediate action to ensure residents were not in jeopardy and threat of harm:
The previous full-time administrator who was in charge of the building at the time of the incident separated employment with the center on the day following the incident. Since then, the center secured a new administrator. This administrator will assume the assignment as the center leader on 9/18/23. Until she arrives, the center will be directed by an interim administrator.
On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome.
On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able.
On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23.
On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23.
If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings.
On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23.
Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training.
Facilities Plan to ensure compliance quickly by the following actions:
All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23.
On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23.
On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary.
On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly.
On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained.
On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23.
The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater monthly to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project.
On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project.
Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent.
Monitoring of the plan of removal included the following:
Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted.
Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on.
Interview with Activity Director on 9/10/23 at 12:02 p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, professionalism, transfers, smoking policy.
Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON.
Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12 p.m., revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, Hoyer lifts and checking for any safety issues in the facility.
Interviews with five CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator.
The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/13/23 at 1:56 p.m. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for 1 of 8 residents (CR#1) reviewed for abuse and neglect.
The facility failed to conduct a thorough investigation and report to State Survey agency when CR #1, who was a total care resident, sustained a supra condylar femur fracture and required surgical procedure.
The facility failed to protect CR #1 for over 24 hours while awaiting results of his suspicious injury of unknown origin.
The facility failed to ensure their Abuse/Neglect policy was implemented and effective to prevent the further decline of CR #1.
An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system.
This failure could place residents at risk of serious injuries requiring hospitalization or surgical intervention, and/or death.
Findings Included:
Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation.
Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia (paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain).
Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following:
Section B0600- Speech clarity- (2) no speech
B0700- Ability to make self-understood (3)-Rarely or never.
B0800- Ability to understand others (3)-Rarely or never
Section C500- Brief Interview of Mental Status was unscored.
Section G0110- Activities of Daily Living (ADL's) included: bathing, toileting, grooming and hygiene) revealed the following:
A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist),
B. Transfer (4-total dependence) support (3) (two-person assist),
C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist)
Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear.
Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns.
Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder.
Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition.
Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease.
Record review of progress note #1, dated 8/1/23 at 6:37 p.m., LVN A wrote: CNA A reported CR #1's knee was swollen, assessed and called MD.
Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status.
Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur.
Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room.
Record review of progress note dated 8/2/23 at 10:16 p.m., CR#1 was transported to a local hospital via ambulance.
Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation.
Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA Z all worked on 8/1, 8/2 and 8/3 and had access to CR#1 for over 24 hours.
Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23).
Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused.
Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way.
Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation.
Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency.
Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency.
Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma.
Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended.
Subsequent interview with DON on 9/8/23 at 5:50pm, she stated that she did conduct an interview she stated that she did start the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She denied staff being suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating.
Interview with LVN A on 9/10/23 at 12:29pm, revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do.
Subsequent interview with DON on 9/11/23 at 2:10pm, revealed her to state that she started an investigation on 8/2/23, she learned that nobody saw anything and CNA A reported the swelling on 8/1/23. She said no one was suspended. What did she do to protect CR#1 during her investigation she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVNA, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a(7/31/23), CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires.
Subsequent interview with Interim Administrator B on 9/11/23 at 2:16pm, revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately.
Interview with HR on 9/11/23 at 2:25pm revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023.
Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting.
Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin.
The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template and a Plan of Removal (POR) was requested.
The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm
Immediate action to ensure residents were not in jeopardy and threat of harm:
On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome.
On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verse those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable.
On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23.
On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23.
If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been prepared and submitted within 5 days of the negative findings.
On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23.
Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training.
Facilities Plan to ensure compliance quickly by the following actions:
All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator . The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23.
On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23.
On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary.
On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly.
On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained.
On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23.
The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews and physical assessments will be presented in QAPI as a PIP project.
On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project.
Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent.
Monitoring of the plan of removal included the following:
Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted.
Interview with the Interim Administrator B on 9/10/23 at 11:24am, revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on.
Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, professionalism, transfers, smoking policy.
Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON.
Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility.
Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator.
The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision and to the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking areas, and smoking safety that also take into account nonsmoking residents for 3 of 23 residents (Resident #4, Resident #5 and Resident #6) reviewed for smoking policies.
The facility failed to ensure CR #1 was free of accidents and injuries causing him to sustain a impacted acute or subacute fracture of the supracondylar distal femur that required surgical procedure. Physician A and Orthopedic Surgeon said that it would require force to break and stated that something traumatic happened to the resident.
1.
The facility failed to ensure Resident #4 did not have smoking materials on his person and in his room.
2.
The facility failed to ensure Resident #5 did not have smoking materials in her room.
3.
The facility failed to ensure Resident #7 was supervised and wore a smoking apron while smoking.
These deficient practices could place residents at risk for an unsafe smoking environment and injury.
An Immediate Jeopardy (IJ) situation was identified on 8/10/2023 at 1:23 p.m. While the IJ was removed on 8/18/2023 at 12:08p.m. the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system.
This failure could place residents at risk of severe injuries, require hospitalization, or death due to lack of supervision by facility staff.
Findings included:
Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain).
Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following:
Section B0600- Speech clarity- (2) no speech
B0700- Ability to make self-understood (3)-Rarely or never.
B0800- Ability to understand others (3)-Rarely or never
Section C500- Brief Interview of Mental Status was unscored.
Section G0110- Activities of Daily Living (ADL's) include: bathing, toileting, grooming and hygiene) revealed the following:
A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist),
B. Transfer (4-total dependence) support (3) (two-person assist),
C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist)
Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear.
Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns.
Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder.
Record review of CR #1's care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition.
Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease.
Record review of progress note, dated 8/1/23 at 6:37 p.m. written by LVN A, revealed CNA A reported CR #1's knee was swollen.
Record review of physician orders revealed Physician A ordered a blood test and x-rays of bilateral knees for CR #1 on 8/1/23.
Record review of progress note dated 8/2/23 at 12:01 p.m, RN C wrote called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status.
Record review of progress note dated 8/2/23 at 9:34 p.m., written by, revealed the results of the x-ray report showed a fractured femur, MD notified, ordered to send CR#1 to local hospital emergency room.
Record review of progress note dated 8/2/23 at 10:16 p.m., written by LVN A, indicated CR#1 was transported to a local hospital via ambulance.
Record review of radiology results for CR #1, dated 8/2/2023 at 2:19 PM, revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur.
Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease.
Record review of CR #1's hospital record revealed CR#1 was admitted on [DATE] at 10:48 PM. Chief complaint was at baseline nonverbal patient with possible fracture of the right femur and swollen right knee. A pre-operative evaluation was conducted and surgical procedure to repair the fracture would take place on 8/3/23.
Observation of CR#1 on 8/4/23 at 2:40 p.m. at the local hospital revealed the resident was asleep. His right leg was wrapped with bandages from his thigh to just passed his knee.
Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23).
Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused.
Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way.
Interview with LVN A on 8/4/23 at 8:40 p.m., revealed on 8/1/23, CNA A called her to the room after discovering CR #1's knee was swollen. She said she called Physician A and he asked her to send a picture of CR #1's knee. He ordered labs and an x-ray. She said the company did not come until the next day to complete the x-ray. She stated the results on (8/2/23) confirmed he had a fractured right femur. She said she sent the results to Physician A and he said to have him transported to the emergency room.
Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the Medical Director was working on a clinical study on CR #1. She stated the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the injury because she said that it was not suspicious.
Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1 knee was swollen (8/1), and a S-Bar was put in on Wednesday (8/2/23). She said that the Director of Clinical Operation requested that the test be done stat due to his co-morbidities, but they believe his fracture was due to his osteoarthritis. She said that he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She said that LVN A was informed of the swelling from CNA A. She denied an investigation because she said that they investigate when an injury is suspicious.
Interview with CNA B on 8/5/23 at 2:38 p.m., she stated she was responsible for CR #1's incontinent care and she provided bed baths. She denied using a mechanical lift with CR #1. She said she had never moved him from the bed using the lift because he never got out of the bed. She said all she would do is turn and position him. She said that she saw him last on 8/2/23. She denied his knee was swollen.
Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures.
Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma.
Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture.
Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws.
Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting.
The interim Administrator and DON was notified of an Immediate Jeopardy (IJ) on 8/10/23 at 1:23p.m., due to the above failures, the interim Administrator was given a copy of the IJ template and a Plan of Removal (POR) was requested.
The following Plan of Removal submitted by the facility was accepted on 8/13/23 at 12:43 p.m.:
Immediate action taken in response to the resident's injures included the following:
The resident no longer resides at the center as of 8/2/23. He has not returned to the center as of 8/13/23. When/if he returns, the IDT team will assess the resident and update the care plan.
ick Compliance Actions:
8/10/23- The Senior director of Clinical Operations conducted a root cause analysis of the injury to this resident.
8/10 /23 -8/12/23- Lift evaluations were completed for all residents by the Director of Nursing and the Assistant Director of Nursing.
8/10/23- 100 % audit was completed by the Director of Nurses, Assistant Director of Nursing and Unit Manager of lift evaluations compared with the care plan to assure accuracy. Care plans were updated as needed.
8/10/23- The Director of Nurses identified the center has 20 bedbound residents in need of assist with bed mobility. The Care Plan coordinator reviewed the care plans for each of the 20 bed bound residents to ensure safety measures and interventions were added for those residents.
8/10/23-8/12/23 -Education related to Turning and Positioning, Use of Lifts, Abuse and Neglect (to include reporting any incidents), and Customer Service was continued by the Administrator, Director of Nursing and the Assistant Director of Nursing. Education regarding use of lifts was based on the manufacture's guidelines. No one will be allowed to work prior to completion of in service. The Turning and Repositioning and Lift competencies criteria will be based on instruction and a successful return demonstration.
8/10/23 The Lift for Care Policy was reviewed by Senior Director of Clinical Operations.
8/10/23- All lifts were assessed by the Maintenance Director and found to be in good working order.
8/10/23-An Ad Hoc QAPI meeting was held to discuss immediate jeopardy findings and the plan of correction going forward on August 10, 2023. Attendees were Administrator, Director of Nursing, Medical Director, Senior Director of Clinical Operations, and Regional [NAME] President.
8/12/23- Competencies for all CNAs and Nurses related to turning/ repositioning and use of lifts were initiated by the Director of Nurses and Assistant Director of Nurses on 8/12 and are on- going until all CNAS are deemed competent. As of 8/12, no CNA or nurse will work until deemed competent.
Going forward to assure continued compliance with corrective actions, the Director of Nursing and Assistant Director of Nursing will conduct audits of resident positioning and lifts at least 3 times per week for one month, then 2 times per week for one month, and then weekly for one month.
A QAPI PIP has been initiated to report the above monitoring and audit procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months.
Monitoring of the plan of removal included the following:
Interview with the Maintenance Director on 8/15/23 at 3:05 p.m., he stated he received parts for the Hoyer lifts and would be repairing 4-5 Hoyer's that were broken.
Observation on 8/16/23 at 3:13pm revealed 9 mechanical lifts were operable and in good repair. The lift from Hall 100 was included in the nine repaired due to a broken brake.
Interviews with multiple anonymous staff between 8/15-8/16/23 revealed they were not able to state if the mechanical lift training was conducted one-on-one or in group setting, demonstration completed or just a verbal training and when/if they had abuse, neglect and exploitation training. More interviews were conducted.
Interview on 8/17/23 at 12:17pm with the DON, VP of Operations (VPO), VP of Clinical Operations (VPCO), and Interim Administration revealed staff were not consistent in what recent in-services and/or demonstration they had in the past week. The DON stated she would ensure everyone had been re-educated before working a shift. This task would be completed by 8/18/23.
Interviews on 8/17/23 and 8/18/23 with 2 LVN's, 1 RN and 3 CNA's, housekeeping, floor tech and maintenance on the 6a-2pm and 2p-10pm shifts were interviewed and had been trained on reporting incidents of abuse, neglect, exploitation, falls, and use of mechanical lifts and safe transfers. Staff reported that the Interim Administrator was the Abuse Coordinator, all incidents or falls should be reported immediately to nursing administration, and they had been in-serviced on using the mechanical lift properly by Therapy Director.
Interviews on 8/18/23 at 8:24am, with two overnight (10p-6am) CNAs stated that they received training on the lift, repositioning and abuse reporting.
Interview with the DON on 8/18/23 at 11:15am, revealed her to state that all but four employees had been trained on the re-positioning and mechanical lift competencies. She said that two were on vacation and the two were not scheduled to work the week of 8/28-9/1/23. She said that she would ensure they were trained before working on the floor.
Interview with the Therapy Director on 8/18/23 at 11:55am, revealed him to state that he provided training on properly using the mechanical lift, turning and repositioning for all CNA's on 6a-2pm and 2pm-10pm shifts. He stated that the overnight charge nurse would train the CNA's and provide documentation to the DON.
Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended.
Record review of the list of bedbound residents included 20 residents were deemed bedfast had updated care plans.
Record review of in-services on 8/17-8/18/23 revealed abuse, neglect and exploitation, reporting incidents, turning and repositioning competencies and EZ way smart lift competencies were completed by all but 4 staff.
Record review of an undated lift care policy revealed the total lift will be used when residents were non-ambulatory and residents could not bear weight or if they did not qualify for the sit-to stand lift.
The Interim Administrator, DON and RVP were informed the Immediate Jeopardy was removed on 8/18/23 at 12:08pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
A second supervision issues was discovered on 8/11/2023 at 12:40pm
Findings Included:
1.
The facility failed to ensure Resident #4 did not have smoking materials on his person and in his room.
2.
The facility failed to ensure Resident #5 did not have smoking materials in her room.
3.
The facility failed to ensure Resident #7 was supervised and wore a smoking apron while smoking.
These deficient practices could place residents at risk for an unsafe smoking environment and injury.
Findings Included:
Record review of the facility list of smokers revealed there were 23 smokers who resided at the facility.
Resident #4
Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included spinal stenosis (spinal narrowing often caused by age-related wear and tear) , abnormality of gait(an usual walking pattern), polyarthritis(when at least five joints are affected by arthritis), presence of left artificial knee joint.
Record review of Resident #4's care plan, dated 4/12/2022 and revised on 8/19/2023, revealed Resident #4 was at risk for smoking related injuries related to attempts to obtain lighters or matches and a history of smoking incidents. Intervention: Resident is not to have cigarettes or smoking material on person.
Record review of nursing progress note, dated 8/12/23, revealed the DON must be notified if Resident # 4 is non-compliant with the facility's smoke policy.
Observation from the items from Administrator, DON and ADON room sweep on 8/11/23 at 2:17 p.m., revealed the administration team found the following:
Resident #4 had a Ziplock bag of cigarette filters, 2 packs of buglers (loose tobacco used for rolling into a cigarette) and 6 lighters found in his room.
Interview with Resident #4 on 8/11/23 at 3:04 p.m., revealed he always kept his cigarette filters and materials with him. He stated as a resident he should be able to keep his smoking material. He said he smoked at least 5-6 times per day. He stated that the former Administrator was going to discharge him. But they could not discharge him without him having someplace to live. He said he guessed that they could not find anywhere else for him to go.
Resident #5
Record review revealed Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Lack of coordination, Abnormality of gait and mobility (change to normal walking pattern), cognitive communication deficit, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder), infection and inflammatory reaction due to internal prosthetic devices, implants or grafts.
Record review of progress note dated 8/12/23, for Resident #5 revealed the DON was to be informed if she should be incompliant with the facility's smoking policy.
Observation on 8/11/23 at 12:40 PM, revealed Resident #5 was smoking a cigarette. No staff was outside at the time.
Observation of items from the sweep on 8/11/23 at 2:17 p.m., revealed 2 packs of cigarettes and a lighter was found in Resident #5's room.
Interview with Resident #5 on 8/11/23 at 3:07 p.m., revealed her to state that she did not have anything to say.
Record review of Resident #7's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included: Chronic systolic (congestive heart failure), Chronic kidney disease, Diabetes Mellitus uncontrolled, Schizophrenia, Hypertension, Dysphagia, Abnormality of gait and mobility, muscle wasting in right and left shoulders.
Record review of Resident #7's smoking assessment dated [DATE] revealed in section D. Summary of evaluation 1. Based on the above evaluation the resident will require supervision with smoking the answer was (1) Yes. Goal: Will have no smoking related injury. Interventions: place patient in position to assure visualization of ashtray, provide smoking apron while smoking, review smoking policy and storage of smoking materials per center policy.
Record review of Resident #7's care plan, dated 6/22/23, revealed the resident was at risk for smoking related injury related to his inability to manage ashes and non-compliant with smoking policies, refuses to wear apron and smoking outside of schedule. Interventions: 6/22/23- Provide smoking apron while smoking.
8/15/23-Resident requires supervision while smoking.
8/21/23-refused to wear smoke apron during smoke break.
Observation on 8/11/23 at 12:40 p.m., revealed Resident #7 was smoking in the smoking area unsupervised and without a smoking apron.
Interview with the ADON on 8/11/23 at 12:47 p.m., revealed her to state that the residents should not have been smoking unsupervised, and it was not their smoke times. She was at the nursing station at the time. But she stated that she did not see them going out there. She said different staff are scheduled to supervise the residents at each smoke time.
Interview with CNA E on 8/11/23 at 1:45 p.m., revealed the residents were aware of the smoke times, they should not have been out there. He said they were also sharing cigarettes because Resident #4 left the facility and got his cigarettes and shared them with other residents.
Interview with Resident #6 on 8/11/23 at 1:49 p.m., he stated although he was sitting out in the smoking area he was not smoking earlier when the State Surveyor was getting the names of the residents that were unsupervised. He stated they all knew the smoke times and the facility threatened the residents with 30-day notices but did not kick them out because they did not have anywhere else to go or they did not want to leave. He said they continued to do whatever they wanted to do and smoked anytime they pleased.
Interview with the DON on 8/11/23 at 2:00 p.m., revealed she was aware there was an issue with compliance of the smoke policy. She said since day one of her employment she learned it was a problem in the facility (July 2023). She said they had given discharge notices and yet the residents still smoked when they should not be smoking. She said she would provide those discharge notices.
Interview with the Interim Administrator on 8/11/23 at 2:00 p.m., revealed they would conduct a sweep of the rooms to search for cigarettes and lighters and report their findings.
Interview with the RVP on 8/11/23 at 2:00 pm, revealed administration would meet resident council, all smokers and give them discharge notices if necessary for them to adhere to the smoking policy.
During an interview with Resident #7 on 8/12/23 at 1:03 p.m., he stated he wanted to know when the State Surveyor would be leaving the facility. He stated he used to smoke when he wanted. He stated he had to sign himself out to smoke outside of the facility smoke times. He said he did not wear an apron because he did not want to.
Record review of the facility's, undated, smoke policy revealed: In order to protect all residents at the facility the following smoking policy must be strictly enforced by Team Members and adhered to by all residents and families and visitors.
1. Resident must smoke in designated area at posted times.
Smoke times are:
8:30- 9:00am (Activity supervise)
11:00am- 11:30am (Nursing supervise)
1:30pm-2pm (Nursing supervise)
3:30pm-4:00pm (Activities supervise)
6:45pm-7:15pm (Station 1)
2. Residents may not have cigarettes, cigars, matches, lighters, light fluid, in their possession or in their rooms at any time.
6. Smoking privileges will be suspended entirely if a resident becomes harmful to self and others. Non-compliance with the facility smoking policy will lead to discharge.
Record review of the facility's Safe Smoking policy, effective date: November 1, 2016, revealed .(4) Staff members will monitor or obtain fire igniting materials (matches/lighters) for the benefit of smokers at the nurses' station or other designated locations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights which included measurable objective and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment for 2 of 21 residents (Residents #83 and #110) reviewed for care plans.
1.
The facility failed to develop and implement care plans for Resident #83's for the triggered care area of communication.
2.
The facility failed to develop a care plan for Resident #110 to include the triggered care areas of cognitive loss, behavioral symptoms, Nutritional status, and dehydration.
These failures could place residents at risk for not receiving care and services to meet their needs.
Findings include:
1. Record review of Resident #83's face sheet, dated 11/09/22, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, (current episode mixed, severe with psychotic feature), paranoid schizophrenia, cognitive communication deficit (difficulty with any aspect of communication), lack of coordination and generalized anxiety.
Record review of Resident #83's admission MDS assessment, dated 05/05/22, reflected Section V, CAAs, communication was triggered.
Record review of Resident #83's care plan, dated 10/27/22 and updated 09/22/22, revealed there was no care plan for communication .
2. Record review of Resident #110's face sheet, dated 11/09/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Cerebral Infraction (stroke - occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen), muscle weakness, type 2 diabetes, essential hypertension (High blood pressure), and lack of movement.
Record review of Resident #110's admission MDS assessments, dated 08/16/22, reflected Section V, CAAs cognitive loss, behavioral symptoms, nutritional status and dehydration were triggered.
Record review of Resident #110's care plan, dated 08/26/22, with a revision date of 11/28/22, revealed there was no care plan for the triggered areas of cognitive loss, behavioral symptoms, nutritional status and dehydration.
During an interview with the MDS Coordinator on 11/10/22 at 11:45AM, he said he was responsible for completing the care plans using the MDS CAAs assessment area. He looked at the MDS and care plan for Resident #110 and gave no answer. He said he did not complete the care plan. He said it was completed before he started the position. He said he would update the care plans as indicated .
Record review of the facility provided policy, dated May 1, 2012, titled Comprehensive Care Plan, read in part:
Practice Guidelines:
1 The interdisciplinary care plan is implemented to guide health care center staff in the provision of necessary care and services to obtained and maintain the highest practicable physical, mental, and psychological wellbeing of resident and promotion of the resident and family in planning care.
2 The interdisciplinary team communicates mental and psychosocial problems, needs and concerns to the care planning team for inclusion in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 3 of 21 residents reviewed (Resident #59, & #110) reviewed for comprehensive assessments and timing.
1.
The facility failed to ensure Resident #59's most recent comprehensive MDS accurately reflected her condition of her oral cavity.
2.
The facility failed to ensure Resident #83's most recent comprehensive MDS accurately reflected her mental condition.
3.
The facility failed to ensure Resident #110's most recent comprehensive MDS accurately reflected her condition of her oral cavity.
These failures could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
The findings were:
1. Record review of Resident #59's face sheet, dated 11/09/22, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior), Pain, muscle weakness and dementia (A group of symptoms that affects memory, thinking and interferes with daily life)
Record review of Resident #59's admission MDS, dated [DATE], revealed, Section L-Oral dental status was assessed as none of the above which indicated she had all her natural teeth; it was not noted her teeth had obvious or likely cavity or broken natural teeth.
Observation and interview on 11/08/22 at 12:00 PM, revealed Resident #59 was in her room waiting for her lunch. Resident #59 was observed with broken and loose teeth. Resident #59 said she still had some of her natural teeth but would like to see a dentist if she could.
2. Record review of Resident #83's face sheet, dated 11/09/22, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs), paranoid schizophrenia (a kind of psychosis, which means the the mind doesn't agree with reality) , cognitive communication deficit (difficulty with any aspect of communication), lack of coordination and generalized anxiety.
Record review of Resident #83's annual MDS, dated [DATE], revealed her BIMs was 15, which indicated she was cognitively intact. Section A-1500 resident review for PASRR-revealed it was checked 0 reflected Resident #83 did not have the diagnoses of mental illness.
Record review of Resident #83's PASRR level 1 screening, dated 10/14/20, revealed Resident #83 was positive for mental illness.
Record review of Resident #83's PASRR level II screening, dated 11/23/20, revealed Resident #83 was positive for a mental illness of Schizophrenia.
3. Record review of Resident #110's face sheet, dated 11/09/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Cerebral Infraction (stroke - occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen), muscle weakness, type 2 diabetes, essential hypertension (High blood pressure), and lack of movement .
Record review of Resident #110's admission MDS, dated [DATE], revealed his BIMs was 15, which indicated he was cognitively intact. Section L-Oral dental status was assessed as none of the above which indicated he had all of his natural teeth.
Observation and interview on 11/09/22 at 2:00 PM, revealed Resident #110 was alert and oriented. Resident #110 had no upper teeth. Resident #110 said he left his dentures at home. He said he had a stroke and was taken to the hospital. He said it was his plan to go back home to his apartment soon. He said he tried to do with what he had.
During an interview with the MDS Coordinator on 11/10/22 at 11:45 AM, he said he was responsible for completing the MDS and assuring the MDS reflected the Resident's condition. He said he was new to the position. He said he did not complete the MDS but would re-assessed all identified residents and correct the MDS to reflect their dental needs.
Interview on 11/10/22 at 2:40 PM, the Administrator revealed the facility followed the RAI manual for assessing all residents . She said the facility had gone through staff changes over the past few months.
Review of the CMS RAI Version 3.0 Manual dated October 2019, stated in part, the RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care pln. It also assists staff with evaluation goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident's status. An RAI must be completed for any resident residing in a facility including short-term and respite residents residing for more than 14 days.