West Janisch Health Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure full visual privacy by having ceiling suspended curtains or furniture designed to give privacy for 1 (Resident #71) of 46 dually occupied rooms reviewed for privacy.<BR/>The facility failed to ensure Resident #71 had privacy curtains in her room. <BR/>This failure placed residents at loss of privacy and dignity and decreased quality of life.<BR/>Findings included:<BR/>Review of Resident #71's face sheet date 06/23/22 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (severe or complete loss of strength) following cerebral infarction affecting right dominant side. <BR/>Review of Resident #71's MDS dated [DATE] revealed she had a BIMS score of 0 indicating she was severely impaired in cognition. Resident #71required total dependence and 2+ persons physical assist for dressing, toilet use and personal hygiene.<BR/>Review of Resident #71's care plan dated 06/09/22, reflected resident has an ADL self-care performance deficit r/t right Hemiparesis/hemiplegia, recent surgery, morbid obesity, aphasia, dysarthria. Interventions included: Resident requires total assistance from two staff to turn and reposition in bed at regular intervals and as necessary. <BR/>Observation on 06/23/22 at 10:04 AM, Resident #71 door was open, and surveyor could see the resident from the hall. The resident was laying on bed A with her gown up and was exposing her brief. The staff entered the room and covered Resident #71and closed the door due to resident not having a privacy curtain. <BR/>Observation on 06/23/22 at 11:45 AM, Resident #71 was in her room sitting in her recliner falling asleep. An attempt was made to interview resident however resident would not respond. There was no privacy curtain for the resident. <BR/>Interview on 06/23/22 at 11:47 AM, CNA A stated Resident #71 had moved yesterday afternoon to room [ROOM NUMBER]. She stated when they provide care to a resident, they use the privacy curtains and close the door for privacy. CNA A stated Resident #71 should have a privacy curtain. CNA B stated Resident #71 did not have a privacy curtains that should be in front of her bed. CNA A stated she was not aware Resident #71 did not have a privacy curtain. CNA A stated maintenance puts the privacy curtains up. <BR/>Observation and interview on 06/23/22 at 11:52 AM, the Maintenance staff stated each room should have 3 privacy curtains. He looked at Resident #71's room and he stated the resident did not have a privacy curtains or the rail to put one. He stated Resident #71 room was remodeled, but could not state when the remodel was completed. The Maintenance staff stated Resident #71 was moved yesterday afternoon and was unaware there was a privacy curtain or that needed one. He stated each resident should have a privacy curtains due to her privacy care. <BR/>Interview on 06/23/22 at 11:55 AM, the Administrator revealed she was just made aware Resident #71 did not have a privacy curtain. She stated she did not realize she did not have one yesterday when she was moved to that room. She stated that room was remodeled back in 2021 due to the ice storm. She stated each room should have a privacy curtains due to dignity.<BR/>Record review of the facility's policy Confidentiality of Information and Personal Privacy revised dated October 2017, reflected, Our facility will protect and safeguard resident confidentiality and personal privacy. The facility will strive to protect the resident's privacy regarding his or her: d) personal care.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (MA C and MA D) of 2 staff reviewed for infection control.<BR/>MA C failed to disinfect the blood pressure cuff between blood pressure checks for Residents #22, #5, #21, and #9.<BR/>MA D failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #21, #50, #25, #123, and #124.<BR/>These failures could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Observation on 06/21/22 at 11:13 AM revealed MA C performing blood pressure check on Residents #5, MA C failed to sanitize the blood pressure cuff before or after use.<BR/>Observation on 06/21/22 at 11:20 AM revealed MA C performing blood pressure check on #21, MA C failed to sanitize the blood pressure cuff before or after use. <BR/>Observation on 06/21/22 at 11:30 AM revealed MA C performing blood pressure check on #9. MA C failed to sanitize the blood pressure cuff before or after use.<BR/>Observation on 06/21/22 at 12:03 PM, MA C performed bedside finger stick glucose check on Resident #22. MA C failed to sanitize the glucometer before or after using it on Resident #22. <BR/>Interview attempted on 06/22/22 at 12:45 PM with MA C was unsuccessful. She was an agency worker and was not available for interview.<BR/>Observation on 06/22/22 from 7:55 AM to 9:00 AM revealed MA D performed morning medication pass, during which time she checked the blood pressures on Residents #21, #50, #25, #123, and #124 without cleaning the blood pressure cuff between each resident use. <BR/>Interview on 06/22/22 at 12:35 PM with MA D stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use in order to prevent transmitting an infection from one resident to another. She stated if she forgot to wipe the cuff it was because of her workload making her have to hurry in order to pass morning medications, and the presence of the surveyor made her more nervous. <BR/>Interview on 06/23/22 at 9:05 AM with the DON revealed her expectation was that staff would sanitize all reusable equipment between each resident use. She stated not doing so placed residents at risk of cross-contamination of infections from one resident to another. Sanitizing equipment is part of infection control and staff are educated on this upon hire and yearly. <BR/>Review of the facility's Standard Precautions policy, revised October 2018, reflected the following: Resident-Care Equipment Resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure and transfer of microorganisms to other residents. Reusable equipment was not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. <BR/>Review of the facility's Infection Prevention and Control Program policy, dated October 2018, reflected the following: An infection prevention and control program was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections Important facets of infection prevention include .(3). Educating staff and ensuring that they adhere to proper techniques and procedures

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 3 residents (CR#1) reviewed for wound care. <BR/>-The facility failed to establish wound care services for CR#1 as ordered from 07/24/2023-07/25/2023.<BR/>This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident CR#1's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE], readmission date on 08/06/2022, with a principal diagnosis of cerebral infarction, also known as a stroke, and secondary diagnosis of diabetes mellitus. CR#1 was discharged on 07/29/2023.<BR/>Record review of CR#1's MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating residents' cognition was severely impaired in Section C. Section I revealed CR#1 was triggered for Diabetes Mellitus. Section I revealed that CR#1 was triggered for risk of developing pressure ulcers, with no current venous or arterial ulcers, and treatments in place for a pressure reduction device for the bed. <BR/>Record review of weekly skin observation completed by LVN E dated 07/19/2023, revealed no new wounds to be identified. <BR/>Record review of progress note completed by LVN A dated 07/24/2023 stated, Wound DR notified of PT wounds.<BR/>Record review of wound care assessment completed by the Wound Care Physician dated 07/24/2023 revealed the following for CR#1:<BR/>Acute Left Medial Ankle Arterial Ulcer that measured at 3cm in length and 2.5cm in width with no onset date provided. <BR/>Acute Left, Medial Foot(proximal) Arterial Ulcer that measured at 1.5cm in length and 1.5cm in width with no onset date provided. <BR/>Orders: Wound Dressing paint with betadine and leave open to air daily. <BR/>Plan of Care discussed with facility staff.<BR/>Follow up next week. <BR/>Record Review of Resident CR#1's MAR dated for July of 2023, revealed that CR#1 did not receive wound care treatment on 07/24/2023 or 07/25/2023.<BR/>Record review of Resident CR#1's physician order summary, dated 08/02/2023, revealed the resident had orders to: <BR/>-Cleanse Wound #1 (left inner ankle) and Wound#2 (left Lateral Leg) with normal saline, pat dry, apply betadine and have open to air daily every day shift for unstageable wound with a start date of 07/26/2023. <BR/>-Portable 2 view x-ray of left lower extremity involving left inner ankle to rule out osteomyelitis(infection) with a start date of 07/26/2023. <BR/>-Left Lower Extremity duplex scan with start date of 07/27/23. <BR/>-Left Lower Extremity duplex scan with start date of 07/28/23. <BR/>Record review radiology exam results dated 07/27/2023 of the left tibia and fibula with no evidence of infection. <BR/>Record review radiology exam results dated 07/27/2023 of the doppler performed on left lower extremity with no abnormalities found.<BR/>Record review radiology exam results dated 07/28/2023 of the doppler performed on left lower extremity with abnormalities found.<BR/>Record review of SBAR completed by LVN A dated 07/29/2023, revealed abnormal arterial study confirmed, physician notified with recommendation to transfer to ER, and family notified. <BR/>Record review of Resident #CR#1's undated care plan, revealed:<BR/>Focus: [CR #1] has left inner ankle wound x2. <BR/>Goal: [CR#1] will maintain or develop clean and intact skin by the review date. <BR/>Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. <BR/>Provide treatment per physician order. <BR/>Specialty mattress to bed. Pressure reduction mattress.<BR/>Turn and reposition per facility protocol and PRN.<BR/>Use a draw sheet or lifting device to move resident.<BR/>Record review of CR#'1 medical records from a local hospital dated 07/29/2023 that indicated that resident presented with a nonhealing wound to the left medial ankle with no palpable pulses on the dorasalis pedis on left foot. MRI indicated, non pressure wound of left ankle, osteomyelitis, and peripheral artery disease. <BR/>In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said that she observed the wound on 07/29/2023 while visiting, and CR#1 was sent to the hospital the same day because of the wound. <BR/>In a phone interview with LVN E on 08/01/2023 at 11:12am, she said that she started at the facility on 02/08/2023 as the wound care nurse. She said that she works Monday -Friday from 8:30am-5pm. She said that she completes all weekly skin assessments and wound care for the residents. She said that the floor nurses complete wound care when she is not in the building, and her last day at work was 07/19/2023. She said that she completed a weekly head to toe skin assessment of CR#1 on 07/19/2023, with no new wounds identified. <BR/>In a phone interview with Physician C on 08/01/2023 at 4:07pm, he said that he is the wound care doctor for the facility. He said that he was notified by nursing staff on 07/24/2023 while rounding that CR#1 had a new wound identified to the left ankle. He said that he assessed the wound to be arterial with Eschar, that was warm to touch, with pulse present. He said that he gave orders to treat the wound with betadine. He said that he ordered x-ray and doppler, to confirm if there was infection or blood flow issues to leg, but the results showed no sign. He said that there was a delay in treatment as he gave verbal orders to the nurse assigned to CR#1, verbal orders for treatment. He said that it could take 1-2 weeks for the wound to progress, but could progress faster due to issues with blood flow. He said that he was notified CR#1 was sent out to the hospital after abnormal doppler results were received by primary doctor. <BR/>In a phone interview with Physician B on 08/01/2023 at 12:48pm, he said that he is the primary doctor for CR#1, he said that he was not made aware that CR#1 had new wounds identified until 07/26/2023. He said that the Wound Care doctor was following CR#1 for the wound, and order x-ray and doppler on the lower extremities. He said that he was contacted with results of x-ray that had no signs of infection. He said that he was contacted on 07/29/2023 with abnormal results from the doppler. He said that gave order to send CR#1 to hospital due to concerns of Peripheral Vascular Disease. He said if he were contacted when wound was first identified he would have told staff to consult wound care doctor. <BR/>In a telephone interview with Physician D on 08/02/2023 at 11:49pm, she said that she is the Medical Director for the facility. She said that she was contacted to assessed CR#1 as a part of QAPI on 07/28/2023 to address wound care. She said that there was a concern that CR#1's wound was not identified timely and reported to wound care doctor. She said that she assessed CR#1 with no concerns for infection but she had concerns with poor circulation. She said that CR#1 had x-ray and doppler that revealed no concern for infection or blood flow. She said that when she assessed CR#1 she saw some discoloration, she gave order to repeat doppler, and the results were abnormal. She said that CR#1 was sent out to the hospital on [DATE] after results were confirmed. She said that she estimated the wound to be 1 week old, and the wound could have progress faster due to circulation issues. She said that if staff identified the wound on 07/24/2023, and resident did not receive treatment until 07/26/2023 that is a concern as treatment was delayed. She said that staff should have notified the family, primary physician, and wound care doctor once the wound was identified. <BR/>In an interview with LVN A on 08/02/2023 at 12:39pm, she said she has worked at the facility for 3 months. She said that she first saw that CR#1 had two wounds to her left ankle on 07/24/2023. She said that she noticed the wound while assisting the CNA F with transfer of resident for bed bath. She said that the CNA F said that the wound was not present when she gave the previous bed bath. She said that the wounds were circular, dark in color, and she held her hand up to show the size that was a little larger than a quarter. She said that she did not see any discoloration of the foot, the foot was warm to touch, and pulse present. She said that the facility has a treatment nurse that completes wound care on all residents. She said that when the treatment nurse is out, the floor nurses must complete wound care. She said that the treatment nurse was not in the building on 07/24/2023. She said that she notified Physician C while he was in the building rounding, and he said that he would assess the resident. She said that when a new wound is identified the appearance should be documented. She said that the primary doctor, wound care doctor, and family should be notified. She said that the Treatment Nurse, ADON, and DON are to be notified. She said that Physician C assessed CR#1 on 07/24/2023 , but she did not remember if he provided orders. She said that she should have followed up with Physician C before he left the building or contacted him by phone to confirm treatment orders for CR#1. She said that she did not notify the family or primary doctor after the wound was identified. She said that she did not notify the ADON or DON when the wound was identified. She said that she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR. She said that she should have completed the tasks, she got busy, and she did not follow up or complete tasks. She said that because she did not complete the tasks CR#1's treatment was delayed. <BR/>In an interview with DON on 08/02/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that the facility has a treatment nurse that completes wound care and weekly skin assessments on all residents Monday-Friday. She said that the Weekend supervisor completes wound care on Saturday-Sunday. She said that if the treatment nurse is out during the week the floor nurses were responsible for completing wound care and skin assessments. She said that the Treatment Nurse has been out since 07/19/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress note completed by LVN A, but resident did not have treatment orders in place, skin assessment, or SBAR. She said that LVN A did notify Physician C, but she did not follow up to confirm orders for CR#1 that caused delay in treatment. She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wound. She said that CR#1 was sent out to the hospital on [DATE] after testing confirmed there was no blood circulation to the left leg. She said that each resident was assessed for new skin issues that may not have been identified. She said that she initiated an in-services, notified the medical director, held a QAPI, and PIP was put in place to address wound care. She said that LVN A will receive disciplinary action. <BR/>In an interview with CNA F on 08/02/2023 at 4:15pm, she said that she started at the facility in 2018. She is assigned the hall where CR#1 was housed while admitted to the facility. She said that she first saw resident to have wound on 07/24/2023 when LVN A was helping her with transfer of CR#1. She said that CR#1 had wound to her ankle, but she could not remember if was located on the right or left. She said that the wound was dark in color close to the skin color of CR#1. She said that she would report a new wound to the floor nurse or wound care nurse depending on who was in the building. She said that she did not have to report the wound because the floor nurse was present, and the wound care nurse has not been at work for a few weeks. She said that the wound care doctor was in the building the same day, and the floor nurse said that she was going to have the wound care doctor look at the wound. She said that when she gave CR#1 a bed bath on 07/21/2023 she did not see the wound. <BR/>Record review of facility policy, Medication and Treatment Orders dated July 2016 read in part, 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescribers last name, credentials, the date and the time of the order. <BR/>Record review of facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol dated July 2016 read in part, 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width and depth .d. current treatments .e. All active diagnoses <BR/>Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR communication Form

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for 1 of 5 Halls (400 Hall) 22 of 22 residents (CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) reviewed for neglect.- On [DATE] the facility failed to timely extinguish the fire when CR #44 was engulfed in flames and failed to assess and render aid to CR #44 after the fire was extinguished. The resident expired in the facility immediately after the fire.- The facility failed to take action for over 6 months when it knew after activation of the fire system, control access doors locked and prevented staff from entering to provide services to residents in the 400 Hall without the use of a code. During a fire on [DATE], while CR #44 was engulfed in flames, staff could not access the 400 Hall to provide aide to CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61 and Resident #66 for 3 minutes when the doors closed and locked with only CNA F on the hall.- The facility failed to ensure staff knew the unlocking mechanisms for controlled access doors in the facility that could prevent them from providing services to residents during emergency circumstances like fires. An Immediate Jeopardy was identified on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 05:00 PM. While the immediacy was removed on [DATE], at 04:54 PM, the facility remained out of compliance at a severity level of no actual harm, with a potential for more than minimal harm that was not an immediate jeopardy, and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of potential smoke inhalation, fire-related burns, debilitating injuries and death. Findings included Observation of the facility time stamped security footage of the front hall dated [DATE] revealed, at 01:16 AM staff at the nursing station looked around with the doors open to the 400 Hall. At 01:17 AM staff in a blue top and black pants (CNA D) walked into the 400 Hall and shortly after 2 staff one in all black (CNA P) and one in blue walked toward the 400 Hall when CNA D runs out from the 400 Hall and to the nursing station. The staff in blue moved out of frame towards the 500/600 Hall, while CNA P walked into the 400 Hall and CNA D entered the med room located behind the nursing station, grabbed the fire extinguisher and walked into the 400 Hall. The staff in blue and 1 other staff walk into the 400 Hall behind her with the staff in blue holding the door. At 01:18 AM staff in a pink jacket (LVN I) comes out of the 400 Hall and walked in a fast pace out of frame towards the [DATE] Hall and the staff in the blue is seen at the front door looking into the 400 Hall with her hands over her mouth as a resident (Resident #4) walked out pushing her wheelchair. As Resident #4 came out of the 400 Hall the door is seen to hit her and the staff in blue held the door open and then entered the 400 hall. CNA D runs out of the 400 Hall followed by 1 other staff and was seen on the phone as the other staff moved out of frame by the 500/600 Hall. At this time Resident 4 was alone, standing while holding her wheelchair immediately in front of the 400 Hall, when CNA P walked out followed by the staff in blue. CNA P walked back into the 400 Hall and out again and the doors to the 400 Hall slowly closed behind her at 01:18:52 AM. At 01:19 AM, the staff realized the door was closed, banged on the door and attempted were seen entering a code at a keypad. At this time, LVN I entered codes at the door to the 400 Hall with 2 other staff, CNA D was on the phone at the nursing station with the staff in blue, and CNA P runs out the door with another staff. Resident #4 sat in her wheelchair in the front hall and received no assessments or evaluation as staff moved in and out of frame. At 1:21 AM an unknown resident (unknown resident #1) in a wheelchair moved toward the door of the 400 Hall, appeared to enter a code on the keypad and the door opened at 01:21: 53 AM (3 minutes after closing and 5 minutes after staff were alerted of the fire) and CNA P ran to the 400 Hall doors, held it open and smoke is seen coming out at the top the door. At 01:22:09 a resident (unknown resident #2) walked out the door, CNA P, CNA D and another staff enter into the 400 Hall as the staff in blue attempted to push the 2nd door in the double door to the 400 Hall. The door did not open and Resident #4 and unknown resident #1 who opened the door are wheeled out of frame toward the 500/600 Hall. At 01:23 AM CNA D is seen wheeling an unknown resident out the front door while unknown resident #2 is seen walking around the hall as smoke is seen coming out of the 400 Hall. CNA D, CNA P, the staff in blue, LVN I and other staff wheeled other residents out the front door until 01:26 AM when fully geared fire men arrived and entered the 400 Hall. At 01:28 AM the firefighters exit the 400 Hall and return into the hall and at 01:29 AM the EMTs arrive and enter into the 400 Hall. More firefighters arrived, moved in and out of the unit, at 1:33 AM (6 minutes after the fire was identified) an EMT walked out of the 400 Hall, while a fire fighter pushed against the 2nd door to the double doored 400 Hall that remained locked in place during this incident. Fire men turned sideways as they carried their equipment and walked through the single door open in the double doors to the 400 Hall and on and off attempted to open the locked door. Record review of the Fired Department NFIRS-1 Basic report dated [DATE] revealed, the fire department arrived to the facility on [DATE] at 01:33 PM (a 7 minute discrepancies from the facility's timestamped video) for a building fire.- Actions taken: evacuate area and ventilate.- Casualties: 1 civilian and no injuries- Hazardous Materials Release: None- Property Use: Nursing HomeRemarks: Dispatched to a nursing home on fire. [fire department staff] were the first to arrive on scene of a 1-story pitched roofbuilding with nothing showing from the exterior. residents were being evacuated by building personnel. [fire department staff]assumed [facility] road command. [fire department staff] was ordered to investigate and reports a haze inside the building. [fire department staff] arrived and was ordered to assist with evacuation & prepare for horizontal ventilation. [fire department staff] reports a [location of fire] was found and the fire is out. [fire department staff] arrived and were ordered to assist with evacuationand ventilation. [fire department staff] were disregarded. arson was requested. [fire department staff] arrived and was assigned toevacuation group. [fire department staff] reports 11 residents were protected in place, haze is clearing out, and the room the 10-50 is in has been secured. the incident was tapped out holding [fire department staff] , [fire department staff] , [fire department staff] , & [fire department staff] . building personnel report the fire alarm was triggered and went to the wing to find the source of the alarm. CNA D was the 1st to find the source and used a fire extinguisher. the [location of fire] was in a 2-person room. the 2nd resident wasevacuated by building personnel. the small fire looks to have started on the bed near the victims head. There was no extension beyond the items on the bed. building personnel report the deceased is a smoker, but no one witnessed how the fire started. no signs of medical oxygen use in the room. a pump can was used to apply a small amount of water on a small book that was next to the deceased . [police department] units arrive .- Ignition: 21-Bedroom - < 5 persons- Area of Fire Origin: Undetermined- Heat Source: Undetermined- Item First Ignited: Undetermined- Cause of Ignition: Cause Under Investigation- Factors Contributing to Ignition: Undetermined- Human Factors Contributing to Ignition: Asleep- Mobile Property Involved: None- Fire Spread: Confined to Object of Origin- Presence of Detectors: Present- Detector Type: Smoke- Detector Operation: Operated- Detector Effectiveness: Alerted Occupants, Occupants Responded- Presence of Automatic Extinguishing System: Present- Operation of Automatic Extinguishing System: Fire Too Small To Activate- [fire department staff]: arrived and was assigned evacuation group. Some patients were evacuated from building and 11 were sheltered in place. [fire department staff]- observed that the deceased pt appeared to not have any oxygen because of the absence of o2 bottle or o2 bib on the wall. notified command and secured the room.- [fire department staff]: arrived on location and was ordered by fire department staff]to investigate. upon entry we found the fire alarm system to be active and there was smoke in the lobby area. nursing home staff were evacuating residents. We made our way to the fire room and found one deceased victim in the first bed. i appears the fire started in the bed she occupied. fire department staff]notified command and we then assisted fire department staff] and fire department staff]with ventilating that wing of thenursing home. we also checked on the other occupants on that hallway. due to smoke conditions the rest of the hallway was sheltered in place. CR #44 Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The residents advanced directive was Full Code and she expired in the facility on [DATE] at 01:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left sided weaknessCare Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 ft 8 inches, and 274 lbs. Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Record review of CR #44's Discharge MDS dated [DATE] revealed, discharged Status- deceased . Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Clinical Assessments revealed, the last clinical assessment documented was on [DATE]. Record review of CR #44's Progress Notes revealed,- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the Hoyer Lift. Resident tolerated well.- [DATE] 01:54 AM signed by the DON, After speaking with the charge nurse and CNA, I called the RP's daughter to inform her that her mother was involved in a fire incident and that she was being treated for possible burns. Explained that the ambulance was working on [CR #44] at this time, and they would probably take her to the [Hospital]. The RP said she was not in town and that she would call her brother to see if he was closer than she was. RP said she would leave where she is and head to [Hospital] to check on her mother.- [DATE] 08:03 AM signed by LVN I, At approximately 01:00 AM the writer was on hall 600 to check on the other resident in my care. On my way back to 400, as I was walking down the hall I observed residents in bed sleeping including room [ROOM NUMBER]. As the writer was at the back of the hall 400, approximately 10 minutes later the writer heard alarm sound with flashing lights. I heard a CNA calling me and telling me the fire was in room [ROOM NUMBER]. As the writer was going to room [ROOM NUMBER], the CNA who was in front of me, grabbed the extinguisher and entered the room before I got there. When I entered the room I said to the CNA to call 911, then I assisted the CNA to evacuate the room-mate while the other 2 CNA's was trying to put the fire out. Once the roommate was safely evacuated, I immediately went to render aide to [CR #44]. As I was getting ready to assess the resident 911 was already here and in the room. The EMT's asked where the other resident was, and I told them she was outside. EMT's were providing medical care to [CR #44] and I left the room to go be with the residents that were outside. I then notified the DON once the residents were evacuated off of the hall and accounted for.- [DATE] 10:21 AM signed by MA C, resident expired. In an interview on [DATE] at 01:27 PM, CNA M said CR #44 did not exhibit any behaviors such as hoarding or hiding items, she was a smoker but she was complaint with the facility smoking policy. CNA M said there were no issues with CR #44 smoking. In an interview on [DATE] at 01:28 PM, LVN C said CR #44 was bed/wheelchair bound, required total assistance with all ADLs, had left side paralysis but could eat with setup/assistance. She said while the resident was grumpy, sarcastic and refused care there were no issues hoarding or hiding times. CR #44 was compliant with the facility smoking policy and would only smoke in the designated area. An observation on [DATE] at 09:58 AM revealed, CR #44's room floor covered by white powder and the room had been cleared of contents. There were gloves and packs of Personal Cleaning Wipes on the floor and on the bed. An off-white metal bed lie closest to the entrance, with no mattress and visible black fire damage. The center of the headboard was warped and melted with black burn marks, black ash/soot was observed on the base of the headboard, bed frame, and on the floor. There was limited evidence of smoke damage on the walls and ceiling with wipe marks on the ceiling directly above CR #44's bed and an imprint caused by smoke on the wall were a something was hung that was now removed. An observation and interview on [DATE] at 01:35 PM revealed, a box containing resident cigarettes and lighters locked in the med room. A box of cigarettes bearing CR #44's initials contained 7 cigarettes. The [NAME] said CR #44 had no behaviors of hoarding or hiding of items like cigarettes. She said her only behavior was to make complaints about staff, and that behavior was in her care plan. The DON said CR #44 diligently followed facility smoking policy and she would wait for staff to take her out to smoke. In an interview on [DATE] at 03:31 PM, the Medical Director said she had been Medical Director in the facility for the last 1 1/2 to 2 years. She said if a resident had extensive burns, the facility would not initially treat the burns while in an emergency situation but would cover the resident with clean, dry sheets; monitor breathing and keep the resident warm after the fire was extinguished. She said a resident with severe burns would need specialized treatment that could only the hospital could provide but she would expect nursing facility staff to assess the residents signs, mainly the breathing. The Medical Director said to maintain a resident's life prior to arrival of EMS, staff must monitor vital signs and monitor alertness. Once the resident was moved away from the fire source, staff should make sure airway was clear, resident was breathing, provide oxygen if necessary, monitor the residents pulse and blood pressure until EMS arrive. The Medical Director said if assessments and aide was not rendered to a resident with severe burns the resident could go into shock and a lot of things could happen. She said a resident with severe burns to the upper chest with shallow breathing should not be left unattended and someone should be with a resident if they have severe burns. The Medical Director said nursing home staff can provide services to help sustain life until EMS arrives and the resident should be continuously monitored. In an interview on [DATE] at 04:15 PM, the DON said when an individual experienced extensive burns they must be immediately assessed. Bleeding should be stopped, the airway must be assessed for lung sounds, and vitals assessed. She said nursing staff must stay with the resident until help arrived, and part of the competency of a nurse is training on how to react in an emergency situation. The DON said prior to the fire on [DATE] staff were not trained on what do to if a resident had a severe burn, but they know what to do now. She said to her knowledge nursing staff did not assess CR #44 after the fire was extinguished. The DON said no one assessed CR #44 after the fire but they should have as it was a professional standard. When asked about the risk to residents if staff failed to assess them following extensive burns, the DON said based on her investigation, she thought CR #44 was expired when she was found on fire and no one told her the resident was moving and groaning at the time of the fire. She said, only god has the power over life and death, and if a resident expired it was in God's Hands. When pressed the [NAME] said treatment rendered to a resident with extensive burns was based on what the assessments yields, but staff should make sure the resident was breathing. In an interview on [DATE] at 03:25 PM, the ME said CR #44's cause of death was still pending but the resident suffered from 2nd (burn that damages the top layer of skin and part of the 2nd layer) and 3rd (burn that destroys the first three layers of skin and the fatty tissue) degree burns on her head, upper torso and extremities. She had significant charring (severe burn that has destroyed all layers of skin and may extend into underlying tissue caused by prolonged exposure to extreme heat that appears black or ash-gray) especially to the left side of her body not the right. There was soot deposition in her airway/bronchi, which indicated she was breathing while on fire. 26% of CR #44's body surface was burned. Resident #2 Record review of Resident #2's Face Sheet dated [DATE], revealed a 93- year- old female who admitted to the facility on 03/13/ 20 with diagnosis which included: Type 2 diabetes, COPD, dementia, epilepsy, and irregular heartbeat. Record review of Resident #2's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 0 out of 15. The resident had lower extremity functional limitations in range of motion used automobile chair and required maximum assistance for most ADL's. For mobility, the resident was either dependent or required maximum assistance. The resident was fully dependent on staff to propel in a motorized wheelchair for 50 to 150 feet. Record review of Resident #2's undated Care Plan revealed, Focus- Requires a wander guard bracelet and is at risk for injury from wandering in an unsafe environment; Interventions: Monitor resident in facility and document attempts to elope out of facility. Focus: ADL self-care performance deficit r/t impaired cognition, poor safety awareness. Ambulates without use of an assistive device. She will at times hold onto the rails in hallway. Resident may require increased assistance with transfers depending on level of surface she is transferring from. Interventions: requires assistance of one staff to turn and reposition in bed at regular intervals. Record review of Resident #2's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- Resident #2 requires assistance of 1 staff to turn and reposition in bed at regular intervals and as necessary; requires assistance with lying to sitting at times. Transfer- requires assistance of one staff for supervision to move between surfaces as tolerated. Resident # 2 May require assistance with sit to stand if sitting for prolonged period of time or level of surface. Resident #3 Record review of Resident #3's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, paralysis following a stroke, dementia, anxiety disorder, and bed confinement status. Record review of Resident #3's Quarterly MDS dated 9/11 25 revealed, severely impaired cognition skills for daily decision making and impairments in functional limitations in range of motion for both sides of her upper and lower extremity. Record review of Resident #3's undated Care Plan revealed, Focus-Resident received oxygen as needed. The shortness of breath. Interventions: Monitor for signs and symptoms of respiratory distress- SOB, dyspnea, low O2, cyanosis, diaphoresis, changes in behavior. Record review of Resident #3's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- total dependence on staff for repositioning and turning in bed. Lying to Sitting on side of bed: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Roll Left and Right: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to lying: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to stand: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Toilet transfer: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transfer: total dependence on staff for transfer. An observation on [DATE] at 10:19 AM revealed, Resident #3 lying in bed with eyes closed, well-dressed well-groomed in no immediate distress. Resident #4 Record Review of Resident #4's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, generalized anxiety disorder, unspecified dementia with other behavioral disturbances, adjustment disorder, major depressive disorder, Constipation, bradycardia, and repeated false. Record review of Resident #4's BIMS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 10.Record review of Resident #4's undated Care Plan revealed, Focus- impaired cognitive function/dementia or impaired thoughtProcesses; Interventions: needs supervision/assistance with all decision making. Focus: impaired visual function r/t Glaucoma; Interventions: during activities provide the resident with items that have larger print and bigger pictures to promote participation. Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs; Interventions: partial/moderate assistance with upper and lower body dressing. Transfer- Supervision by 1 staff to move between surfaces, as necessary. Bed Mobility- Supervision by 1 staff to move between surfaces, as necessary.An observation and interview on [DATE] at 02:41 PM revealed, Resident #4 was well groomed, well dressed in no immediate distress in a wheelchair. The resident was not interviewable, she was confused and repeated that she did not want to spend a night. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis), type 2 diabetes, difficulty swallowing, dementia, and anorexia. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The use of a manual wheelchair, total dependence on most ADL's, and total dependence for most functional abilities. Record review of Resident #6's undated Care Plan revealed, Focus: Impaired visual function; Interventions: notify where you are placing their items. Be consistent and cater to the resident's preference of item placement. Focus: ADL self-care performance deficit, requires staff assist with ADL cares, refused to get out of bed daily; Interventions: Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Record review of Resident #6's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Am observation on [DATE] at 10:20 AM revealed, Resident #6 well dressed, well-groomed lying in bed awake. The resident responded to the surveyor with head nods and indicated she needed help. Resident #11 Record review of Resident #11's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia, bipolar disorder, diabetes and hypertension. Record review of Resident #11's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, one sided upper extremity and 2 sided lower extremity functional limitations in range of motion. Use of a wheelchair, total dependence with most ADLs and all functional abilities, total dependence for use of a manual scooter. Record review of Resident #11's undated Care Plan revealed, ADL self-care performance deficit and requires maximum assistance with ADLs r/t activity intolerance, Alzheimer's, impaired balance and limited M=mobility Record review of Resident #11's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- lying to sitting on side of the bed- dependent helper does all the effort; roll left and right- substantial/maximal assistance helper does more than half of the effort. Sit to stand- dependent helper does all the effort. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more was required for the resident to complete the activity. Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Parkinsonism. epilepsy, hypertension, difficulty breathing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, short term and long term memory OK. And independent cognitive skills for daily decision making The use of a wheelchair, no upper or lower extremity functional limitations in range of motion, substantial or maximum assistance to total dependence for all ADL's and substantial maximum assistance to total dependence on staff for mobility. Record review of Resident #18's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Parkinson's Disease. Interventions: chair/bed-to-chair transfer: Resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Lying to sitting on side of bed: resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Roll left and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces Resident #25 Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure. Depression, dependence on dialysis, and dementia. The resident discharged to the hospital on [DATE]. Record review of Resident #25's Discharge MDS dated [DATE] revealed, Modified independence. Cognitive skills for daily decision making and set up or clean up assistance with most ADL's. As well as partial to moderate assistance with most functional abilities. Record review of Resident #25's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues,setup, and/or assistance with ADLs r/t dx dementia, anxiety, depression; Interventions- Chair/bed-to-chair transfer: resident's usual independent - resident completes the activity with no assistance from a helper. Lying to sitting on side of bed- resident's usual independent - resident completes the activity with no assistance from a helper. Roll left and right- resident's usual independent - resident completes the activity with no assistance from a helper. Sit to lying- resident's usual independent - resident completes the activity with no assistance from a helper. Sit to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 22 of 22 (CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) reviewed for neglect. - The Administrator failed to report to the State Survey Agency a fire in the 400 Hall, in which 22 residents (Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) were exposed to smoke and CR #44 expired, to the State Survey Agency within 2 hours. This failure could result in the state agency receiving late notification of alleged incidents of fire, resident injuries and resident deaths. Findings included: Record review of the HHSC TULIP (system to which providers report accidents and incidents) on [DATE] revealed, the facility reported a fire with a fatality on [DATE] at 05:15 AM via through an email. Reporter's Name and Title: [Administrator]; Date/Time the administrator first learned of the incident on [DATE] at 01:31 AM; Date/Time the incident occurred: [DATE], approximately 01:20 AM. This administrator was informed by the Director of Nursing that there was a fire in the facility. It was reported that a CNA saw smoke and identified a resident on fire. The fire was extinguished. The staff immediately contacted 911 and notified the DON and this Administrator. The resident's roommate was removed from the room and surrounding residents were relocated to other rooms in the facility. Upon arrival to the facility, this administrator was informed by a first response officer that the affected resident was pronounced deceased . Assessment Details: The date and time of the assessment: The resident expired Record review of the Intake Investigation Worksheet dated [DATE] revealed, the reporter states that the upper part of the resident was engulfed in flames, along with the upper left part of their bed. the fire was contained and was isolated to the resident (upper half/above the waist) and the bed. additional reporters stated that they spoke with arson investigators and ruled out the usage of cigarettes, smoking, electrical, cellphone, or parts from a lighter as the cause of the fire, at this time it is still unknown how the fire started. Observation of the facility time stamped security footage of the front hall dated [DATE] revealed, at 01:16 AM staff at the nursing station looked around with the doors open to the 400 Hall. At 01:17 AM staff in a blue top and black pants (CNA D) walked into the 400 Hall and shortly after 2 staff one in all black (CNA P) and one in blue walked toward the 400 Hall when CNA D runs out from the 400 Hall and to the nursing station. The staff in blue moved out of frame towards the 500/600 Hall, while CNA P walked into the 400 Hall and CNA D entered the med room located behind the nursing station, grabbed the fire extinguisher and walked into the 400 Hall. The staff in blue and 1 other staff walk into the 400 Hall behind her with the staff in blue holding the door. At 01:18 AM staff in a pink jacket (LVN I) comes out of the 400 Hall and walked in a fast pace out of frame towards the [DATE] Hall and the staff in the blue is seen at the front door looking into the 400 Hall with her hands over her mouth as a resident (Resident #4) walked out pushing her wheelchair. As Resident #4 came out of the 400 Hall the door is seen to hit her and the staff in blue held the door open and then entered the 400 hall. CNA D runs out of the 400 Hall followed by 1 other staff and was seen on the phone as the other staff moved out of frame by the 500/600 Hall. At this time Resident 4 was alone, standing while holding her wheelchair immediately in front of the 400 Hall, when CNA P walked out followed by the staff in blue. CNA P walked back into the 400 Hall and out again and the doors to the 400 Hall slowly closed behind her at 01:18:52 AM. At 01:19 AM, the staff realized the door was closed, banged on the door and attempted were seen entering a code at a keypad. At this time, LVN I entered codes at the door to the 400 Hall with 2 other staff, CNA D was on the phone at the nursing station with the staff in blue, and CNA P runs out the door with another staff. Resident #4 sat in her wheelchair in the front hall and received no assessments or evaluation as staff moved in and out of frame. At 1:21 AM an unknown resident (unknown resident #1) in a wheelchair moved toward the door of the 400 Hall, appeared to enter a code on the keypad and the door opened at 01:21: 53 AM (3 minutes after closing and 5 minutes after staff were alerted of the fire) and CNA P ran to the 400 Hall doors, held it open and smoke is seen coming out at the top the door. At 01:22:09 a resident (unknown resident #2) walked out the door, CNA P, CNA D and another staff enter into the 400 Hall as the staff in blue attempted to push the 2nd door in the double door to the 400 Hall. The door did not open and Resident #4 and unknown resident #1 who opened the door are wheeled out of frame toward the 500/600 Hall. At 01:23 AM CNA D is seen wheeling an unknown resident out the front door while unknown resident #2 is seen walking around the hall as smoke is seen coming out of the 400 Hall. CNA D, CNA P, the staff in blue, LVN I and other staff wheeled other residents out the front door until 01:26 AM when fully geared fire men arrived and entered the 400 Hall. At 01:28 AM the firefighters exit the 400 Hall and return into the hall and at 01:29 AM the EMTs arrive and enter into the 400 Hall. More firefighters arrived, moved in and out of the unit, at 1:33 AM (6 minutes after the fire was identified) an EMT walked out of the 400 Hall, while a fire fighter pushed against the 2nd door to the double doored 400 Hall that remained locked in place during this incident. Fire men turned sideways as they carried their equipment and walked through the single door open in the double doors to the 400 Hall and on and off attempted to open the locked door. Record review of the Fired Department NFIRS-1 Basic report dated [DATE] revealed, the fire department arrived to the facility on [DATE] at 01:33 PM (a 7 minute discrepancies from the facility's timestamped video) for a building fire. - Actions taken: evacuate area and ventilate.- Casualties: 1 civilian and no injuries- Hazardous Materials Release: None- Property Use: Nursing HomeRemarks: Dispatched to a nursing home on fire. [fire department staff] were the first to arrive on scene of a 1-story pitched roofbuilding with nothing showing from the exterior. residents were being evacuated by building personnel. [fire department staff]assumed [facility] road command. [fire department staff] was ordered to investigate and reports a haze inside the building. [fire department staff] arrived and was ordered to assist with evacuation & prepare for horizontal ventilation. [fire department staff] reports a [location of fire] was found and the fire is out. [fire department staff] arrived and were ordered to assist with evacuationand ventilation. [fire department staff] were disregarded. arson was requested. [fire department staff] arrived and was assigned toevacuation group. [fire department staff] reports 11 residents were protected in place, haze is clearing out, and the room the 10-50 is in has been secured. the incident was tapped out holding [fire department staff] , [fire department staff] , [fire department staff] , & [fire department staff] . building personnel report the fire alarm was triggered and went to the wing to find the source of the alarm. CNA D was the 1st to find the source and used a fire extinguisher. the [location of fire] was in a 2-person room. the 2nd resident wasevacuated by building personnel. the small fire looks to have started on the bed near the victims head. There was no extension beyond the items on the bed. building personnel report the deceased is a smoker, but no one witnessed how the fire started. no signs of medical oxygen use in the room. a pump can was used to apply a small amount of water on a small book that was next to the deceased . [police department] units arrive .- Ignition: 21-Bedroom - < 5 persons- Area of Fire Origin: Undetermined- Heat Source: Undetermined- Item First Ignited: Undetermined- Cause of Ignition: Cause Under Investigation- Factors Contributing to Ignition: Undetermined- Human Factors Contributing to Ignition: Asleep- Mobile Property Involved: None- Fire Spread: Confined to Object of Origin- Presence of Detectors: Present- Detector Type: Smoke- Detector Operation: Operated- Detector Effectiveness: Alerted Occupants, Occupants Responded- Presence of Automatic Extinguishing System: Present- Operation of Automatic Extinguishing System: Fire Too Small To Activate- [fire department staff]: arrived and was assigned evacuation group. Some patients were evacuated from building and 11 were sheltered in place. [fire department staff]- observed that the deceased pt appeared to not have any oxygen because of the absence of o2 bottle or o2 bib on the wall. notified command and secured the room.- [fire department staff]: arrived on location and was ordered by fire department staff]to investigate. upon entry we found the fire alarm system to be active and there was smoke in the lobby area. nursing home staff were evacuating residents. We made our way to the fire room and found one deceased victim in the first bed. i appears the fire started in the bed she occupied. fire department staff]notified command and we then assisted fire department staff] and fire department staff]with ventilating that wing of thenursing home. we also checked on the other occupants on that hallway. due to smoke conditions the rest of the hallway was sheltered in place. CR #44 Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The residents advanced directive was Full Code and she expired in the facility on [DATE] at 01:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left sided weakness Care Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 ft 8 inches, and 274 lbs. Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Record review of CR #44's Discharge MDS dated [DATE] revealed, discharged Status- deceased . Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Clinical Assessments revealed, the last clinical assessment documented was on [DATE]. Record review of CR #44's Progress Notes revealed,- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the Hoyer Lift. Resident tolerated well.- [DATE] 01:54 AM signed by the DON, After speaking with the charge nurse and CNA, I called the RP's daughter to inform her that her mother was involved in a fire incident and that she was being treated for possible burns. Explained that the ambulance was working on [CR #44] at this time, and they would probably take her to the [Hospital]. The RP said she was not in town and that she would call her brother to see if he was closer than she was. RP said she would leave where she is and head to [Hospital] to check on her mother.- [DATE] 08:03 AM signed by LVN I, At approximately 01:00 AM the writer was on hall 600 to check on the other resident in my care. On my way back to 400, as I was walking down the hall I observed residents in bed sleeping including room [ROOM NUMBER]. As the writer was at the back of the hall 400, approximately 10 minutes later the writer heard alarm sound with flashing lights. I heard a CNA calling me and telling me the fire was in room [ROOM NUMBER]. As the writer was going to room [ROOM NUMBER], the CNA who was in front of me, grabbed the extinguisher and entered the room before I got there. When I entered the room I said to the CNA to call 911, then I assisted the CNA to evacuate the room-mate while the other 2 CNA's was trying to put the fire out. Once the roommate was safely evacuated, I immediately went to render aide to [Resident #24]. As I was getting ready to assess the resident 911 was already here and in the room. The EMT's asked where the other resident was, and I told them she was outside. EMT's were providing medical care to [Resident #24] and I left the room to go be with the residents that were outside. I then notified the DON once the residents were evacuated off of the hall and accounted for.- [DATE] 10:21 AM signed by MA C, resident expired. In an interview on [DATE] at 01:27 PM, CNA M said CR #44 did not exhibit any behaviors such as hoarding or hiding items, she was a smoker but she was complaint with the facility smoking policy. CNA M said there were no issues with CR #44 smoking. In an interview on [DATE] at 01:28 PM, LVN C said CR #44 was bed/wheelchair bound, required total assistance with all ADLs, had left side paralysis but could eat with setup/assistance. She said while the resident was grumpy, sarcastic and refused care there were no issues hoarding or hiding times. CR #44 was compliant with the facility smoking policy and would only smoke in the designated area. An observation on [DATE] at 09:58 AM revealed, CR #44's room floor covered by white powder and the room had been cleared of contents. There were gloves and packs of Personal Cleaning Wipes on the floor and on the bed. An off-white metal bed lie closest to the entrance, with no mattress and visible black fire damage. The center of the headboard was warped and melted with black burn marks, black ash/soot was observed on the base of the headboard, bed frame, and on the floor. There was limited evidence of smoke damage on the walls and ceiling with wipe marks on the ceiling directly above CR #44's bed and an imprint caused by smoke on the wall were a something was hung that was now removed. An observation and interview on [DATE] at 01:35 PM revealed, a box containing resident cigarettes and lighters locked in the med room. A box of cigarettes bearing CR #44's initials contained 7 cigarettes. The [NAME] said CR #44 had no behaviors of hoarding or hiding of items like cigarettes. She said her only behavior was to make complaints about staff, and that behavior was in her care plan. The DON said CR #44 diligently followed facility smoking policy and she would wait for staff to take her out to smoke. In an interview on [DATE] at 03:31 PM, the Medical Director said she had been Medical Director in the facility for the last 1 1/2 to 2 years. She said if a resident had extensive burns, the facility would not initially treat the burns while in an emergency situation but would cover the resident with clean, dry sheets; monitor breathing and keep the resident warm after the fire was extinguished. She said a resident with severe burns would need specialized treatment that could only the hospital could provide but she would expect nursing facility staff to assess the residents signs, mainly the breathing. The Medical Director said to maintain a resident's life prior to arrival of EMS, staff must monitor vital signs and monitor alertness. Once the resident was moved away from the fire source, staff should make sure airway was clear, resident was breathing, provide oxygen if necessary, monitor the residents pulse and blood pressure until EMS arrive. The Medical Director said if assessments and aide was not rendered to a resident with severe burns the resident could go into shock and a lot of things could happen. She said a resident with severe burns to the upper chest with shallow breathing should not be left unattended and someone should be with a resident if they have severe burns. The Medical Director said nursing home staff can provide services to help sustain life until EMS arrives and the resident should be continuously monitored. In an interview on [DATE] at 04:15 PM, the DON said when an individual experienced extensive burns they must be immediately assessed. Bleeding should be stopped, the airway must be assessed for lung sounds, and vitals assessed. She said nursing staff must stay with the resident until help arrived, and part of the competency of a nurse is training on how to react in an emergency situation. The DON said prior to the fire on [DATE] staff were not trained on what do to if a resident had a severe burn, but they know what to do now. She said to her knowledge nursing staff did not assess CR #44 after the fire was extinguished. The DON said no one assessed CR #44 after the fire but they should have as it was a professional standard. When asked about the risk to residents if staff failed to assess them following extensive burns, the DON said based on her investigation, she thought CR #44 was expired when she was found on fire and no one told her the resident was moving and groaning at the time of the fire. She said, only god has the power over life and death, and if a resident expired it was in God's Hands. When pressed the [NAME] said treatment rendered to a resident with extensive burns was based on what the assessments yields, but staff should make sure the resident was breathing. In an interview on [DATE] at 03:25 PM, the ME said CR #44's cause of death was still pending but the resident suffered from 2nd (burn that damages the top layer of skin and part of the 2nd layer) and 3rd (burn that destroys the first three layers of skin and the fatty tissue) degree burns on her head, upper torso and extremities. She had significant charring (severe burn that has destroyed all layers of skin and may extend into underlying tissue caused by prolonged exposure to extreme heat that appears black or ash-gray) especially to the left side of her body not the right. There was soot deposition in her airway/bronchi, which indicated she was breathing while on fire. 26% of CR #44's body surface was burned. Resident #2 Record review of Resident #2's Face Sheet dated [DATE], revealed a 93- year- old female who admitted to the facility on 03/13/ 20 with diagnosis which included: Type 2 diabetes, COPD, dementia, epilepsy, and irregular heartbeat. Record review of Resident #2's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 0 out of 15. The resident had lower extremity functional limitations in range of motion used automobile chair and required maximum assistance for most ADL's. For mobility, the resident was either dependent or required maximum assistance. The resident was fully dependent on staff to propel in a motorized wheelchair for 50 to 150 feet. Record review of Resident #2's undated Care Plan revealed, Focus- Requires a wander guard bracelet and is at risk for injury from wandering in an unsafe environment; Interventions: Monitor resident in facility and document attempts to elope out of facility. Focus: ADL self-care performance deficit r/t impaired cognition, poor safety awareness. Ambulates without use of an assistive device. She will at times hold onto the rails in hallway. Resident may require increased assistance with transfers depending on level of surface she is transferring from. Interventions: requires assistance of one staff to turn and reposition in bed at regular intervals. Record review of Resident #2's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- Resident #2 requires assistance of 1 staff to turn and reposition in bed at regular intervals and as necessary; requires assistance with lying to sitting at times. Transfer- requires assistance of one staff for supervision to move between surfaces as tolerated. Resident # 2 May require assistance with sit to stand if sitting for prolonged period of time or level of surface. Resident #3 Record review of Resident #3's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, paralysis following a stroke, dementia, anxiety disorder, and bed confinement status. Record review of Resident #3's Quarterly MDS dated 9/11 25 revealed, severely impaired cognition skills for daily decision making and impairments in functional limitations in range of motion for both sides of her upper and lower extremity. Record review of Resident #3's undated Care Plan revealed, Focus-Resident received oxygen as needed. The shortness of breath. Interventions: Monitor for signs and symptoms of respiratory distress- SOB, dyspnea, low O2, cyanosis, diaphoresis, changes in behavior. Record review of Resident #3's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- total dependence on staff for repositioning and turning in bed. Lying to Sitting on side of bed: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Roll Left and Right: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to lying: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to stand: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Toilet transfer: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transfer: total dependence on staff for transfer. An observation on [DATE] at 10:19 AM revealed, Resident #3 lying in bed with eyes closed, well-dressed well-groomed in no immediate distress. Resident #4 Record Review of Resident #4's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, generalized anxiety disorder, unspecified dementia with other behavioral disturbances, adjustment disorder, major depressive disorder, Constipation, bradycardia, and repeated false. Record review of Resident #4's BIMS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 10.Record review of Resident #4's undated Care Plan revealed, Focus- impaired cognitive function/dementia or impaired thoughtProcesses; Interventions: needs supervision/assistance with all decision making. Focus: impaired visual function r/t Glaucoma; Interventions: during activities provide the resident with items that have larger print and bigger pictures to promote participation. Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs; Interventions: partial/moderate assistance with upper and lower body dressing. Transfer- Supervision by 1 staff to move between surfaces, as necessary. Bed Mobility- Supervision by 1 staff to move between surfaces, as necessary.An observation and interview on [DATE] at 02:41 PM revealed, Resident #4 was well groomed, well dressed in no immediate distress in a wheelchair. The resident was not interviewable, she was confused and repeated that she did not want to spend a night. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis), type 2 diabetes, difficulty swallowing, dementia, and anorexia. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The use of a manual wheelchair, total dependence on most ADL's, and total dependence for most functional abilities. Record review of Resident #6's undated Care Plan revealed, Focus: Impaired visual function; Interventions: notify where you are placing their items. Be consistent and cater to the resident's preference of item placement. Focus: ADL self-care performance deficit, requires staff assist with ADL cares, refused to get out of bed daily; Interventions: Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Record review of Resident #6's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Am observation on [DATE] at 10:20 AM revealed, Resident #6 well dressed, well-groomed lying in bed awake. The resident responded to the surveyor with head nods and indicated she needed help. Resident #11 Record review of Resident #11's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia, bipolar disorder, diabetes and hypertension. Record review of Resident #11's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, one sided upper extremity and 2 sided lower extremity functional limitations in range of motion. Use of a wheelchair, total dependence with most ADLs and all functional abilities, total dependence for use of a manual scooter. Record review of Resident #11's undated Care Plan revealed, ADL self-care performance deficit and requires maximum assistance with ADLs r/t activity intolerance, Alzheimer's, impaired balance and limited M=mobility Record review of Resident #11's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- lying to sitting on side of the bed- dependent helper does all the effort; roll left and right- substantial/maximal assistance helper does more than half of the effort. Sit to stand- dependent helper does all the effort. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more was required for the resident to complete the activity. Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Parkinsonism. epilepsy, hypertension, difficulty breathing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, short term and long term memory OK. And independent cognitive skills for daily decision making The use of a wheelchair, no upper or lower extremity functional limitations in range of motion, substantial or maximum assistance to total dependence for all ADL's and substantial maximum assistance to total dependence on staff for mobility. Record review of Resident #18's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Parkinson's Disease. Interventions: chair/bed-to-chair transfer: Resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Lying to sitting on side of bed: resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Roll left and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces Resident #25 Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure. Depression, dependence on dialysis, and dementia. The resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the MDS assessment was accurately completed for 1 of 15 residents (Resident #50) reviewed for MDS assessments, in that:<BR/>- <BR/>The facility failed to ensure Resident #50 was accurately assessed to not need translation services although she could only communicate in the Russian language.<BR/>This failure placed residents at risk of not receiving adequate services and/or care.<BR/>Findings included:<BR/>Record review of Resident #50's face sheet revealed an [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia and stage 1 pressure ulcer of sacral region.<BR/>Record review of Resident #50's comprehensive MDS assessment, dated 06/26/2023, revealed the resident was noted to be rarely/never understood, therefore had no BIMS score. The resident was also assessed to not need or want an interpreter to communicate with a doctor or health care staff and preferred language was not identified. <BR/>In an interview with Resident #50 on 08/08/2023 at 9:45AM, the resident did not respond to surveyor's questions when asked in English. <BR/>In an interview with Resident #43 on 08/08/2023 at 9:45AM, the resident stated Resident #50 had been her roommate for a while, and Resident #50 was able to communicate but was only able understand and speak in her native language. She stated the staff usually had to call her family member or use a translation app to communicate with her.<BR/>In an interview with Resident #50 on 08/08/2023 at 11:45AM, with a use of a translator over the phone, the resident was able to respond stating that she was doing well and had no complaints.<BR/>In an interview with RN A on 08/10/2023 at 9:44AM, she stated to communicate with Resident #50, she had called Resident #50's family member to encourage her to eat. She stated the resident would often respond by shaking her head yes or no but required translation for almost every interaction except basic yes or no questions, like offering food or medicine. The resident only speaks back in Russian. RN A stated they had not run into a situation where Resident #50's family member had not been reached over the phone to translate.<BR/>In a phone interview with the Corporate MDS Nurse on 08/10/2023 at 11:34AM, she stated if a resident did not speak English, she would expect to see the answer, Yes to the MDS question regarding the resident's need for translation services to communicate with health care staff. She stated the resident's specific language should have also be identified on the MDS. She stated the risk of not accurately assessing communication barriers was an impact on care, especially for residents who are more dependent on the staff for providing direct care. The corporate MDS Nurse stated the facility used the RAI manual for guidance on MDS assessments.<BR/>In an interview with the Administrator on 08/10/2023 at 2:34PM, she stated Resident #50 was able to respond to her when miming. She stated the resident was very observant and quiet, and she had a family member who would help translate for her, and when he was not available, another family member or friend was available to help them with translation. She said the resident did need translation services for effective communication, especially when encouraging her to eat. She stated they have not been in been a situation before in which either of these family members were unavailable to translate for them over the phone and she has not thought as far as how they would communicate with her if none of them were available in the time of an emergency. <BR/>Record review of the RAI Manual, dated October 2019, revealed, . Language barriers can interfere with accurate assessment . When a resident needs or wants an interpreter, the nursing home should ensure that an interpreter is available An alternate method of communication also should be made available to help to ensure that basic needs can be expressed at all times, such as a communication board with pictures on it for the resident to point to (if able) . 1. Ask the resident if he or she needs or wants an interpreter to communicate with a doctor or health care staff. 2. If the resident is unable to respond, a family member or significant other should be asked .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1(Resident #11) of 6 residents reviewed for care plan.Resident #11's care plan printed 9/30/25 was not revised to reflect removal of a urinary catheter with an order to remove the foley catheter on 8/13/24 and when a pressure ulcer wound resolved with a discontinued order dated 9/1/25. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included:Record review of Resident #11's face sheet dated 10/1/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Other Schizophrenia (disorder characterized by hallucinations, delusions, disorganized thinking and difficulty distinguishing reality from imagination).Record review of Resident #11's quarterly MDS dated [DATE] revealed a BIMS score of 9 that indicated moderate cognitive impairment. Section H revealed Resident #11 did not have an indwelling catheter. Section M revealed 1 number of Stage 3 pressure ulcers. Record review of Resident #11's discontinued orders revealed wound care to left lower extremity with end date on 9/1/25 and order to remove Foley catheter on 8/13/24.Record review of Resident #11's August 2025 MAR revealed Remove Foley catheter with documentation on 8/13/25.Record review of Resident #11's Progress Note dated 8/13/25 at 11:37 p.m. revealed Resident #11's Foley catheter was removed at 9:45 p.m. Record review of Resident #11's Weekly Wound Observation dated 8/28/25 revealed Stage 3 pressure ulcer to left distal posterior lower leg that was closed, and wound progress was resolved. Record review of Resident #11's care plan printed 9/30/25 revealed a focus of an indwelling suprapubic catheter and actual impairment to skin integrity from a left lower leg pressure ulcer. Record review of Resident #11's order Summary Report as of 10/1/25 did not reveal any orders regarding a catheter or wound care for left lower leg pressure ulcer.Record review of Resident #11's Skin Observation dated 10/1/25 revealed no documentation regarding pressure ulcers with only documentation regarding rashes. Record review of Resident #11's care plan printed 10/3/25 no longer had a focus if an indwelling suprapubic catheter or actual impairment to skin integrity from a left lower leg pressure ulcer. This care plan was revised after surveyor intervention. Observation on 9/29/25 at 10:21 a.m. of Resident #11 revealed no visible catheter. During an interview on 9/29/25 at 11:59 a.m., LVN C said she had been the wound care nurse for the last two weeks and would be the wound care nurse for the next two weeks and then there would be someone coming to be the wound care nurse. During an interview on 9/29/25 at 12:27 p.m., LVN E said Resident #11 did not have a suprapubic catheter. During an interview on 9/29/25 at 12:39 p.m., CNA L said Resident #11 did not have a catheter. During an interview on 10/3/25 at 2:22 p.m., LVN F said if a catheter was removed or it a wound resolved then she would relay the message to the wound care nurse or ADON and they would update the care plan. During an interview on 10/3/25 at 2:33 p.m., MDS RN said the DON and ADON was who made changes to the care plan like if a resident's catheter was removed. During an interview on 10/3/25 at 2:41 p.m., DON said the nurse on the unit, herself or the ADON, was responsible for updating care plans like when a Foley catheter was removed. The DON said the wound care nurse, ADON or herself would be responsible for updating the care plan when a wound was resolved. The DON said if the care plan was not revised that it did not directly reflect the care that they were providing to Resident #11. At 3:03 p.m., the DON went to check Resident #11 as the DON said she was still learning the residents and confirmed that Resident #11 did not have a catheter. At 3:05 p.m., the DON said she removed the catheter from Resident #11's care plan. The DON said a wound should come off the resident's care plan when the wound was resolved. During an interview on 10/3/25 at 3:10 p.m., ADON said she completed the baseline care plans for new admissions. ADON said the previous DON preferred to update the care plans and attended the care plan meetings. ADON said the MDS RN was responsible for completing the MDS. During an interview on 10/3/25 at 5:23 p.m., LVN C, who was the current wound care nurse, said she was only responsible for wound care and not updating the resident's care plans. LVN C said probably DON or ADON was responsible for updating the residents' care plans regarding wound care. Record review of facility's policy Comprehensive Care Plans dated 2025 revealed The comprehensive care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 3 residents (CR#1) reviewed for wound care. <BR/>-The facility failed to establish wound care services for CR#1 as ordered from 07/24/2023-07/25/2023.<BR/>This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident CR#1's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE], readmission date on 08/06/2022, with a principal diagnosis of cerebral infarction, also known as a stroke, and secondary diagnosis of diabetes mellitus. CR#1 was discharged on 07/29/2023.<BR/>Record review of CR#1's MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating residents' cognition was severely impaired in Section C. Section I revealed CR#1 was triggered for Diabetes Mellitus. Section I revealed that CR#1 was triggered for risk of developing pressure ulcers, with no current venous or arterial ulcers, and treatments in place for a pressure reduction device for the bed. <BR/>Record review of weekly skin observation completed by LVN E dated 07/19/2023, revealed no new wounds to be identified. <BR/>Record review of progress note completed by LVN A dated 07/24/2023 stated, Wound DR notified of PT wounds.<BR/>Record review of wound care assessment completed by the Wound Care Physician dated 07/24/2023 revealed the following for CR#1:<BR/>Acute Left Medial Ankle Arterial Ulcer that measured at 3cm in length and 2.5cm in width with no onset date provided. <BR/>Acute Left, Medial Foot(proximal) Arterial Ulcer that measured at 1.5cm in length and 1.5cm in width with no onset date provided. <BR/>Orders: Wound Dressing paint with betadine and leave open to air daily. <BR/>Plan of Care discussed with facility staff.<BR/>Follow up next week. <BR/>Record Review of Resident CR#1's MAR dated for July of 2023, revealed that CR#1 did not receive wound care treatment on 07/24/2023 or 07/25/2023.<BR/>Record review of Resident CR#1's physician order summary, dated 08/02/2023, revealed the resident had orders to: <BR/>-Cleanse Wound #1 (left inner ankle) and Wound#2 (left Lateral Leg) with normal saline, pat dry, apply betadine and have open to air daily every day shift for unstageable wound with a start date of 07/26/2023. <BR/>-Portable 2 view x-ray of left lower extremity involving left inner ankle to rule out osteomyelitis(infection) with a start date of 07/26/2023. <BR/>-Left Lower Extremity duplex scan with start date of 07/27/23. <BR/>-Left Lower Extremity duplex scan with start date of 07/28/23. <BR/>Record review radiology exam results dated 07/27/2023 of the left tibia and fibula with no evidence of infection. <BR/>Record review radiology exam results dated 07/27/2023 of the doppler performed on left lower extremity with no abnormalities found.<BR/>Record review radiology exam results dated 07/28/2023 of the doppler performed on left lower extremity with abnormalities found.<BR/>Record review of SBAR completed by LVN A dated 07/29/2023, revealed abnormal arterial study confirmed, physician notified with recommendation to transfer to ER, and family notified. <BR/>Record review of Resident #CR#1's undated care plan, revealed:<BR/>Focus: [CR #1] has left inner ankle wound x2. <BR/>Goal: [CR#1] will maintain or develop clean and intact skin by the review date. <BR/>Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. <BR/>Provide treatment per physician order. <BR/>Specialty mattress to bed. Pressure reduction mattress.<BR/>Turn and reposition per facility protocol and PRN.<BR/>Use a draw sheet or lifting device to move resident.<BR/>Record review of CR#'1 medical records from a local hospital dated 07/29/2023 that indicated that resident presented with a nonhealing wound to the left medial ankle with no palpable pulses on the dorasalis pedis on left foot. MRI indicated, non pressure wound of left ankle, osteomyelitis, and peripheral artery disease. <BR/>In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said that she observed the wound on 07/29/2023 while visiting, and CR#1 was sent to the hospital the same day because of the wound. <BR/>In a phone interview with LVN E on 08/01/2023 at 11:12am, she said that she started at the facility on 02/08/2023 as the wound care nurse. She said that she works Monday -Friday from 8:30am-5pm. She said that she completes all weekly skin assessments and wound care for the residents. She said that the floor nurses complete wound care when she is not in the building, and her last day at work was 07/19/2023. She said that she completed a weekly head to toe skin assessment of CR#1 on 07/19/2023, with no new wounds identified. <BR/>In a phone interview with Physician C on 08/01/2023 at 4:07pm, he said that he is the wound care doctor for the facility. He said that he was notified by nursing staff on 07/24/2023 while rounding that CR#1 had a new wound identified to the left ankle. He said that he assessed the wound to be arterial with Eschar, that was warm to touch, with pulse present. He said that he gave orders to treat the wound with betadine. He said that he ordered x-ray and doppler, to confirm if there was infection or blood flow issues to leg, but the results showed no sign. He said that there was a delay in treatment as he gave verbal orders to the nurse assigned to CR#1, verbal orders for treatment. He said that it could take 1-2 weeks for the wound to progress, but could progress faster due to issues with blood flow. He said that he was notified CR#1 was sent out to the hospital after abnormal doppler results were received by primary doctor. <BR/>In a phone interview with Physician B on 08/01/2023 at 12:48pm, he said that he is the primary doctor for CR#1, he said that he was not made aware that CR#1 had new wounds identified until 07/26/2023. He said that the Wound Care doctor was following CR#1 for the wound, and order x-ray and doppler on the lower extremities. He said that he was contacted with results of x-ray that had no signs of infection. He said that he was contacted on 07/29/2023 with abnormal results from the doppler. He said that gave order to send CR#1 to hospital due to concerns of Peripheral Vascular Disease. He said if he were contacted when wound was first identified he would have told staff to consult wound care doctor. <BR/>In a telephone interview with Physician D on 08/02/2023 at 11:49pm, she said that she is the Medical Director for the facility. She said that she was contacted to assessed CR#1 as a part of QAPI on 07/28/2023 to address wound care. She said that there was a concern that CR#1's wound was not identified timely and reported to wound care doctor. She said that she assessed CR#1 with no concerns for infection but she had concerns with poor circulation. She said that CR#1 had x-ray and doppler that revealed no concern for infection or blood flow. She said that when she assessed CR#1 she saw some discoloration, she gave order to repeat doppler, and the results were abnormal. She said that CR#1 was sent out to the hospital on [DATE] after results were confirmed. She said that she estimated the wound to be 1 week old, and the wound could have progress faster due to circulation issues. She said that if staff identified the wound on 07/24/2023, and resident did not receive treatment until 07/26/2023 that is a concern as treatment was delayed. She said that staff should have notified the family, primary physician, and wound care doctor once the wound was identified. <BR/>In an interview with LVN A on 08/02/2023 at 12:39pm, she said she has worked at the facility for 3 months. She said that she first saw that CR#1 had two wounds to her left ankle on 07/24/2023. She said that she noticed the wound while assisting the CNA F with transfer of resident for bed bath. She said that the CNA F said that the wound was not present when she gave the previous bed bath. She said that the wounds were circular, dark in color, and she held her hand up to show the size that was a little larger than a quarter. She said that she did not see any discoloration of the foot, the foot was warm to touch, and pulse present. She said that the facility has a treatment nurse that completes wound care on all residents. She said that when the treatment nurse is out, the floor nurses must complete wound care. She said that the treatment nurse was not in the building on 07/24/2023. She said that she notified Physician C while he was in the building rounding, and he said that he would assess the resident. She said that when a new wound is identified the appearance should be documented. She said that the primary doctor, wound care doctor, and family should be notified. She said that the Treatment Nurse, ADON, and DON are to be notified. She said that Physician C assessed CR#1 on 07/24/2023 , but she did not remember if he provided orders. She said that she should have followed up with Physician C before he left the building or contacted him by phone to confirm treatment orders for CR#1. She said that she did not notify the family or primary doctor after the wound was identified. She said that she did not notify the ADON or DON when the wound was identified. She said that she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR. She said that she should have completed the tasks, she got busy, and she did not follow up or complete tasks. She said that because she did not complete the tasks CR#1's treatment was delayed. <BR/>In an interview with DON on 08/02/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that the facility has a treatment nurse that completes wound care and weekly skin assessments on all residents Monday-Friday. She said that the Weekend supervisor completes wound care on Saturday-Sunday. She said that if the treatment nurse is out during the week the floor nurses were responsible for completing wound care and skin assessments. She said that the Treatment Nurse has been out since 07/19/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress note completed by LVN A, but resident did not have treatment orders in place, skin assessment, or SBAR. She said that LVN A did notify Physician C, but she did not follow up to confirm orders for CR#1 that caused delay in treatment. She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wound. She said that CR#1 was sent out to the hospital on [DATE] after testing confirmed there was no blood circulation to the left leg. She said that each resident was assessed for new skin issues that may not have been identified. She said that she initiated an in-services, notified the medical director, held a QAPI, and PIP was put in place to address wound care. She said that LVN A will receive disciplinary action. <BR/>In an interview with CNA F on 08/02/2023 at 4:15pm, she said that she started at the facility in 2018. She is assigned the hall where CR#1 was housed while admitted to the facility. She said that she first saw resident to have wound on 07/24/2023 when LVN A was helping her with transfer of CR#1. She said that CR#1 had wound to her ankle, but she could not remember if was located on the right or left. She said that the wound was dark in color close to the skin color of CR#1. She said that she would report a new wound to the floor nurse or wound care nurse depending on who was in the building. She said that she did not have to report the wound because the floor nurse was present, and the wound care nurse has not been at work for a few weeks. She said that the wound care doctor was in the building the same day, and the floor nurse said that she was going to have the wound care doctor look at the wound. She said that when she gave CR#1 a bed bath on 07/21/2023 she did not see the wound. <BR/>Record review of facility policy, Medication and Treatment Orders dated July 2016 read in part, 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescribers last name, credentials, the date and the time of the order. <BR/>Record review of facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol dated July 2016 read in part, 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width and depth .d. current treatments .e. All active diagnoses <BR/>Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR communication Form

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 6 of 6 meals reviewed for food and nutrition services.The facility failed to ensure the menu was followed for the lunch and dinner meals on 10/02/25, 10/03/25, and 10/04/25. This failure placed the residents at risk of not receiving meals that are adequate to meet their nutritional needs and a decline in nutritional health status.The findings included:Review of the facility's weekly menu, entitled Senior Living S/S Southern 2024, Week 2, revealed the following menu plan:10/02/25 Lunch: Breaded catfish, potato wedges, creamy cole slaw, wheat bread, and [NAME] hash pie10/02/25 Dinner: Roasted red pepper soup, saltines, French dip sandwich, cottage cheese, and mixed melon salad.10/03/25 Lunch: Fried Chicken, okra, cornbread, brownie mousse bar.10/03/25 Dinner: Cheese Quesadilla, seasoned black beans, southwest slaw, apple slices.10/04/25 Lunch: Baked glazed ham, au gratin potatoes, Key [NAME] vegetable blend, wheat bread, banana cupcake10/04/25 Dinner: Unstuffed peppers, roll, orange wedges.Review of the Menu board posted outside of the dining room on 10/02/25 at 11:28 AM revealed the following:lunch menu for the day: bacon maple fish, potato wedges, coleslaw, pudding.dinner menu: homemade soup, cottage cheese, melon salad, corn bread. Everyday Menu listed Grill Cheese comes with soup and side salad, Hamburgers Basket comes with fries or chips, Sandwich of the day comes with fries, chips, or soup. There was no weekly menu posted. In an observation and interview on 10/02/2025 at 12:40 PM, Resident #53 received a hamburger from the Everyday Menu as requested but no side came with the hamburger. Resident #53 did not know why she did not receive a side with her hamburger. The posted Everyday Menu has comes with fries or chips for the Hamburger Basket, which Resident #53 had ordered.In an interview on 10/03/25 at 9:30 AM Resident #53 reported she was offered broccoli cheese soup and cornbread for dinner the previous evening, 10/02/25. She declined the soup and ate cornbread with milk. She ate in her room and did not see what other residents were offered.In an interview on 10/03/2025 at 10:36 AM with the Dietary Director, she reported they served a vegetable soup with hamburger meat, cornbread, a sandwich, and the cottage cheese and melons for dinner on 10/02/25. She reported that the residents do not like roasted red pepper soup, so it was substituted for a soup with hamburger meat with vegetables because the meat makes it a more substantial meal with the protein. She reported all the changes were approved by the dietitian. They just had a quarterly meeting to review the menus with the dietitian. The menu in her office had red pen marks noting changes for each meal in the month. She said there would be a new menu coming with the changes. When asked for records of dietitian approval for menu changes, she was not able to produce any paperwork or documentation. The Dietary Director reported that the residents do not like the fancy food on the menu such as quesadillas and chicken parmesan. The residents prefer the southern cooking that reminds them of home. She also reported that she was unable to order the desserts listed on the menu due to the cost of the ingredients. The Brownie Mousse Bar was substituted for cake because they could not purchase ingredients like chocolate or purchase pre-prepared deserts like lemon cookies or tiramisu cake and stay within the budget. They make the deserts from scratch to save money. The menus are prepared by a new service provider to this facility. The menus were previously done by another company, but that contract was cancelled recently. They order food from the new vendor as well as getting the menus quarterly. She orders food by determining needs from her changed menu.In an interview on 10/03/25 at 12:22 PM the [NAME] who prepared the dinner on 10/02/25 reported there was not a sandwich served with the soup. The soup was broccoli cheddar. Grilled cheese sandwich was served as alternate meal. There was not a side served with the soup other than cottage cheese with fruit syrup on it. No fruit was served. The [NAME] reported that she cooks whatever the Dietary Director tells her is the meal. The menu is not posted in the kitchen.Review of the Menu board posted outside of the dining room on 10/03/25 at 10:06 AM revealed the following:lunch menu for the day: oven fried chicken, okra/tomato, rice, cornbread, cake with whipped topping.dinner menu: Enchiladas, southwest salad, black beans, apple slices.Review of the Menu board posted outside of the dining room on 10/04/25 at 11:26 AM revealed the following:lunch menu for the day: pork loin, au gratin potatoes, Malibu vegetable blend, rolls, chocolate chip cookies. dinner menu: Unstuffed peppers, green beans, bread, apple slices. In an interview on 10/06/25 at 12:08 PM with the Registered Dietitian for the facility, she revealed the approvals for changes of the weekly menu were made by the Regional Registered Dietitian and she had not approved any menu changes made by the Dietary Director.In an interview on 10/07/25 at 10:16 AM with the Regional Registered Dietitian, she reported the menu process is that the vendor sends out Spring and Summer menus. The facility started using them for menus in February of this year. She reported that they try to focus on residents' choices. They have a food committee of residents that meet and the upcoming menu is reviewed. The resident council can submit feedback on the meals as well. Their feedback is used in decision making to change menu items but they stay within the same nutritional value. The protein will stay the same and swap a vegetable for a vegetable. They have a substitution log that should be completed and signed off by the Registered Dietitian. She was not aware if there was a specific food committee at the facility. She reported they always have an alternate menu available. Residents should be offered what is on the printed menu or a substitute of equal nutritional value.In an interview on 10/07/25 at 12:26 PM with the Administrator, she reported she was not aware that the Dietary Director was not following the weekly printed menu and substitutions were being made without appropriate approval. She reported she will ensure the menus and meal preparations are carried out following the policies going forward.Record review of the facility policy, Menus and Adequate Nutrition, 2025 revision, revealed: Policy section titled Policy Explanation and Compliance Guidelines: 3. Menus shall be prepared at least two weeks in advance for timely approval and ordering of food. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance. 4. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods with comparable nutritive value.8. The facility's dietitian or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to ensure comprehensive care plans with the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being were developed for 2 of 3 residents (Resident #34 and #28) reviewed for care plans, in that:<BR/>Resident #34 and #28, who were both identified as high risk for falls and in need of fall mats, did not have the intervention of fall mat included in their care plans. <BR/>This failure places residents at for not receiving adequate care. <BR/>Findings included:<BR/>Resident #34<BR/>Record review of Resident #34's face sheet reflected a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.<BR/>Record review of the facility incident log reported, dated 03/10/2024 - 09/10/2024 revealed the Resident #34 had three falls in the past six months, on dates 07/14/2024, 08/03/2024 and 08/07/2024.<BR/>Record review of Resident #34's care plan reflected the resident was care planned for falls and documented to have an actual fall that occurred on 08/07/2024 but did not include the intervention of a fall mat.<BR/>Record review of Resident #34's quarterly MDS, dated [DATE], reflected the resident did not have any falls since their prior assessment upon admission.<BR/>Observations on 09/12/24 at 11:54AM, revealed Resident #34 lying in bed with a fall mat to the side of her bed.<BR/>Record review of Resident #28's face sheet reflected a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia and metabolic encephalopathy.<BR/>Record review of the facility incident reported, dated 03/10/2024 - 09/10/2024 reflected the Resident #28 had on fall that occurred on 07/28/2024.<BR/>Record review of Resident #28's nurses notes reflected the resident on 09/06/2024, that the resident slid off her bed and fell onto the fall mat.<BR/>Record review of Resident #28's care plan, not dated, reflected the resident was care planned for falls and documented to have an actual fall that occurred on 07/28/202, but did not include the intervention of a fall mat.<BR/>Record review of Resident #28's admission MDS, dated [DATE], reflected the resident did not have any falls since their admission.<BR/>In an interview with CNA T on 09/12/24 at 12:00PM, who stated he usually worked often with Residents #34 and #28. He stated he referenced a chart or kiosk to know who needs a fall mat. He stated Resident #34 tended to swing herself to the right while sleeping causing her to slide off the bed and Resident #28 would sometimes throw herself off the bed. If the fall mat was not placed for both of the residents, they could possibly be injured in a fall.<BR/>In an interview with LVN E on 09/12/24 at 12:08PM, who stated she worked frequently with Resident #34 who rolled out of her bed. She said they keep a wedge to prevent her from rolling off the bed, kept fall mats in place and the bed low. She stated Resident #34 did fall on the end of her shift once. She also said Resident #28 had a history of being confused and rolling herself out of the bed. The fall mat was there when she fell, and she did not have any major injury as a result. She stated the interventions should be listed on the care plan, and because she was new, she would not have known if the fall mat if she did not already see it placed on the floor when she came in. She stated nurses were to at least verbally report needs of patients to the nursing team and bring up pertinent information such as interventions at the morning meetings for the MDS or another staff to note and update the care plan. She said without fall mats residents can experience an increased risk of injury of the head. <BR/>In an interview with the DON on 09/12/24 12:41PM, who stated that her and the Administrator were responsible for updating the care plans to add new information and resolved interventions that are no longer applicable. Residents can change, they need to keep the care plan interventions updated and they can also attach the task attached to the [NAME] (desktop file system) for the CNAs to reference it as well. Fall mats should have been on the care plan. She stated Resident #34 and #28 both need fall mats, or else they would injure themself in fall.<BR/>Record review of the facility's policy on Care Plan Revisions Upon Status Change, not dated, reflected, . The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . The care plan will be updated with the new or modified interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of two medication carts reviewed for medication storage.<BR/>The facility failed to keep resident medications in their original containers/packaging located in the medication cart assigned to LVN M. There were 18 loose pills at the bottom of one of the drawers belonging to unknown residents. <BR/>These failures could affect residents receiving medications placing them at risk of receiving the wrong medication and adverse side effects.<BR/>Findings included:<BR/>During observation and interview on [DATE] at 2:45PM, the medication aide cart for the skilled unit which was assigned to LVN M had 18 loose pills of various shapes, sizes, and colors at the bottom of the second drawer from the left of the cart. The loose pills were underneath the medication blister cards that were tightly packed together. LVN M stated her role for the day was to administer medications that were usually assigned to a medication aide. LVN M stated she was responsible to keep the medication cart clean and ensure there were no expired meds and no loose pills. LVN M stated the potential issues were allergic reaction to a resident if loose pills fall out onto the floor and a resident takes it. LVN M stated she did not know but would check with DON on how to dispose of the loose pills.<BR/>During an interview on [DATE] at 3:15PM the DON who stated the charge nurses, DON and ADON were responsible to check med carts. The DON stated the risks to having loose pills would be not knowing exactly what the pills were for and if a resident were to get a hold of loose pills it could cause side effects, it could cause harm, vital signs could drop, and heart rate could increase. The DON stated the medication supply could run out for that resident and a refill order would have to be placed. The Regional Nurse Consultant stated there would be no extra cost to the resident when reordered. The Regional Nurse Consultant stated that at times pills tend to fall out of blister cards d/t pharmacy packaging when cards are removed or replaced back into the cart.<BR/>During an interview on [DATE] at 8:30AM, the DON who stated that LVN M did come to her after the loose pills were found and she instructed LVN M to crush the pills then put them into the sharps container. The DON stated, during audits, she ensured carts are checked, that over-the-counter medications were dated, insulins were dated accordingly, blister cards were not ripped, foil intact and made sure liquid medications were not leaking. She stated the DON would do audits weekly and the pharmacist checked carts monthly. The DON stated moving forward, she will check carts more often, conduct in-services for the nurses and medication aides, lift everything out cart and check bottom of drawers for loose pills.<BR/>Record review of the undated facility policy and procedures for Medication Storage read in part: .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medications rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation .and security All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate care to maintain highest practical physical and psychosocial well-being for 1 of 15 residents (Resident #27) reviewed for ADL care, in that:<BR/>- <BR/>The facility failed to ensure Resident #27 did not have long fingernails with black grime packed underneath the nails. <BR/>This failure placed residents at risk of experiencing a decreased quality of life and an increase risk of infection.<BR/>Findings included:<BR/>Record review of Resident #27's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, glaucoma, and hemiplegia and hemiparesis.<BR/>Record review of Resident #27's comprehensive MDS assessment, dated 07/16/2023, revealed the resident had a BIMS score of 99, indicating the resident's cognition was not intact or the resident was rarely or never understood during the BIMS assessment. It also revealed the resident was dependent on staff for personal hygiene. <BR/>Observation and interview with Resident #27 on 08/08/2023 at 9:52AM revealed Resident #27 lying in a geri chair. The resident stated they had been cutting her nails and shaving her but was found to have long fingernails, approximately a quarter-inch past the nail bed with black grime packed in three of her of nails on the right hand and under all of her nails on the left hand. When the surveyor pointed out the condition of the resident's nails, Resident #27 agreed and said her nails needed to be cut.<BR/>In an interview with CNA J on 08/08/2023 at 9:59AM, she acknowledged the Resident #27's nails were very dirty and would not like it if her nails were to look similarly to hers. She said the residents' showers days were usually on Tuesday, Thursday and Saturday but they could clean the resident as needed. <BR/>In a phone interview with CNA W on 08/10/2023 at 9:06AM, she stated she worked with Resident #27 on the 2-10 PM shift on 08/07/2023 and it was not Resident #27's bath day on Monday. She said she usually never cut residents' nails, including Resident #27's nails. She stated she only wiped resident hands down with a cloth to clean them. She stated she didn't notice the condition of Resident #27 nails and could not recall whether they were dirty or not. She stated she had never been instructed to cut any resident's nails before but believed that it was the job of a specialist to do to avoid injury. <BR/>In an interview with RN A on 08/10/2023 at 9:44AM, she stated CNAs, nurses, and the wound treatment nurse all took part in nail care. She stated she worked on Tuesday, 08/08/2023, with Resident #27 and generally looked at all her residents' nails once a day. She stated grooming and nail care usually occured on their shower days. She stated she did not notice Resident #27's nails while working on Tuesday. She stated nails were to be clean for infection control purposes, especially if the resident was touching their mouth and face. She said black grime under the nails are to be cleaned and CNAs are usually the first to notice them and clean them.<BR/>In an interview with the DON on 08/10/2023 at 2:05PM, she stated shower days were Tuesdays, Wednesdays and Thursdays for Resident #27 and nurses, CNAs, and treatment nurses were responsible for monitoring residents' hygiene. She stated it was up to mainly the nurses and CNAs to check if the residents need nail care on at least the shower days. She said nail care was important for infection prevention, good hygiene and to prevent the residents from scratching themselves.<BR/>Record review of the facility's policy on ADL, dated March 2018, revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10.26 % based on 4 errors out of 39 opportunities, which involved 2 of 6 residents (Resident #167, Resident #26) reviewed for medication errors.<BR/>1. The facility failed to ensure Medication Aide A administered medications as ordered to Resident #167 by administering Ferrous Sulfate 325 mg instead of the ordered Ferrous Fumarate 325 mg (medication for low red blood cells).<BR/>2. Medication Aide A failed to administer medications as ordered to Resident #26 by omitting the ordered Potassium Chloride ER 8 mEq (medication for build-up of fluid in the body's tissue).<BR/>3. Medication Aide A failed to administer medications as ordered by Resident #26 by omitting the ordered Vitamin B Complex (medication for Vitamin deficiency).<BR/>4. Medication Aide A administered Vitamin D 25 mcg to Resident #26 without a physician order.<BR/>These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and side effects of medications that were not intended for the residents to receive.<BR/>Resident #167<BR/>Record review of Resident #167's Face Sheet dated 08/09/2023 revealed, a [AGE] year-old male, that admitted to the facility on [DATE] with diagnoses which included fracture to the left hip, multiple fractures of the ribs, and pain.<BR/>Record review of Resident #167's admission MDS assessment with the ARD (assessment reference date) date of 08/10/2023, revealed a BIMS score of 15 indicating intact cognition.<BR/>Record review of Resident #167's Baseline Care Plan dated 08/05/2023 revealed, he was receiving antibiotic therapy and did not self-administer medications. He required one person assistance with personal hygiene, toilet use, dressing and bathing. He required two-person physical assistance with bed mobility.<BR/>Record review of Resident #167's order sheet signed by the resident's Physician on 08/08/2023 at 9:44AM, revealed a telephone order dated 08/05/2023 at 2:19AM for Ferretts Oral Tablet (Ferrous Fumarate) give 325 mg by mouth two times a day for anemia with breakfast and dinner. The order was confirmed by RN B.<BR/>An observation on 08/09/2023 at 8:50AM revealed, Med Aide A preparing for administration of medications to Resident #167. Med Aide A retrieved one tablet of Ferrous Sulfate 325 mg and placed into one medication cup along with four other medications. Med Aide A prepared the Miralax 17 gm powder and mixed it with 8 oz of water into a cup and entered Resident #167's room. Med Aide A administered all six medications to Resident #167.<BR/>Resident #26<BR/>Record review of Resident #26's Face Sheet dated 08/09/2023 revealed, a [AGE] year-old male, that admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included metabolic encephalopathy (a brain dysfunction), chronic deep vein blood clots to the lower extremity, diabetes, enlarged prostate, urinary tract infection, muscle wasting and cognitive communication deficit.<BR/>Record review of Resident #26's admission MDS dated [DATE] revealed, a BIMS score of 12 out of 15 indicating he had moderate cognitive impairment. He required extensive assistance with 2 persons for bed mobility, dressing, toilet use and personal hygiene. He required total assist with 2 persons for transfers. <BR/>Record review of Resident #26's Order Summary Report of active orders dated 08/09/2023 at 11:31AM revealed Potassium Chloride ER oral capsule 8 mEq, give one capsule by mouth one time a day for edema, order date 08/08/2023, Vitamin B complex oral tablet order date 07/16/2023, give one tablet by mouth in the morning for Vitamin Deficiency and Vitamin B12 oral tablet (Cyanocobalamin) give 2 tablets by mouth in the morning every Monday, Wednesday, and Friday for Vitamin Deficiency order date 07/16/2023. Further review revealed there was no order for Vitamin D 25 mcg tablets.<BR/>An observation on 08/09/2023 at 9:00AM revealed Med Aide A preparing for administration of medications to Resident #26. Med Aide A retrieved one tablet of Vitamin D 25 mcg and placed into one medication cup along with Omeprazole 20 mg capsule, Allopurinol 100 mg 2 tablets, Carvedilol 25 mg tablet, Colestipol 1 gm tablet, Aspirin 81 mg tablet, Ferrous Sulfate 325 mg tablet, Furosemide 20 mg tablet, Gabapentin 300 mg two capsules, Losartan Potassium 25 mg tablet, Vitamin B-12 two tablets. Med Aide A entered Resident #26's room and administered the medications that were in the medication cup. <BR/>In an interview on 08/09/2023 at 2:13PM, Medication Aide A was asked about the medications given to Resident #167 and Resident #26. Medication Aide A stated she was unable to get into the computer to view past medications administered. Medication Aide A stated, Resident #167's had a bottle of Ferrous Fumarate tablets at one time, and it was completed. Medication Aide A stated that Ferrous Sulfate 325 mg was in stock and can be given in replacement of Ferrous Fumarate. When ask who gave the instructions to give Ferrous Sulfate 325 mg, she did not reply with an answer. Medication Aide A stated she recalled giving the Potassium Chloride to Resident #26 and that she took the blister pack away before the surveyor could look at it. She stated that there was a Potassium Chloride tablet taken from the blister pack and that was the one she administered in the morning.<BR/>In an interview on 08/09/2023 at 2:14PM, Medication Aide A removed the bottles of Aspirin 81 mg, Ferrous Sulfate 325 mg, vitamin D 25 mcg and Vitamin B-12 500 mcg from the top drawer of the medication cart and stated those were the floor stock medications she gave to Resident #26. When asked about why she did not administer Vitamin B Complex. Medication Aide A stated she was unable to go back into the computer to find past orders administered. When asked about why she gave Vitamin D 25 mcg to Resident #26 without an order, Medication Aide A stated she was unable to go back into the computer to find past orders administered.<BR/>In an interview on 08/09/2023 at 2:15PM, LVN K stated the Iron supplement given to Resident #167 should match up with the physician order for Ferrous Fumarate 325 mg. LVN K stated, We can always call the physician to change the order to what we have in stock. LVN K stated she was not here and that it was the admitting nurse's responsibility to put orders in correctly.<BR/>In an interview on 08/10/2023 at 7:50AM, the DON was asked who was authorized to make changes to the Ferrous Fumarate 325mg to Ferrous Sulfate 325mg for Resident #167, she stated the order needed to be fixed and did not know who didn't catch the issue. She stated that Ferrous Fumarate was interchangeable with Ferrous Sulfate, and this was what the pharmacy wrote on the sheet. She stated the assumption was that the medication aides knew these two drugs were interchangeable. When asked exactly how much Ferrous Sulfate was equivalent to Ferrous Fumarate 325mg, she stated it was written on the list from the pharmacy that they were interchangeable. When asked what she expected the Medication Aide to do prior to administering the iron supplement, she stated that the order would be corrected because the two iron supplements were interchangeable. The DON stated prior to administering any medication, she expected the Medication Aide to verify the medication, verify the order and pass medications using aseptic technique. The DON stated she spoke with Medication Aide A who told her that she did not give Vitamin D to Resident #26 and pulled out the bottle of Vit B Complex when she realized she retrieved the wrong bottle. The DON stated Medication Aide A told her that she did give Resident #26 Potassium Chloride on 08/09/2023 at 9:00AM. The DON stated she had only been at the facility for 2 weeks and was still getting to know the residents. She stated she would have to follow up with the physician about the reason Resident #26 was ordered Potassium Chloride ER 8 mEq. She stated generally, the potential risk to a resident if they did not receive Potassium Chloride was cardiac issues. She stated all members of Nursing Administration would oversee to ensure the Medication Aides were following the policy for Medication Administration.<BR/>Record review of the Iron Preparation list from the Pharmacy, revised on 06/2012 revealed one tablet of Ferrous Fumarate 200mg was interchangeable with 1 tablet of Ferrous Sulfate 325mg. The equivalent iron preparation for Ferrous Fumarate 325mg was 3 tablets of Ferrous Gluconate 325mg. Further review revealed there was no equivalent Ferrous Sulfate dose for Ferrous Fumarate 325mg.<BR/>In an interview on 08/10/2023 at 8:00AM, the Administrator stated medication administration was not her area of expertise, but she would expect the Medication Aide would first verify the medication order to make sure it was the right medication, right route, right dose and to follow facility policy and procedures. The Administrator stated it was ultimately the facility's responsibility to clarify the physician order for the iron supplement for Resident #167. She stated she would expect the nurse to contact the physician and it would be the physician's decision whether to substitute a medication or not. She stated she would expect if the Medication Aide found a discrepancy, to stop and get clarification by notifying the charge nurse and DON who would then contact the physician. The Administrator stated the Ferrous Fumarate 325mg was not interchangeable with Ferrous Sulfate 325mg, on the list of iron supplements from the pharmacy and that we made the mistake. The Administrator stated she did not like that the Medication Aide lied about administering Vitamin D and not administering Vitamin B Complex, that there would be nothing wrong with just being honest.<BR/>In a telephone interview on 08/10/2023 at 9:19AM, the Physician C stated she was not right in front of her computer but typically Ferrous Sulfate was ordered and the iron supplement for Resident #167 was not written correctly. Physician C stated the order had been corrected. Physician C stated Resident #26 was put on Lasix. She stated residents tended to lose some potassium, and that was why she added low dose Potassium Chloride. Physician C stated she was keeping an eye on his kidney function as well. Physician C stated there was no risk if Resident #26 missed a dose of Potassium d/t he was getting potassium in the foods he was eating. Physician C stated she had ordered labs for Resident #26 next week as a follow up. Physician C stated there was no risk to Resident #26 if he missed receiving Vitamin B complex d/t he was also receiving Vit B-12. Physician C stated she would have to look at Resident #26's records as she was not in front of her computer to see what the risks would be for receiving Vitamin D if he did not need it. She stated if Vitamin D was given without an order, she would expect the facility to follow facility policy and procedures. She stated she expected the Medication Aides/Nurses who pass medications to check the resident's medication list to ensure they were giving the correct medication.<BR/>Record review of the facility policy and procedure for Administrating Medications, revised on April 2019 read in part: Medications are administered in a safe and timely manner and as prescribed .2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions .4. Medications are administered in accordance with prescriber orders .6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .<BR/>Record review of the facility In-Service Training Report dated 07/18/2023, conducted by the ADON for Medication Aides on the topic of Medication Administration/Availability, revealed the summary of training session: Med Aides please make sure you are notifying your charge nurse for any medications that is not available. Ensure you are notifying and asking questions about any medications you are not sure about to reduce errors/omissions. Further review revealed Medication Aide A signed the training.<BR/>Record review of the Med-Pass Observation Checklist for Medication Aide A, dated on 06/072023 and observed by LVN T, revealed the technique #6. Correct medication verified by visual check of medication, label and MAR was checked as met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 3 residents (CR#1) reviewed for wound care. <BR/>-The facility failed to establish wound care services for CR#1 as ordered from 07/24/2023-07/25/2023.<BR/>This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident CR#1's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE], readmission date on 08/06/2022, with a principal diagnosis of cerebral infarction, also known as a stroke, and secondary diagnosis of diabetes mellitus. CR#1 was discharged on 07/29/2023.<BR/>Record review of CR#1's MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating residents' cognition was severely impaired in Section C. Section I revealed CR#1 was triggered for Diabetes Mellitus. Section I revealed that CR#1 was triggered for risk of developing pressure ulcers, with no current venous or arterial ulcers, and treatments in place for a pressure reduction device for the bed. <BR/>Record review of weekly skin observation completed by LVN E dated 07/19/2023, revealed no new wounds to be identified. <BR/>Record review of progress note completed by LVN A dated 07/24/2023 stated, Wound DR notified of PT wounds.<BR/>Record review of wound care assessment completed by the Wound Care Physician dated 07/24/2023 revealed the following for CR#1:<BR/>Acute Left Medial Ankle Arterial Ulcer that measured at 3cm in length and 2.5cm in width with no onset date provided. <BR/>Acute Left, Medial Foot(proximal) Arterial Ulcer that measured at 1.5cm in length and 1.5cm in width with no onset date provided. <BR/>Orders: Wound Dressing paint with betadine and leave open to air daily. <BR/>Plan of Care discussed with facility staff.<BR/>Follow up next week. <BR/>Record Review of Resident CR#1's MAR dated for July of 2023, revealed that CR#1 did not receive wound care treatment on 07/24/2023 or 07/25/2023.<BR/>Record review of Resident CR#1's physician order summary, dated 08/02/2023, revealed the resident had orders to: <BR/>-Cleanse Wound #1 (left inner ankle) and Wound#2 (left Lateral Leg) with normal saline, pat dry, apply betadine and have open to air daily every day shift for unstageable wound with a start date of 07/26/2023. <BR/>-Portable 2 view x-ray of left lower extremity involving left inner ankle to rule out osteomyelitis(infection) with a start date of 07/26/2023. <BR/>-Left Lower Extremity duplex scan with start date of 07/27/23. <BR/>-Left Lower Extremity duplex scan with start date of 07/28/23. <BR/>Record review radiology exam results dated 07/27/2023 of the left tibia and fibula with no evidence of infection. <BR/>Record review radiology exam results dated 07/27/2023 of the doppler performed on left lower extremity with no abnormalities found.<BR/>Record review radiology exam results dated 07/28/2023 of the doppler performed on left lower extremity with abnormalities found.<BR/>Record review of SBAR completed by LVN A dated 07/29/2023, revealed abnormal arterial study confirmed, physician notified with recommendation to transfer to ER, and family notified. <BR/>Record review of Resident #CR#1's undated care plan, revealed:<BR/>Focus: [CR #1] has left inner ankle wound x2. <BR/>Goal: [CR#1] will maintain or develop clean and intact skin by the review date. <BR/>Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. <BR/>Provide treatment per physician order. <BR/>Specialty mattress to bed. Pressure reduction mattress.<BR/>Turn and reposition per facility protocol and PRN.<BR/>Use a draw sheet or lifting device to move resident.<BR/>Record review of CR#'1 medical records from a local hospital dated 07/29/2023 that indicated that resident presented with a nonhealing wound to the left medial ankle with no palpable pulses on the dorasalis pedis on left foot. MRI indicated, non pressure wound of left ankle, osteomyelitis, and peripheral artery disease. <BR/>In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said that she observed the wound on 07/29/2023 while visiting, and CR#1 was sent to the hospital the same day because of the wound. <BR/>In a phone interview with LVN E on 08/01/2023 at 11:12am, she said that she started at the facility on 02/08/2023 as the wound care nurse. She said that she works Monday -Friday from 8:30am-5pm. She said that she completes all weekly skin assessments and wound care for the residents. She said that the floor nurses complete wound care when she is not in the building, and her last day at work was 07/19/2023. She said that she completed a weekly head to toe skin assessment of CR#1 on 07/19/2023, with no new wounds identified. <BR/>In a phone interview with Physician C on 08/01/2023 at 4:07pm, he said that he is the wound care doctor for the facility. He said that he was notified by nursing staff on 07/24/2023 while rounding that CR#1 had a new wound identified to the left ankle. He said that he assessed the wound to be arterial with Eschar, that was warm to touch, with pulse present. He said that he gave orders to treat the wound with betadine. He said that he ordered x-ray and doppler, to confirm if there was infection or blood flow issues to leg, but the results showed no sign. He said that there was a delay in treatment as he gave verbal orders to the nurse assigned to CR#1, verbal orders for treatment. He said that it could take 1-2 weeks for the wound to progress, but could progress faster due to issues with blood flow. He said that he was notified CR#1 was sent out to the hospital after abnormal doppler results were received by primary doctor. <BR/>In a phone interview with Physician B on 08/01/2023 at 12:48pm, he said that he is the primary doctor for CR#1, he said that he was not made aware that CR#1 had new wounds identified until 07/26/2023. He said that the Wound Care doctor was following CR#1 for the wound, and order x-ray and doppler on the lower extremities. He said that he was contacted with results of x-ray that had no signs of infection. He said that he was contacted on 07/29/2023 with abnormal results from the doppler. He said that gave order to send CR#1 to hospital due to concerns of Peripheral Vascular Disease. He said if he were contacted when wound was first identified he would have told staff to consult wound care doctor. <BR/>In a telephone interview with Physician D on 08/02/2023 at 11:49pm, she said that she is the Medical Director for the facility. She said that she was contacted to assessed CR#1 as a part of QAPI on 07/28/2023 to address wound care. She said that there was a concern that CR#1's wound was not identified timely and reported to wound care doctor. She said that she assessed CR#1 with no concerns for infection but she had concerns with poor circulation. She said that CR#1 had x-ray and doppler that revealed no concern for infection or blood flow. She said that when she assessed CR#1 she saw some discoloration, she gave order to repeat doppler, and the results were abnormal. She said that CR#1 was sent out to the hospital on [DATE] after results were confirmed. She said that she estimated the wound to be 1 week old, and the wound could have progress faster due to circulation issues. She said that if staff identified the wound on 07/24/2023, and resident did not receive treatment until 07/26/2023 that is a concern as treatment was delayed. She said that staff should have notified the family, primary physician, and wound care doctor once the wound was identified. <BR/>In an interview with LVN A on 08/02/2023 at 12:39pm, she said she has worked at the facility for 3 months. She said that she first saw that CR#1 had two wounds to her left ankle on 07/24/2023. She said that she noticed the wound while assisting the CNA F with transfer of resident for bed bath. She said that the CNA F said that the wound was not present when she gave the previous bed bath. She said that the wounds were circular, dark in color, and she held her hand up to show the size that was a little larger than a quarter. She said that she did not see any discoloration of the foot, the foot was warm to touch, and pulse present. She said that the facility has a treatment nurse that completes wound care on all residents. She said that when the treatment nurse is out, the floor nurses must complete wound care. She said that the treatment nurse was not in the building on 07/24/2023. She said that she notified Physician C while he was in the building rounding, and he said that he would assess the resident. She said that when a new wound is identified the appearance should be documented. She said that the primary doctor, wound care doctor, and family should be notified. She said that the Treatment Nurse, ADON, and DON are to be notified. She said that Physician C assessed CR#1 on 07/24/2023 , but she did not remember if he provided orders. She said that she should have followed up with Physician C before he left the building or contacted him by phone to confirm treatment orders for CR#1. She said that she did not notify the family or primary doctor after the wound was identified. She said that she did not notify the ADON or DON when the wound was identified. She said that she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR. She said that she should have completed the tasks, she got busy, and she did not follow up or complete tasks. She said that because she did not complete the tasks CR#1's treatment was delayed. <BR/>In an interview with DON on 08/02/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that the facility has a treatment nurse that completes wound care and weekly skin assessments on all residents Monday-Friday. She said that the Weekend supervisor completes wound care on Saturday-Sunday. She said that if the treatment nurse is out during the week the floor nurses were responsible for completing wound care and skin assessments. She said that the Treatment Nurse has been out since 07/19/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress note completed by LVN A, but resident did not have treatment orders in place, skin assessment, or SBAR. She said that LVN A did notify Physician C, but she did not follow up to confirm orders for CR#1 that caused delay in treatment. She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wound. She said that CR#1 was sent out to the hospital on [DATE] after testing confirmed there was no blood circulation to the left leg. She said that each resident was assessed for new skin issues that may not have been identified. She said that she initiated an in-services, notified the medical director, held a QAPI, and PIP was put in place to address wound care. She said that LVN A will receive disciplinary action. <BR/>In an interview with CNA F on 08/02/2023 at 4:15pm, she said that she started at the facility in 2018. She is assigned the hall where CR#1 was housed while admitted to the facility. She said that she first saw resident to have wound on 07/24/2023 when LVN A was helping her with transfer of CR#1. She said that CR#1 had wound to her ankle, but she could not remember if was located on the right or left. She said that the wound was dark in color close to the skin color of CR#1. She said that she would report a new wound to the floor nurse or wound care nurse depending on who was in the building. She said that she did not have to report the wound because the floor nurse was present, and the wound care nurse has not been at work for a few weeks. She said that the wound care doctor was in the building the same day, and the floor nurse said that she was going to have the wound care doctor look at the wound. She said that when she gave CR#1 a bed bath on 07/21/2023 she did not see the wound. <BR/>Record review of facility policy, Medication and Treatment Orders dated July 2016 read in part, 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescribers last name, credentials, the date and the time of the order. <BR/>Record review of facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol dated July 2016 read in part, 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width and depth .d. current treatments .e. All active diagnoses <BR/>Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR communication Form

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change for 1 of 3 residents (Resident CR#1) reviewed for notification of changes.<BR/>The facility failed to notify Resident CR#1's responsible party on 07/24/2023 when a new wound was identified on the left ankle. <BR/>This failure could place residents who experience a change in condition at risk of responsible party not being informed in care decisions.<BR/>Findings include:<BR/>Record review of Resident CR#1's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE], readmission date on 08/06/2022, with a principal diagnosis of cerebral infarction, also known as a stroke, and secondary diagnosis of diabetes mellitus. CR#1 was discharged on 07/29/2023.<BR/>Record review of CR#1's MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating residents' cognition was severely impaired in Section C. Section I revealed CR#1 was triggered for Diabetes Mellitus. Section I revealed that CR#1 was triggered for risk of developing pressure ulcers, with no current venous or arterial ulcers, and treatments in place for a pressure reduction device for the bed. <BR/>Record review of progress note dated 07/24/2023 read in part, Wound DR notified of PT wounds.<BR/>Record review of wound care assessment completed by the Wound Care Physician dated 07/24/2023 revealed the following for CR#1:<BR/>Acute Left Medial Ankle Arterial Ulcer and Acute Left, Medial Foot(proximal) Arterial Ulcer. <BR/>Orders: Wound Dressing paint with betadine and leave open to air daily. <BR/>Plan of Care discussed with facility staff.<BR/>Follow up next week. <BR/>Record review of Resident CR#1's physician order summary, dated 08/02/2023, revealed the resident had an order to: <BR/>-Cleanse Wound #1 (left inner ankle) and Wound#2 (left Lateral Leg) with normal saline, pat dry, apply betadine and have open to air daily every day shift for unstageable wound with a start date of 07/26/2023. <BR/>Record review of Resident #CR#1's undated care plan, revealed:<BR/>Focus: [CR #1] has left inner ankle wound x2. <BR/>Goal: [CR#1] will maintain or develop clean and intact skin by the review date. <BR/>Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. <BR/>Provide treatment per physician order. <BR/>Specialty mattress to bed. Pressure reduction mattress.<BR/>Turn and reposition per facility protocol and PRN.<BR/>Use a draw sheet or lifting device to move resident.<BR/>In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said she observed the wound on 07/29/2023 while visiting.<BR/>In an interview with LVN A on 08/02/2023 at 12:39pm, she said she first saw CR#1 had two wounds to her left ankle on 07/24/2023. She said she worked at the facility for 3 months. She said when a new wound was identified the appearance should be documented. She said the primary doctor, wound care doctor, and family should be notified. She said the Treatment Nurse, ADON, and DON are to be notified. She said she notified Physician C on 07/24/2023. She said she did not notify the family or primary doctor after the wound was identified. She said she did not notify the ADON or DON when the wound was identified. She said she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR when the wound was assessed on 07/24/2023. She said she did not complete the tasks which caused a delay in CR#1's treatment. <BR/>In an interview with DON on 08/01/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress notes completed by LVN A who identified the wound initially on 07/24/23. She said that LVN A documented that she notified the wound care doctor but not the family or DON . She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wounds identified. She said that LVN A did not follow up on treatment orders after CR#1 was assessed by the wound care doctor on 07/24/2023. She said that because she did not complete the tasks CR#1's treatment was delayed. She said that LVN A did not follow the facilities protocol, and she will receive disciplinary action.<BR/>Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, .4. Unless otherwise instructed by the resident, a nurse will notify the residents representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status; .