FOCUSED CARE AT SHERMAN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for two (Resident #2 and an unknown Resident) of four residents reviewed for abuse.<BR/>The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 12/13/24 between Resident #2 and an unknown Resident. <BR/>This deficient practice could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings included:<BR/>Record review of the facility policy titled Abuse revised on 01/01/2023, reflected, Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation .All events that involve an allegation of abuse or involved a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of the alleged violation .Protection: It is of utmost importance that a resident(s) suspected of being abused, and other residents must be protected during the initial identification, and investigation process . <BR/>Record review of Resident #2's face sheet, dated 03/12/25, reflected Resident #2 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included traumatic subarachnoid hemorrhage (stroke caused by bleeding on the surface of the brain), oropharyngeal phase (difficulty swallowing), altered mental status and dementia.<BR/>Record review of Resident #2's quarterly MDS assessment, dated 01/08/25, reflected Resident #2 had a BIMS of 8, which indicated her cognition was moderately impaired. The MDS reflected Resident #2 had physical and verbal behaviors directed toward others. <BR/>Record review of Resident #2's comprehensive care plan revised 12/31/24, reflected Resident #2 had a Focused area of behavior problem related to low frustration tolerance .history of hitting, propelling wheelchair at a fast pace and running into other residents, grabbing, and screaming at staff, takes off colostomy bag (medical device that collects stool from the body)) and throws it on the floor. The care plan interventions included: administer medications as ordered, monitor and document for side effects and effectiveness, if reasonable, discuss resident's behaviors, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, psych notification for PRN evaluation for increased behaviors, and remove from the situation and take to alternate location as needed. <BR/>Record review of the facility incident reports for 3 months (12/12/24-3/12/25), did not reveal any incidents involving Resident #2 and an unknown Resident on 12/13/24.<BR/>Record review of LVN H written nurse's notes dated 12/13/24 reflected, LVN H was standing out at the med cart in the hall when we heard shouting. Get off me! shouted [Resident #2.] LVN H turned around and witnessed [Resident #2 ] hitting another resident . LVN H immediately walked over to [Resident #2] and educated her about keeping her hands to herself. [Resident #2] started repeating I'm sorry. LVN H asked [Resident #2] to apologize to the resident she hit. [Resident #2] did. In addition, review of LVN H notes revealed no assessed for Resident #2.<BR/>In an interview on 03/12/25 at 11:18 a.m. with Resident #2 revealed she denied she hit anyone. She denied she was in an altercation with anyone. <BR/>In an attempted phone interview on 03/13/25 at 1:50 p.m. with LVN H, left voice message for LVN H to call back the writer . The writer received no returned call prior to the survey exit. <BR/>In an interview on 03/13/25 at 2:49 p.m. with RN J, revealed she had no knowledge of the 12/13/24 incident that involved Resident #2 and an unknown resident. RN J revealed she knew what the abuse reporting policy was. RN J revealed any abuse is to be reported to the abuse coordinator/administrator within 24 hours unless it involves serious bodily injury, then you would report it within 2 hours. <BR/>In an interview on 03/13/25 at 3:06 p.m. with CNA I, revealed she had no knowledge of the 12/13/24 incident that involved Resident #2 and an unknown resident . CNA I revealed any abuse or neglect is to be reported to the charge nurse and administrator immediately. <BR/>In an interview on 03/13/25 at 3:36 p.m. the DON stated she was unaware of the unreported incident. She stated the incident should have been reported per the facility policy. She stated her expectations is for her staff to report all incidents of abuse and neglect within the timeframes per the policy. She stated facility staff is aware of the facility's reporting protocols , which was provided in their trainings. She stated she is responsible for staff trainings on abuse and neglect and reporting policy. She stated failure to report could place other residents at risk for injury or harm. <BR/>In a phone interview on 03/13/25 at 4:28 p.m., the Administrator stated he was the abuse coordinator for the facility. The Administrator stated he was unaware of the unreported incident. The Administrator stated his expectations is for his staff to report all incidents of abuse and neglect within the timeframes per the facility policy. The Administrator stated it was important to report any allegations of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. <BR/>The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. Resident #1 had history of confusion, exit seeking behavior and wandering behavior. On 12/20/24, Resident #1 eloped out of the facility and the facility was not aware the resident eloped. Resident #1 was walking the streets about 3 blocks away from the facility in a residential area. <BR/>The noncompliance was identified as PNC. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began.<BR/>These failures could place residents at risk of potential accidents, injuries, harm or death. <BR/>Findings include:<BR/>Review of Resident #1's face sheet undated reflected Resident #1 was admitted to the facility on [DATE] from another skilled nursing facility with diagnoses of Muscle Wasting and Atrophy (significant shortening of the muscle fibers and loss of overall muscle mass), Syncope and Collapse (fainting), Dementia (loss of cognitive functioning that interferes with daily life and activities), Depression, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Glaucoma (eye disease that can cause vison loss and blindness and blindness), Hypertension, Osteoarthritis (chronic degenerative joint disease), Generalized Muscle Disease, Unsteadiness on feet, lack of coordination and cognitive communication deficit. Resident #1 was not her own responsible party. <BR/>Review of Resident #1's admission MDS dated [DATE] reflected Resident #1 had a BIMS of 7 indicating she was severely cognitively impaired. Resident #1 had wandering behavior daily. Resident #1 was independent with ambulation with no assistive devices. Resident #1 required supervision with ADLs except she required partial/moderate assistance with bathing. <BR/>Review of Resident #1's Admitting paperwork from previous facility discharge summary reflected: [Resident #1] has cognitive impairments and requires redirection for orientation, care and safety. [RP] would like to secure placement in a long-term care facility that can assist with redirection for wandering/exit seeking and a secure unit as needed. <BR/>Review of Resident #1's baseline care plan dated 12/06/24 reflected Resident #1 was an elopement risk. Resident #1 was cognitively impaired due to forgetfulness and dementia.<BR/>Review of Resident #1's Comprehensive Care Plan dated 12/20/24 reflected the following:<BR/>-dated 12/20/24 Resident #1 had impaired cognitive function or impaired thought processes related to impaired decision making abilities, is not always understand or able to understand verbal and non-verbal expression related to dementia. <BR/>-revised 12/31/24 Resident #1 is an elopement risk/wanderer and is at risk for possible injury [related to] impaired safety awareness and diagnosis of dementia 12/20/24 Resident had elopement event. Interventions included Distract resident from wandering ., Provide structured activities ., secure unit placement for increased monitoring.<BR/>-revised 02/06/25 Resident #1 resides on the facility security unit [due to] wander/elopement risks related to history of attempts to leave facility unattended, impaired safety awareness, resident wanders aimlessly. Interventions included Identify pattern of wandering: Is wandering purposeful, aimless or escapist? .Intervene as appropriate.<BR/>Review of Resident #1's Incident Report dated 12/20/24 reflected elopement incident for Resident #1. It reflected received phone call that resident was at a nearby house. Resident of the home was able to retrieve this resident's cell phone and call resident's[RP]. [RP] picked resident up and returned resident to facility. Resident states 'the girls and I went to a dance and got lost. Head to toe assessment performed, with no injuries noted. Resident on one-on-one monitoring until moved to secure unit on this day .Admin initiated self-report. Medical Director informed. Resident #1 was oriented to person only. Resident #1 had predisposing physiological factor s of confused and impaired memory. <BR/>Review of Resident #1's 24 Hour report dated 12/20/24 reflected Resident #1 elopement 12/20/24. One to one monitoring until moved to unit moved to 509B. <BR/>Observation and Interview on 03/12/25 at 10:28 AM revealed Resident #1 was sitting on her bed in her room on the secure unit. Resident #1 was confused and could not recall the incident. She stated she felt safe at the facility. <BR/>Review of Resident #1's progress note for December 2024 reflected the following:<BR/>Dated 12/05/24 12:45 PM by RN A resident admitted to facility ambulatory has dx of dementia and wondering alzheimers .very pleasant oriented to room .will continue to monitor and assess will update [medical doctor] family and admin prn status changes.<BR/>Dated 12/06/24 12:40 PM by LVN B Resident exit seeking and attempting to exit out of 200 hall exit door. Resident redirected to eat lunch.<BR/>Dated 12/06/24 1:55 PM by LVN B Resident continuing to attempt to exit seek. Resident pushing on exit doors. Staff attempting to redirect resident. Resident confused. [Alert and Oriented] x1. DON notified.<BR/>Review of Incident/Accident Reports December 2024 to March 2025 reflected no other elopement incidents for any other residents in the facility.<BR/>Interview on 03/12/24 at 1:54 PM with LVN C revealed Resident #1 eloped on 12/20/24 but he was not working when the incident occurred. He stated Resident #1 was confused, had wandering behavior and would ask about leaving the facility. He stated he had been in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. He was knowledgeable about his role as a charge nurse for a missing resident. He stated Resident #1 was placed on the secure unit after the elopement incident.<BR/>Interview on 03/12/24 at 3:22 PM with LVN B revealed Resident #1 had expressed desire to go home constantly, would say her family member was coming to pick her up, and asked LVN B what door do I exit from. She stated she would redirect Resident #1 when she expressed wanting to leave and go home. She stated on the morning of 12/20/24 before the incident Resident #1 was confused and did not understand why she was at facility. She stated Resident #1 required redirection and distraction from wanting to leave. She stated on 12/06/24 Resident #1 did have 2 occurrences of exit seeking on pushing on hall 200 doors and she documented it in the nurse's note. She stated she redirected Resident #1 when she attempted to exit seek and distracted her. She stated she was not aware of Resident #1's history if she was an elopement risk upon admission. She stated on 12/06/24 she was not Resident #1's charge nurse and could not recall who she notified about the exit seeking behavior for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident. She was unaware of any elopement incidents since Resident #1's elopement on 12/20/24.<BR/>Follow-up Interview on 03/13/25 at 10:15 AM with LVN B revealed on 12/20/24 Resident #1 was last seen at the facility's Christmas party at 1:45 PM or 2 PM. She stated 2:00 PM is shift change so she was not working when Resident #1 returned to the facility after the elopement. She stated she documented Resident #1's exit seeking behavior on 12/06/24 in a nurse's note since she was not Resident #1's charge nurse. <BR/>Interview on 03/12/24 at 3:40 PM with MDS Coordinator revealed Resident #1 admitted from another skilled nursing facility. She stated Resident #1 did have wandering behavior and the baseline care plan reflected she was at risk for elopement. She could not find an elopement assessment upon admission for Resident #1. She stated she was not working the day of Resident #1's elopement. She stated the charge nurse who admits a resident was responsible to ensure elopement assessment completed to determine resident's elopement risk level. She stated she was in-serviced after the incident in December 2024 on elopement policy and signs/symptoms of residents at risk for elopement.<BR/>Interview on 03/13/24 at 8:45 AM with RN A revealed Resident #1 was oriented to her self only but confused about the place. Resident #1 was ambulatory and wandered within the facility. She stated Resident #1 would go to the door but was not aware of her attempting to exit prior to the elopement. She stated Resident #1 was a risk for elopement due to confusion and wandering behavior. She stated she was the admitting nurse for Resident #1 and she could not recall why elopement assessment was not done at admission. She stated she could not recall reviewing Resident #1's discharge paperwork from the previous facility. She was not aware Resident #1 was an elopement risk. She stated she was not aware Resident #1's baseline care plan showed Resident #1 as an elopement risk. She stated the DON was the charge nurse at time of elopement incident for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. She stated after being in-serviced she was aware all residents upon admission should have elopement assessment completed to determine elopement risk. <BR/>Interview on 03/13/25 at 9:25 AM with CNA D revealed Resident #1 was confused and would misplace her phone asking for assistance from facility staff to find it. She stated Resident #1 had occasional exit seeking behavior of going towards the exit doors. She stated Resident #1 constantly wandered within the facility and would ask to go to go with Resident #1's RP. She stated nurses were aware of Resident #1's wandering, confusion and exit seeking behavior. She stated Resident #1 was placed on the secure unit after the elopement incident. <BR/>Interview on 03/13/25 at 9:32 AM with Med Aide E revealed she did could not recall Resident #1 prior to being on the secure unit and did not recall elopement incident for Resident #1 in December 2024. She stated Resident #1 was currently on the secure unit for resident safety. She stated she had been in-serviced on elopement policy and signs/symptoms of residents at risk for elopement.<BR/>Interview on 03/13/25 at 9:55 AM with Resident #1's RP revealed at the previous facility she exhibited behavior of wandering and would go to the exit doors to look out. She stated Resident #1 was confused and had dementia. She stated Resident #1 had not eloped at previous facility but they had Resident #1 moved to this facility for the resident safety and risk for elopement. She stated she had not had a care plan meeting with the facility. She stated nursing had not reached out to her prior to this incident of any exit seeking behavior for Resident #1. She stated she did not meet with facility staff to review the baseline care plan and facility had not discussed with her secure unit until after this elopement incident. She stated on 12/20/24 when she was shopping at a local store she received a phone call from a stranger using Resident#1's phone informing Resident #1 was walking the streets in a residential area. She stated she responded by telling the stranger the resident could not be there she was a resident at the facility. She stated she immediately left to go get Resident #1. She attempted to call the facility and was not able to get through but called a friend who called the facility to inform them Resident #1 was found walking the streets. She stated when she got to Resident #1 it was about like 10 minutes from when she first received the phone call. She stated she found her about 3 blocks away from the facility in a black sweatshirt with pants, socks and shoes on. Resident #1 told her she was dancing with her friends and got lost. She stated Resident #1 was cold and shivering with a blanket covering her provided by the bystander. She stated the bystander told her Resident #1 had flagged them down on the street saying she knew them and was walking the streets in residential area. She stated the facility had informed her later she must have gone out the door after the Christmas party when other visitors were exiting. She stated she took Resident #1 back to the facility in her car and nurse assessed her. She stated Resident #1 was not injured and was mad when Resident #1's RP left. She stated Resident #1 was placed on the secure unit after the elopement incident. <BR/>Interview on 03/13/25 at 10:29 AM with CNA F revealed she saw Resident #1 at the facility's Christmas party eating but she had to leave about 2 pm to transport another resident to an appointment. She stated Resident #1 did have exit seeking behavior and would express her desire to leave the facility especially after her family would visit. She stated she had been in-serviced after Resident #1's elopement on elopement policy, signs/symptoms of residents at risk for elopement, abuse/neglect.<BR/>Interview on 03/13/25 at 10:48 AM with Activity Director revealed on 12/20/24 facility had a Christmas party in the dining room including facility staff, residents and visitors from 1:30 PM to 2:00 PM. She stated she saw Resident #1 at the Christmas party but she did not recall seeing her after that. She stated she was not at the facility when Resident #1 returned to facility after elopement incident later that day. She stated Resident #1 was ambulatory on her own, had some confusion and looked like a visitor. She stated she was not aware of Resident #1 exit seeking behavior. She stated there was like 60 people at the Christmas party and maybe she had followed visitors out the door after the party. <BR/>Interview on 03/13/25 at 10:35 AM with CNA K revealed she was knowledgeable on elopement policy, signs of residents with elopement risk, abuse/neglect and would immediately report to Charge Nurse, Administrator and DON if a resident was found missing. She had been recently in-serviced on elopement protocol and abuse/neglect policy. <BR/>Interviews on 03/12/25 at 1:21 PM and 03/13/25 at 11:45 AM with CNA G revealed she had been recently in-serviced on elopement policy and signs of residents with elopement risk. She was aware she needed to notify Charge Nurse, Administrator and DON when resident is found missing. She was knowledgeable of types of abuse/neglect and had been in-serviced on abuse/neglect recently. <BR/>Interview on 03/13/25 at 11:28 AM with ADON revealed she was working today as a charge nurse and works the floor as needed as the charge nurse. She stated she was in-serviced on elopement protocol including signs of residents at risk for elopement and the nurse's role when resident is found missing. She stated she had been in-serviced on nurse responsibility to complete elopement assessment upon admission and as needed when resident exhibits exit seeking behavior. She stated when Resident #1 eloped she was at risk of injury.<BR/>Interviews on 03/13/25 at 12:10 PM with LVN L revealed she worked 2 pm to 10 pm shift on 12/20/24 but was not the charge nurse for Resident #1. She stated she was unaware of resident elopement risk and had not witnessed any exit seeking behavior from Resident #1. She stated Resident #1 was ambulatory on her own and did look like a visitor. She stated Resident #1 had confusion. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident.<BR/>Interview on 03/13/25 at 1:13 PM with DON revealed she was unable to provide any witness statements of Resident #1's elopement. She stated she was the charge nurse for Resident #1 on 2 pm to 10 pm shift on 12/20/24. She received a phone call from a friend to Resident #1's RP who also worked for the facility that Resident #1's RP had received a phone call from a stranger that Resident #1 was found at a neighboring house. The DON looked at incident report and stated she had received the phone call at 3:45 PM on 12/20/24 because this is when she initiated the incident report for Resident #1. She stated Resident #1's RP brought Resident #1 back to the facility and Resident #1 was confused saying she went dancing with her friends. She stated she assessed Resident #1 head to toe with no injury noted. She could not recall the specific vitals but stated Resident #1's vitals were within normal limits. She stated facility initiated 1:1 for resident safety when she returned and after consent placed her on the secure unit for exit seeking behavior and elopement incident. She stated when interviewing staff after the elopement Resident #1 was last seen by staff at Christmas party on 12/20/24. She stated Resident #1 did wander within the facility but she was not aware of any exit seeking behavior. She stated when she reviewed Resident #1's progress notes she found the note on 12/06/24 stating Resident #1 had exit seeking behavior and stated she was not made aware of it. She stated she completed the baseline care plan for Resident #1 and stated she put down Resident #1 was an elopement risk based on previous stay at skilled nursing facility. She stated she did not review the baseline care plan with Resident #1's RP and did not look to see if elopement assessment had been completed upon admission. She stated she completed Resident #1's elopement assessment after the incident on 12/20/24 indicating she was high elopement risk due to elopement. She could not recall discussing secure unit placement with Resident #1's RP until after she had eloped on 12/20/24. She stated nursing had been in-serviced on completing elopement assessments upon admission and as needed when residents exhibit exit-seeking behavior. She stated if she had been made aware of Resident #1's exit seeking behavior on 12/06/25 she stated an elopement assessment would have been completed to determine elopement risk and to discuss with team about secure unit placement for safety. She stated the potential risk of elopement was serious injury or accident for Resident #1. She stated Resident #1 had intermittent cognition especially after Resident #1's RP visited and did not understand why she was placed at facility. <BR/>Interview on 03/13/25 at 1:55 PM with Administrator revealed Resident #1's Previous Facility expressed she would go to the exit door asking about a car. He was not aware of Resident #1 having exit seeking behavior until after elopement incident in December 2024. He stated facility investigation revealed Resident #1 was last seen at the Christmas party on 12/20/24 and may have exited behind visitors or other people at the end of the party. He stated Resident #1 did elope and was immediately placed on 1:1 with staff until placed on secure unit for elopement and resident safety. He stated there have been no other elopements. He stated if he was aware of the exit seeking behavior prior to incident they could have assessed her with elopement assessed and review to determine if she required more supervision. He stated the potential risk to Resident #1 could be injury and serious harm. He stated the facility completed an elopement drill with facility staff to ensure staff were knowledgeable of facility policy on elopement. <BR/>Review of staff In-services reflected:<BR/>12/20/24 and 12/26/24 staff in-serviced on elopement education including elopement drill<BR/>12/26/24 nurses in-serviced on completing all admission assessments by DON included RN A, LVN B, LVN C, ADON, MDS Coordinator and other nurses.<BR/>12/20/24 and 12/28/24 staff in-serviced on abuse/neglect<BR/>Review of facility's policy Elopement dated 11/01/19 reflected To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing .6. When the patient/resident is located, the nurse completes a head-to-toe assessment. The social service designee assesses the patient/resident for emotional distress. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Examples of criteria that put a resident at higher risk of elopement .Cognitive impairment (example: those who dementia, Alzheimer's, brain injury) Exit-seeking behaviors (example: confused resident that thinks he/she needs to go pick their kids up from the school) New admission wanting desperately to leave .History of elopement at other communities<BR/>Review of facility's policy Elopement Risk assessment dated [DATE] reflected facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. PROCEDURE 1. All patients/residents are assessed on admission by a licensed nurse for elopement risk utilizing the elopement risk assessment form. 2. All patients/residents are re-assessed for elopement potential by the licensed nurse/social service designee quarterly throughout a patient's/resident's stay and with a significant change .4. The licensed nurse or social service designee completes the elopement risk assessment form and presents to the interdisciplinary team for further intervention.6. The physician and the patient/resident or the patient's/resident's representative are notified of the patient's/resident's risk for elopement and the interventions that are recommended for prevention of elopement and patient/resident safety. 7. The patient's/resident's legal representative should be contacted, if possible, to obtain all pertinent information in relation to elopement risk .10. A licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjust as needed. 11. A baseline plan of care should be completed on admission and any elopement risks should be identified. <BR/>The DON and Administrator were notified and provided the IJ template on 03/13/25 at 6:05 PM of PNC IJ for F689. The DON was provided the IJ template for PNC F689 on 03/13/25 at 6:05 PM. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 5 residents (Resident #1) reviewed for misappropriation of resident property.<BR/>RN A used Resident #1's prescribed Fentanyl (an opioid pain medicine that is used to treat moderate to severe chronic pain around the clock) 100 mcg 72-hour transdermal (skin) patch for personal recreational use on 02/12/25.<BR/>This failure placed residents at risk of not receiving timely pain management care which could result in prolonged pain and diminished quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 12/06/24, revealed an [AGE] year-old female, who admitted to the facility on [DATE] - most recent re-admission on [DATE], with the following diagnoses: Ankylosing Spondylitis (an inflammatory disease that can fuse the vertebrae in the spine and cause back pain, stiffness and hunched posture), lumbar region; Erosive Osteoarthritis ([EOA] a type of osteoarthritis that create deformities with a distinctive shape); and Chronic Pain Syndrome. Resident #1's BIMS score was 05, which indicated severe cognitive impairment. The Quarterly MDS, Section J - Health Conditions reflected Resident #1 received a scheduled pain medication regimen. Resident #1 admitted to hospice on 02/05/25.<BR/>Record review of Resident #1's comprehensive care plan, admission date 02/02/24, reflected:<BR/>[Resident #1] was at increased potential for pain due to chronic pain (Initiated 03/13/18; Revised 08/23/21) and included interventions to Assess characteristics of pain; administer pain medication as per orders; and monitor for potential side effects of pain medication.<BR/>[Resident #1] was on pain medication therapy r/t disease process (Initiated 02/11/25; Revised 02/11/25) and included interventions to Administer analgesic medications as ordered; Monitor, document, report adverse side effects to medications; and review every shift for pain medication efficacy.<BR/>[Resident #1] complained of increased pain/discomfort and was at Risk for Injury from decreased ADLs and Osteoarthritis (Initiated 02/14/25; Revised 02/14/25) and included interventions to Anticipated the resident's need for pain relief; Evaluate the effectiveness of pain relief interventions; Monitor, document, report non-verbal s/s of pain; adverse side effects to medications; and review every shift for pain medication efficacy.<BR/>Resident #1's clinical physician's orders reflected:<BR/>- <BR/>Order date 10/06/22: Verify Fentanyl patch placement every shift.<BR/>- <BR/>Order date 11/29/24: Fentanyl Transdermal 72-hour Patch 100 mcg/hr. Apply one patch topically every 72 hours for pain and remove per schedule. <BR/>- <BR/>Order date 12/13/24: Monitor for side effects of opioid medications - Fentanyl every shift by indicating the corresponding number as follows: 0) None; 1) Constipation; 2) Nausea; 3) Dry Mouth; 4) Dizziness; 5) Drowsiness; 6) Confusion; 7) Withdrawn; 8) Itching; 9) Sweating; 10) Increased Tolerance; 11) Respiratory Depression. Notify MD with changes in condition every shift.<BR/>Record review of Resident #1's February 2025 MAR reflected:<BR/>- <BR/>The orders were implemented as written to Fentanyl Transdermal 72-hour Patch 100 mcg/hr. Apply one patch topically every 72 hours for pain and remove per schedule. as evidenced by a checkmark and a nurse's initials. The patch was last replaced on 02/09/25. On 02/12/25 at 1211, RN A entered a 9 (See Progress Notes) and her initials.<BR/>An attempt to review Resident #1's Fentanyl Patch narcotic count sheet revealed it was missing.<BR/>Review of Resident #1's progress notes indicated:<BR/>- <BR/>Nurse's Note Effective Date: 02/12/25 at 7:10 AM, RN A entered, [Resident #1] refused to allow nurse to remove and replace her Fentanyl patch. Attempted to educate but [Resident #1] became very combative.<BR/>During an observation and interview on 02/15/25 at 10:15 AM, LVN E removed a patch from Resident #1 upper back. The patch reflected the date 02/09/25 and LVN E's initials. LVN E placed a new Fentanyl 100 mcg/24-hour patch to Resident #1's left upper mid shoulder. The patch reflected 02/15/25 and LVN E's initials. Resident #1 could not participate in a meaningful interview. Resident #1 stated that she was always in pain when asked if she was in pain. Resident #1 could not rate her pain level. Resident #1 did not verbalize or demonstrate non-verbal cues suggestive of pain during removal and placement of patches.<BR/>During an interview on 02/15/25 at 3:35 PM, the DON stated she and LVN B discovered RN A unresponsive on the floor of the staff bathroom located on the secured unit on 02/12/25. The DON said that RN A worked 02/12/25 6A - 2P shift, on the hall Resident #1 resided. The DON said that RN A agreed to work part of the 2P - 10P shift on the secured unit until the on-coming nurse (LVN H) arrived. The DON said (on 02/12/25) she entered the secured unit around 5:00 PM to notify RN A that LVN H would arrive soon. The DON said that she did not see RN A on the unit and RCP C informed (the DON) that RN A was in the bathroom. The DON said that she exited the secured unit and tried calling RN A on the phone (at 5:05 PM), but the call was unanswered. The DON said that RN A did not reply to the text sent. The DON said that she became concerned because RN A would send a message if unable to answer a call or replied to a text within a timely manner. The DON said that she returned to the secured unit after 10 minutes and still could not locate RN A. The DON said that RCP C indicated RN A had not come out of the bathroom. The DON said that she knocked on the bathroom door and RN A did not answer. The DON said that she could hear the fan blowing in the bathroom and can see the light shine from under the door. The DON said that she knocked again and walked over to the nurses' station to see if the bathroom key was returned, it was not there. The DON said that she stepped out of the secured unit, not allowing the door to close completely, and asked LVN B to come to the secured unit. The DON said that she told LVN B about her concerns. The DON said that LVN B kneeled to look under the bathroom door and could see that someone was leaning against the door. The DON said that she and LVN B tried to force the door open. The DON said that LVN B left to try to find a tool to pry the door open. The DON said that LVN B used the tool to unlock the door and shoved on the door until they were able to enter. The DON said that she observed RN A sitting on the floor with her back against the wall, slumped to her left side. The DON said that RN A drooled foam from her mouth, her lips had a bluish tint, and presented with decreased respirations. The DON said that RN A's eyes were open with a blank stare, and RN A's fingertips and hands were colorless. The DON said that she and LVN B pulled RN A from the bathroom into the hall and placed [RN A] on her back. The DON said that RMP F entered the secured unit and the DON redirected [RMP F] to get the crash cart and AED. The DON told LVN B to call 911. The DON said that oxygen was applied to RN A and rescue breathing was initiated until EMS arrived. The DON said that EMS assessed RN A and transferred her onto a stretcher. The DON said as she started her car to follow behind the ambulance, LVN H approached and presented a Fentanyl patch that she found on the bathroom floor. LVN H informed EMS about the Fentanyl patch, a paramedic acknowledged, and indicated Narcan would be initiated for opioid overdose. The DON said when she returned to the facility (02/12/25) she conducted cart audits and initiated in-services. The DON said that RN A was suspended during investigation and terminated on 02/14/25.<BR/>During an interview on 02/15/25 at 5:17 PM, LVN E said that Resident #1 would refuse the removal and placement of a Fentanyl patch at times. LVN E said that the patch was scheduled at 6:00 AM. LVN E said that he felt it was too early to try to remove and apply a patch when Resident #1 was just waking, and other care tasks were being performed. LVN E said that on days Resident #1 was irritated, he was often successful at a second try after breakfast. LVN E said that he never worked behind or alongside RN A to have concerns regarding drug diversion.<BR/>During a phone interview on 02/16/25 at 12:51 PM, RCP C said that she worked 02/12/25. RCP C said that she arrived around 4:00 PM. RCP C said that she saw RN A briefly before she (RN A) went into the bathroom. RCP C said that she has worked with RN A in the past, but RN A seemed overly happy or was marked by an overwhelming pleasurable emotion on that day (02/12/25). RCP C said that it was different but did not think anything about it. RCP C said that she never suspected RN A was under the influence of drugs when worked together.<BR/>During a phone interview on 02/16/25 at 3:27 PM, RN A stated that she was the treatment nurse at the facility. RN A said that she had a history of substance abuse and had been sober for 12 years. RN A said that she had a relapse on 02/12/25. RN A said that she worked 6A - 2P as a floor nurse on 02/12/25 and was assigned to Resident #1. RN A said that Resident #1 refused when she (RN A) attempted to remove and place a new Fentanyl patch. RN A said that she had already signed the narcotic sheet that the patch was administered and did not know how to correct it after Resident #1 refused. RN A said that she kept the Fentanyl patch for personal recreational use and shredded the narcotic count sheet so she would not have to explain the missing patch. RN A said that it was the last Fentanyl patch and needed to be reordered. RN A said that she agreed to work the secured unit from 2:00 PM until the on-coming nurse arrived. RN A said that she went into the bathroom, cut a piece of the Fentanyl patch, and placed in her mouth to chew on it. RN A said that was all she remembered until she woke up in the hospital. RN A said that she did not expect a reaction. <BR/>Record review of the Abuse Neglect and Exploitation policy, last revised 01/01/23, indicated, The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The misappropriation of resident property included the diversion of a resident's medication(s), including, but not limited to, controlled substances for staff use or personal gain.

Based on observation, interview, and record review the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 2 (Medication Cart #1 and Medication Cart #2) of 2 medication carts observed for medication storage, in that:<BR/>The facility failed to ensure controlled medications in unsecure bubble packaging cards were immediately removed from Medication Cart #1 and Medication Cart #2.<BR/>These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.<BR/>Findings Included:<BR/>During an observation and record review of medication cart #1 on 02/15/25 at 2:09 PM revealed a pill bubble packaging card filled with Tramadol 50 mg tablets (controlled medication used to treat insomnia [trouble sleeping]). The seals that secured 3 pill bubbles (#6, #7, and #13) were not intact and covered with tape. A pink and blue capsule was noted inside each bubble. There were 14 pills remaining. The narcotic log count sheet reflected the appropriate count. During a continued observation of medication cart #1, a full pill bubble packaging card (30 pills) filled with Alprazolam 0.25 mg (controlled medication used to treat panic and anxiety disorders) had 1 seal (#16) that was not intact. A small white, oval tablet was inside the bubble. The narcotic log count sheet reflected the appropriate count. <BR/>During an interview, observation, and record review of medication cart #2 on 02/15/25 at 2:20 PM revealed a pill bubble packaging card filled with Lorazepam 0.5 mg (a controlled substance used to relieve anxiety) with 1 seal (#6) not intact. A white, round tablet was noted inside the bubble. There were 11 pills remaining. The narcotic log count sheet reflected the appropriate count. During an interview, RMP D indicated that controlled medications were counted at the beginning and at the end of shift. RMP D said that controlled medications must be secured in a separately locked compartment within the medication cart. RMP D stated she did not see the broken seals during the count. RMP D stated she was unaware that the bubble seal was broken or when it happened. RMP D said that best practice would be to discard the pill with a second nurse. RMP D said the risk of an exposed pill was exposure, cross-contamination, the pill could be stolen, or replaced with a similar looking pill. RMP D stated the risk of a damaged bubble seal would be a potential for drug diversion. RMP D stated the RMP's, and nurses were responsible to check the medication bubble packs for broken seals during the count of narcotics at change of the shift.<BR/>During an interview on 02/15/25 at 3:06 PM, the DON said that nurses were responsible for following the medication rights (the right resident, right medication, right dose, right form, right time) and review expiration dates. The DON said if a nurse discovered the seal of a medication bubble pack was altered (opened, torn, ripped) then the nurse should notify the DON and discard the pill with a second nurse. The DON said that the second nurse witnessed the pill disposal of controlled medications as a secure and safe method to prevent diversion.<BR/>Review of the facility's policy Pharmacy Services, revised April 2007 reflected the following: . 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 4 (Residents #7, #13, #49 and #325) of 12 residents reviewed for resident abuse.<BR/>1. The facility failed to ensure Resident #325 was free from physical abuse by CNA O on [DATE]<BR/>2. The facility failed to ensure Resident #49 was free from physical abuse by CNA O on [DATE].<BR/>3. The facility failed to ensure Resident #7 was free from physical abuse by CNA O.<BR/>4. The facility failed to ensure Resident #13 was free from physical abuse by RN G on [DATE].<BR/>These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 6:10 PM. While the IJ was removed on [DATE] at 7:00 PM, the facility remained out of compliance at actual harm with a scope identified as pattern.<BR/>These failures placed residents at risk for serious injuries, abuse, and serious harm.<BR/>Findings included:<BR/>1. Record Review of Resident #325's Baseline Care Plan completed by ADON revealed resident admitted on [DATE] for end-of-life care and was on hospice services with Hospice KK and required extensive assistance with ADLs, and was not able to communicate easily with staff and not understood by staff. <BR/>Record review of Hospice KK medical records for Resident #325 revealed a document titled Visit Report dated [DATE] which stated resident required maximum to total assistance, total assistance with ADLS, and was a two (2) person transfer. <BR/>Record review of Resident #325's nurse's progress note dated [DATE] completed by ADON revealed resident expired on [DATE]. <BR/>Review of grievance log for [DATE] revealed grievance dated [DATE] regarding CNA O being rough regarding Resident #325. There were blank spaces for categories of resolved, followed up with resident, or reported to state, or if follow up was needed.<BR/>Record review of document titled Witness Interview dated [DATE] at 8:30 AM by Resident #325's family member and signed by the DON revealed complaint alleging on the morning of [DATE] [CNA O] was very rough in the way he got her up from the wheel chair and threw her into the bed.<BR/>Record review revealed grievance complaint form dated [DATE] provided by Administrator on [DATE] for Resident #325 by family member and signed by the Administrator revealed there was an established pattern with complaints of staff members while providing care and CNA O was suspended pending investigation. <BR/>Record review of Resident #325 nurse progress note dated [DATE] at 4:00 PM by RN G revealed Upon entering the room at 1600 the resident was noted to have her right leg caught in the blinds and her leg was bleeding and there was blood on the blinds and the wall. The resident was noted to be restless and agitated . called [Hospice K] asking for a nurse to come see her and that I needed the comfort kit sent here faster than it seemed to be coming. Resident was cleaned and repositioned. The bed was positioned away from the wall. The blinds were taken down due to being torn and having blood on them. One of the [family member of Resident #325] arrived around 1630 and then shortly after that the Hospice nurse arrived. Resident was given a one-timedose of Lorazepam 0.5mg PO and a short time after that began calming down.<BR/>Interview on [DATE] at 3:24 PM with RN G revealed she contacted the DON on [DATE] after family member of Resident #325 complained about not receiving the care kits timely for Resident #325 and that CNA O was rough with his transfer of resident and tossed her into the bed. RN G stated she called the DON and was told CNA O tossing resident into the bed was a reportable incident and to contact the Administrator. RN G stated she then called the Administrator on [DATE] and the family spoke with the Administrator over the phone and then was told by the Administrator because the family did not use the word abuse it was not reportable incident to the state and CNA O continued to work and CNA O continued to work despite this allegation. RN G stated she assessed the cut on Resident #325 leg but did not complete a head-to-toe assessment.<BR/>Interview on [DATE] at 11:59 AM with Resident #325's family member revealed she observed on the morning of [DATE] CNA O picked up Resident #325 from her wheelchair by himself and transferred resident into the bed. Family member stated she would describe the transfer as resident was plopped or tossed into the bed and the resident cried out. Family member stated she asked CNA O if he needed help before transferring resident and he said no. Family member stated she reported incident along with other concerns about care on the evening of [DATE] to RN G and then spoke with the Administrator. Family member stated Resident #325 was heavy and should have been a two person transfer which was why it appeared that resident was tossed into bed, and there was a lack of staff to assist. Family member stated she also arranged a meeting the following morning on [DATE] with the DON to go over her concerns further. Family member stated during her meeting with the DON and was told that they would look into the incident and did not recall filling out a witness statement or a grievance. Family member stated Resident #325 expired the following day and she had not been contacted by facility with an update. <BR/>Interview on [DATE] at 2:57 PM with DON revealed Resident #325 was admitted to facility for end of life care and expired on [DATE]. DON stated Resident #325 required a significant amount of care and needed assistance to be turned. DON stated on the evening of [DATE] RN G called to report family of Resident #325 stated CNA O roughly picked up and tossed Resident #325 into the bed. DON stated she told RN G that the abuse allegation was reportable and instructed RN G to call the Administrator immediately. DON stated she came to the facility around 8:00 PM and asked Administrator what needed to be done for the investigation. DON stated Administrator told her everything had been done except for the in-services on abuse and neglect. DON stated Administrator printed the abuse and neglect policy and DON went to every CNA and clinical staff member and reviewed the policy with them and had them sign the in-service sheet. DON stated she met with the family member on [DATE], wrote a witness statement, and the Administrator refused to take the statement during the morning meeting in-service on abuse and neglect. Administrator told DON she did not want the statement because she did not think it was abuse, she was already investigating the allegation of abuse by CNA O to Resident #49, and CNA O was already suspended. DON stated Administrator expressed irritation at having to come back to facility the evening on [DATE]. DON stated she took the witness statement back to her office. DON stated the Corporate Nurse DD was onsite on [DATE] and saw the witness statement on her desk and instructed DON to give it to Administrator. DON stated she told Corporate Nurse DD that Administrator refused to take the statement and Corporate Nurse DD suggested she file a grievance for the family of Resident #325 because the Administrator was the abuse coordinator and would have to report and investigate the incident. DON stated she gave the information to SSD who wrote the grievance and put it back on DON's desk. DON stated Corporate Nurse DD gave grievance to Administrator. DON stated she was not aware the allegations regarding CNA O and Resident #325 were not reported to HHSC. DON stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse. <BR/>Interview on [DATE] at 3:42 PM with Administrator revealed she had concerns regarding CNA O handling of Resident #325 during transfer on [DATE] and spoke to family member on [DATE] over the phone but because family member did not use the words abuse she thought it was more of a training issue she did not believe CNA O would intentionally abuse any resident so she did not report the allegation with Resident #325. Administrator stated there were no witness statements for Resident #325. Administrator stated she did not suspend CNA O until a second similar allegation later in the evening on [DATE] about a rough transfer was made by Hospice RN stated she and RN G regarding Resident #49. Administrator commonly would receive conflicting reports from staff regarding different issues and took this report more seriously because Hospice RN was a neutral party. Administrator stated sometimes what may look like abuse was just a transfer and that sometimes staff had to just pick up a resident and it may appear to be rough. <BR/>Interview on [DATE] at 9:48 AM with MDS Coordinator revealed she was present during the morning meeting on [DATE]. MDS Coordinator stated the Administrator was leading the meeting and reviewing the abuse and neglect policy with the department heads including the DON. MDS Coordinator stated that all allegations of abuse are to be reported to the Administrator who was the abuse coordinator. MDS Coordinator stated when Administrator read aloud examples of neglect the DON interjected and stated- see that was what I am talking about, it was abuse. MDS Coordinator stated Administrator became upset and stated it was not abuse, and ADON had observed CNA O provide care to residents and there were no concerns. MDS Coordinator stated Administrator stated she already recorded all the witness statements and did not want the witness statement from DON. MDS Coordinator stated Administrator and DON began to argue and MDS Coordinator and staff quickly left the room. MDS Coordinator stated she did not know which residents Administrator and DON were talking about. <BR/>Interview on [DATE] at 2:56 PM with DON revealed she did not provide a thorough physical assessment for Resident #325 or Resident #49 and thought they had been done by the charge nurse and it should be documented in the resident's chart such as the progress notes. DON stated that RN G would have done an assessment and she did not follow up with RN G. DON stated she had asked Administrator the evening of [DATE] after the incident if the assessments had been done and what she could help with and Administrator stated only the in-services were left. <BR/>Interview on [DATE] at 4:25 PM with Administrator revealed she did not report the family complaint about CNA O's treatment of Resident #325 because she did not think it was abuse at the time and did not think CNA O would intentionally abuse a resident. Administrator stated CNA O admitted to inappropriately transferring residents.<BR/>Interview on [DATE] at 5:15 PM with Director of Therapy with Director of Therapy revealed Resident #325 was at facility for end of life care and would have concern with a CNA transferring Resident #325 by scooping resident out of bed by themselves and into shower chair because it could result in a resident being dropped or injured. Director of Therapy stated residents who required extensive assistance meant the person required a resident to be transferred with 2 people assisting and with gait belt at a minimum, possibly Hoyer lift. <BR/>Interview on [DATE] at 11:02 AM with ADON revealed she worked the day of [DATE] until 6:00 PM. ADON stated Resident #325 had admitted to facility on [DATE] for hospice services, was on oxygen and was restless. ADON stated on [DATE] around 3:30 PM, she was in her office and heard RN G call for help and immediately went to assist RN G who was in Resident #325's room. ADON stated she observed RN G in Resident #325 room and Resident #325 was in bed next against the window and Resident #325 appeared confused of her surroundings, restless, agitated, and was flailing her arms around and kicking her legs. ADON stated she did not see any visible injuries on Resident #325 ADON stated she and RN G did not perform a head-to-toe assessment because the resident was restless and they stayed with resident to ensure safety while they waited for hospice services to arrive. ADON stated RN G asked CNA O to assist with moving the bed from the window to against a wall. ADON stated that family members of Resident #325 arrived before hospice services and were talking with RN G about their concerns and ADON left the room to give them privacy. ADON stated she was not aware that an allegation was made against CNA O until the following day at the morning meeting on [DATE]. ADON stated during the morning meeting the Administrator was reviewing the abuse and neglect policy and stated that there was an allegation of abuse of Resident #49 and Resident #325 by CNA O and that Administrator had done an investigation and felt that no abuse occurred. ADON stated DON interjected and said that she believed there was abuse. ADON stated Administrator replied that DON was showing favoritism to the nurse that reported the abuse, RN G. ADON stated DON stated it was the same favoritism the Administrator showed the Maintenance Director and began to leave the meeting and the Administrator told DON not to get in her feelings and that she had done this investigation and talked to family members of the residents and she did not feel like it was abuse. ADON stated she spoke with the Administrator after the meeting and the Administrator told her that she did not believe abuse occurred and that if RN G witnessed abuse then why did she not intervene. ADON stated she was responsible for assessing competencies quarterly of MA's and CNA's and assessed for peri-care, hand washing, and use of Personal Protective Equipment (PPE). ADON stated she had only assessed CNA O for hand washing and PPE use because CNA O used to work full time then switched to only a couple days a week as needed and she had not gotten to him to assess the peri-care. ADON stated she was aware that Administrator spoke with CNA O in the past about not communicating with residents when providing care by not introducing himself and letting them know what care he was going to provide. <BR/>2. Record Review of Resident #49's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] and diagnoses of dementia (loss of cognition), bi-polar disorder (mood disorder with periods of intense feelings), major depressive disorder (a mood disorder causing persistent feeling of sadness and loss of interest), and pseudobulbar affect (episodes of uncontrollable and inappropriate laughing or crying), unspecified pain, and a BIMS score of 0 (severely impaired cognition). Review revealed Resident #49 was dependent on assistance for ADL care including showers and transfers.<BR/>Record review of medical record for Resident #49 revealed document titled Physical Therapy PT Evaluation and Plan of Treatment dated [DATE] revealed resident experienced mood swings, visual and auditory hallucinations, had a history of agitation, aggressive behavior and was combative. Record review of physical therapy evaluation or Resident #49 revealed resident was known for grabbing hold of individuals nearby and hit and kicked. Record review of physical therapy evaluation revealed Resident #49 habitually coiled legs into extreme flexion at hip and knees which led to recurrent tightness and contractures and was non-weight bearing on her legs which caused additional challenges with assisted transfers. Review of physical therapy evaluation revealed Resident #49 did not ambulate on her own and used a geri chair. <BR/>Record review of witness statement by Hospice RN, dated [DATE] at 8:05 PM, and signed by Administrator revealed Resident #49 had vomited multiple times on [DATE] and Hospice RN asked CNA O to shower resident. Hospice RN stated CNA O entered the room and did not say anything to Resident #49 before he rolled resident over and picked her up and roughly sat her in the chair. Hospice RN stated that Resident #49 was startled and was not covered all the way when transported through the hallway. Hospice RN stated she did not think he was abusive, but it was overly rough and aggressive. <BR/>Record review of witness statement by RN G, dated [DATE] at 8:22 PM, and signed by Administrator revealed RN G witnessed CNA O roughly handled the shower chair as he transported Resident #49 out of shower room and she did not see his hands on physically on Resident #49 at any time.<BR/>Record review of Resident #49 revealed nurse's progress notes dated [DATE] at 10:51 PM by RN G that resident had frequent vomiting and Hospice nurse gave Resident #49 new order for Zofran. <BR/>Review of nurse's progress notes from [DATE] through [DATE] revealed no mention of incident with CNA O and no physical assessment.<BR/>Record review of hospice medical records for Resident #49 revealed visit note report dated [DATE] by Hospice RN that CNA O was aggressive when providing care for Resident #49 and she had redness around her collarbone and incident was reported to Administrator and Hospice Director. <BR/>Observation on [DATE] at 3:22 PM of Resident #49 revealed she was laying in geri chair wearing a long sleeve shirt, pants, with hair that appeared clean, with her legs curled up and arms in contracture, she was non-interviewable.<BR/>Interview on [DATE] at 3:24 PM with RN G revealed on the evening of [DATE] she was at the nurses station when she observed Hospice RN appeared upset. RN G stated Hospice RN told her CNA O picked up resident out of bed roughly and put Resident #49 into the shower chair. RN G was unable to explain why she did not intervene. RN G stated she felt startled when the shower door opened and CNA O jerked Resident #49 out of shower room and placed her at the nurses station. RN G stated she had training on Abuse, Neglect, and Exploitation during onboarding and in-services and was not sure if what she witnessed was abuse. RN G stated she called DON and Administrator and was told to have CNA O leave pending investigation.<BR/>Interview on [DATE] at 6:54 PM with Hospice RN revealed she visually assessed Resident #49 shoulders and demeanor when she was seated in the geri chair at the nurses station after the incident and observed some redness on resident's shoulders. Hospice RN stated she did not complete any additional assessment other than the assessment for pain, nausea and vomiting, and a visual observation of resident. <BR/>Interview on [DATE] at 3:19 PM with CNA N revealed Resident #49 required a two person transfer or hoyer lift with two people assisting because she was very strong and swings her limbs around and kicks during transfers. CNA N stated CNA O was a male and was stronger than the female CNA's and they would call CNA O when they needed assistance with heavy residents.<BR/>Interview on [DATE] at 2:57 PM with DON revealed Resident #49 required at least two (2) staff and a Hoyer lift to be transferred.<BR/>Interview on [DATE] at 5:17 PM with Director of Therapy revealed Resident #49 was in PT therapy for contraction management and for balance training and had a tendency to grab things like ears, arms, anything within reaching distance and kicked. Director of Therapy stated Resident #49 was totally dependent with care and was a two (2) person assist or hoyer lift. Director of Therapy stated concern with a CNA who lifted Resident #49 by himself by scooping resident out of bed into shower chair would be CNA could have dropped or injured resident. <BR/>Interview on [DATE] at 9:04 AM with Hospice LL Director revealed she received a phone call from Hospice RN on [DATE] regarding a concern with possible physical abuse of Resident #49 by CNA O and Hospice RN had reported incident to Administrator and RN G, the charge nurse, and CNA O had been removed from facility. Hospice LL Director stated that abuse should be reported to HHSC within 2 hours and did not report it herself because she was told the facility had reported incident. Hospice LL Director stated she received a phone call on [DATE] from Administrator who asked her how often hospice staff receive training on abuse and neglect. Hospice LL Director stated Administrator told her she did not feel that what CNA O did was abuse and that if a hospice nurse was present and believed they witnessed abuse then they should be the one to report the incident. Hospice LL Director stated Administrator told her that sometimes a transfer could look abusive if the observer was not trained to recognize abuse and sometimes staff just needed to pick up residents. Hospice LL Director stated Administrator sounded annoyed to have to conduct an investigation and told her CNA O had been suspended and the incident was self-reported. Hospice LL Director stated she documented her phone call with Administrator and submitted a report of abuse to state following her phone call with Administrator. Hospice LL Director stated that showers for Resident #49 would require two staff members because of Resident #49's functional status. Hospice LL Director stated risk to resident if not properly transferred or are showered with one staff member when they require two staff would be resident could be dropped, injured, or develop a skin tear due to friction or shearing. <BR/>Interview on [DATE] at 9:49 AM with MDS Coordinator revealed Resident #49 required two people to transfer including a hoyer lift because resident has involuntary movements of her arms and legs and grabs on to anything within reach, kicks, and hits. MDS Coordinator stated the risk to residents when improperly transferred were injury from being dropped or pull on improperly. <BR/>Interview on [DATE] at 3:33 PM with SSD revealed she was not in-serviced on the facility's abuse and neglect policy before she provided an in-service to staff on abuse and neglect on [DATE] and used the previous Abuse and Neglect policy dated 2020 by mistake instead of the most current policy dated [DATE].<BR/>Interview on [DATE] at 11:49 AM with CNA P revealed Resident #49 required two people and a Hoyer lift to transfer because she is a fall risk and commonly grabs anything within reach when being transferred. CNA P stated the risk to residents by not properly transferring would be injury from being dropped. <BR/>Interview on [DATE] at 6:05 PM with MA Z revealed she had worked at facility since 2019 and typically worked on Hall 200 and 300. MA Z stated Resident #49 was a two (2) person assist and was not aware of her surroundings and would swing her limbs around, hit, and bite the elbows of staff during transfers. MA Z stated hospice usually gave Resident #49 showers with two (2) people assisting and she would always hear Resident #49 yelling during showers. MA Z stated she liked CNA O because he was strong and assisted with transfers of residents and could not recall ever seeing CNA O use a gait belt. MA Z stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse.<BR/>3. Record review of Resident #48 Discharge MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to facility on [DATE] with diagnoses of chronic pulmonary disease (chronic lung disease obstructing airflow), Parkinson's disease (a chronic and progressive movement disorder), hypotension (low blood pressure), major depressive disorder (mood disorder with persistent feeling of sadness and loss of interest), was hospitalized on [DATE] and had a BIMS score of 14 (cognitively intact). <BR/>Record review of resident safe surveys performed by SSD on [DATE] revealed Resident #48 reported she witnessed CNA O rip Resident #7's pants off roughly from her hip to her ankles and Resident # 7 was screaming.<BR/>Observation of Resident #48 on [DATE] at 11:27 AM revealed resident was lying in bed asleep and wearing hospital gown. Surveyor attempted to interview resident #48 but was unable to due to illness. <BR/>Interview on [DATE] at 3:24 PM with RN G revealed when she left work on [DATE], Resident #48 was smoking outside and talking with someone else about witnessing a CNA O treating Resident #7 roughly. RN G stated she asked Resident #48 about the incident. RN G stated that Resident #48 said she was in the hallway and able to see in Resident #7's room because the door and privacy curtain were not closed and she saw CNA O put Resident #7 in her bed and rip the pants off of Resident #7 when providing care. RN G stated she asked Resident #48 if she reported this incident and Resident #48 stated she told the social worker the previous day, [DATE]. RN G stated she called and let DON know of the conversation and was told it was being investigated. <BR/>Interview on [DATE] at 5:05 PM with SSD revealed she conducted a safe survey on [DATE], in regard to Resident #49's allegation of abuse by CNA O, and Resident #48 reported she witnessed CNA O rip off the pants of Resident #7 while providing ADL care. SSD stated Resident #48's room was across the hall from Resident #7. SSD stated during safe surveys, Resident #44, who was the roommate of Resident #7, indicated a concern regarding treatment of Resident #7 by CNA O but Resident #44 declined to give further information. SSD stated she did not follow up with Resident #44. SSD stated she attempted to interview Resident #7 but resident was non-interviewable. SSD stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse.<BR/>4. Record Review of Resident #7 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of late onset Alzheimer's disease (loss of cognitive function), generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear or unease), spondylolysis (crack or break in the bone of the spine), a BIMS score of 5 (severely impaired cognition). <BR/>Record review of Resident #7 Care Plan dated [DATE] and revised [DATE] revealed resident required moderate assistance by one (1) staff to move between surfaces. <BR/>Observation and interview on [DATE] at 2:07 PM of Resident #7 revealed resident was sitting in an electric wheelchair with her hair brushed wearing a long sleeve shirt, pants, and shoes. Resident #7 was non-interviewable due to cognitive impairment and could not recall incident with CNA O. <BR/>Record review of medical record for Resident #7 revealed document titled Physical Therapy PT Evaluation and Plan of Treatment dated [DATE] revealed resident was confused regarding her surroundings, had difficulty communicating, was a fall risk, and required substantial to maximal assistance with ADL care. <BR/>Interview on [DATE] at 5:17 PM with Director of Therapy revealed Resident #7 required moderate assistance with transfers, a one person assist with staff using a gait belt at the minimum. Director of Therapy stated a CNA who lifted Resident #7 under her arms to transfer from wheelchair to bed without gait belt placed the resident at risk of being dropped and injury. Director of Therapy stated improper transfers such as picking up a resident from under their arms when transferring increased risk of resident injury, fracture, and multiplied the fall risk for resident.<BR/>Interview on [DATE] at 11:38 AM with LVN J revealed Resident #7 was care planned as a one person transfer assist which would mean always use a gait belt. LVN J stated she had seen Resident #7 be transferred from wheelchair to bed and usually the staff member would have Resident #7 put her hands on their shoulders and wrap around the resident and lift while wearing a gait belt. LVN J stated improper transfers of residents increased a resident risk of injury and harm. LVN J stated that if she observed abuse she would immediately inform the Administrator who is the abuse coordinator.<BR/>5. Record Review of Resident #44's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (loss of cognition), hypertension (high blood pressure), anxiety disorder (feelings of worry and fear or unease), depression (persistent feelings of sadness) and BIMS score of 10 (moderately impaired cognition).<BR/>Observation on [DATE] at 11:16 AM revealed Resident #44 was seated upright in wheelchair in 200 Hall wearing shirt, pants, and shoes and her hair was brushed. <BR/>Interview on [DATE] at 11:18 AM with Resident #44 revealed she was roommates with Resident #7 and about a week ago she was in her room lying in bed and Resident #7 was sitting in an electric wheelchair next to her bed when CNA O entered the room and said he was going to change Resident #7. Resident #44 stated CNA O picked up Resident #7 by lifting from underneath both armpits and placed her roughly in bed. She recalled Resident #7 told CNA O to stop as soon as CNA O began to lift Resident #7 up from the armpits and CNA O continued to transfer resident. Resident #44 stated he roughly and quickly jerked Resident #7's pants off to perform ADL care and recalled Resident #7 screamed and said stop several times and that he was being rough with her and she was going to tell. Resident #44 stated she felt upset when she witnessed this and told CNA O to leave Resident #7 alone and CNA O finished providing ADL care to resident. Resident #44 stated that she told SSD about the incident during a safe survey ([DATE]) and that she was told CNA O was no longer at the facility. Resident #44 stated she had no issues with CNA O and she currently felt safe at facility. <BR/>Interview on [DATE] at 3:44 PM with Administrator revealed she did not report or investigate allegation of abuse for Resident #7. Administrator stated she did not interview Resident #48 about their allegation from safe survey or the roommate of Resident #7 (Resident #44) because she thought it was more of a dignity issue than abuse allegation. Administrator stated she should have investigated the incidents by including the additional residents because it was a similar allegation to Resident #49. Administrator stated Resident #7 should have been assessed by either the charge nurse or DON and was not aware if an assessment had been completed.<BR/>Interview on [DATE] at 2:56 PM with DON revealed she was not aware of any abuse allegation for Resident #7 at the time of the safe survey and had only heard about it from other staff recently. DON stated she did not provide a physical assessment of Resident #7. DON stated she did not speak with Resident #44 about the incident. <BR/>Interview on [DATE] at 3:10 PM with LVN K revealed she began working at facility at the end of [DATE]. LVN K stated that she had observed CNA O transfer Resident #7 without a gait belt in the past. LVN K stated she observed CNA O put Resident #7's hands on his shoulders then he lifted resident and put her into bed. LVN K stated she could not recall if CNA O lifted Resident #7 from under her arms or if he bear hugged resident. <BR/>Interview on [DATE] at 3:20 PM with CNA N revealed she had observed CNA O transfer other residents and did not see CNA O use a gait belt. CNA N stated she observed CNA O pick up at least two (2) different residents, over the past two (2) months, who were two (2) person assists and were on the floor by bear hugging them and lifted residents into bed without a gait belt and without asking for assistance from herself and other staff. <BR/>Interview on [DATE] at 3:24 PM with RN G revealed she did not perform a thorough physical assessment for Resident #49 after allegation of abuse and she thought Hospice RN did an assessment. RN G stated she only assessed Resident #325 for the cut on her leg. <BR/>Interview on [DATE] at 2:57 PM with DON revealed [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for two (Resident #2 and an unknown Resident) of four residents reviewed for abuse.<BR/>The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 12/13/24 between Resident #2 and an unknown Resident. <BR/>This deficient practice could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings included:<BR/>Record review of the facility policy titled Abuse revised on 01/01/2023, reflected, Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation .All events that involve an allegation of abuse or involved a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of the alleged violation .Protection: It is of utmost importance that a resident(s) suspected of being abused, and other residents must be protected during the initial identification, and investigation process . <BR/>Record review of Resident #2's face sheet, dated 03/12/25, reflected Resident #2 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included traumatic subarachnoid hemorrhage (stroke caused by bleeding on the surface of the brain), oropharyngeal phase (difficulty swallowing), altered mental status and dementia.<BR/>Record review of Resident #2's quarterly MDS assessment, dated 01/08/25, reflected Resident #2 had a BIMS of 8, which indicated her cognition was moderately impaired. The MDS reflected Resident #2 had physical and verbal behaviors directed toward others. <BR/>Record review of Resident #2's comprehensive care plan revised 12/31/24, reflected Resident #2 had a Focused area of behavior problem related to low frustration tolerance .history of hitting, propelling wheelchair at a fast pace and running into other residents, grabbing, and screaming at staff, takes off colostomy bag (medical device that collects stool from the body)) and throws it on the floor. The care plan interventions included: administer medications as ordered, monitor and document for side effects and effectiveness, if reasonable, discuss resident's behaviors, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, psych notification for PRN evaluation for increased behaviors, and remove from the situation and take to alternate location as needed. <BR/>Record review of the facility incident reports for 3 months (12/12/24-3/12/25), did not reveal any incidents involving Resident #2 and an unknown Resident on 12/13/24.<BR/>Record review of LVN H written nurse's notes dated 12/13/24 reflected, LVN H was standing out at the med cart in the hall when we heard shouting. Get off me! shouted [Resident #2.] LVN H turned around and witnessed [Resident #2 ] hitting another resident . LVN H immediately walked over to [Resident #2] and educated her about keeping her hands to herself. [Resident #2] started repeating I'm sorry. LVN H asked [Resident #2] to apologize to the resident she hit. [Resident #2] did. In addition, review of LVN H notes revealed no assessed for Resident #2.<BR/>In an interview on 03/12/25 at 11:18 a.m. with Resident #2 revealed she denied she hit anyone. She denied she was in an altercation with anyone. <BR/>In an attempted phone interview on 03/13/25 at 1:50 p.m. with LVN H, left voice message for LVN H to call back the writer . The writer received no returned call prior to the survey exit. <BR/>In an interview on 03/13/25 at 2:49 p.m. with RN J, revealed she had no knowledge of the 12/13/24 incident that involved Resident #2 and an unknown resident. RN J revealed she knew what the abuse reporting policy was. RN J revealed any abuse is to be reported to the abuse coordinator/administrator within 24 hours unless it involves serious bodily injury, then you would report it within 2 hours. <BR/>In an interview on 03/13/25 at 3:06 p.m. with CNA I, revealed she had no knowledge of the 12/13/24 incident that involved Resident #2 and an unknown resident . CNA I revealed any abuse or neglect is to be reported to the charge nurse and administrator immediately. <BR/>In an interview on 03/13/25 at 3:36 p.m. the DON stated she was unaware of the unreported incident. She stated the incident should have been reported per the facility policy. She stated her expectations is for her staff to report all incidents of abuse and neglect within the timeframes per the policy. She stated facility staff is aware of the facility's reporting protocols , which was provided in their trainings. She stated she is responsible for staff trainings on abuse and neglect and reporting policy. She stated failure to report could place other residents at risk for injury or harm. <BR/>In a phone interview on 03/13/25 at 4:28 p.m., the Administrator stated he was the abuse coordinator for the facility. The Administrator stated he was unaware of the unreported incident. The Administrator stated his expectations is for his staff to report all incidents of abuse and neglect within the timeframes per the facility policy. The Administrator stated it was important to report any allegations of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one of two (Resident #57) residents reviewed for baseline care plans.<BR/>The facility failed to complete a baseline care plan for Resident #57.<BR/>This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services. <BR/>Findings included:<BR/>Review of Resident #57's 5-day MDS assessment dated [DATE], reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. She had a BIMS of 12 which indicated she was moderately cognitively impaired. She was always incontinent of bowel and bladder, required substantial to maximum assistance with ADL's and had diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow and make if difficult to breath) and heart failure. She required continuous oxygen. <BR/>Record review of Resident #52's electronic record census information reflected an admission date of 04/15/25- discharged [DATE]-Re-admit on 04/22/25-discharged on 04/23/25-re-admitted on [DATE]. <BR/>Record review of Resident #57s electronic record reflected the baseline care plan had been initiated on 05/02/25, but the baseline care plan was never completed. The only section completed was for Social Services. <BR/>In an observation and interview with Resident #57 on 05/05/25 at 06:40 p.m. Resident #57 was observed lying in bed with O2 via nasal canula. O2 was set to deliver 5 liters per minute. Resident #57 was noted to have a Foley catheter draining dark amber colored urine. Resident #57 stated she was on antibiotics for a urinary tract infection. She stated she used O2 continuously at 5 liters per minute. She stated she had been back at the facility for about 5 days. <BR/>In an interview with RN F on 05/08/25 at 01:50 p.m. she stated she thought the DON was responsible for completing the baseline care plan. She stated she had never received any instruction on completing the baseline care plan.<BR/>In an interview with LVN A on 05/08/25 at 01:53. p.m. she stated was told only an RN could complete the baseline care plan. She stated she assumed the DON or the MDS nurse completed the care plan. She stated she had never been instructed on the completion of the baseline care plan.<BR/>In an interview with the Corporate MDS Nurse on 05/08/25 at 01:55 p.m. she stated she searched Resident #57's electronic record and determined the baseline care plan had not been completed. She stated the care plan was an interdisciplinary approach, stating nursing needed to add their information, therapy, social services and dietary. She stated all parties were to sign after completion and then the care plan was to be printed and signed by the resident and or responsible party. She stated a copy was to be provided to the resident or responsible party and the signed baseline care plan was to be uploaded into the electronic record. She stated the baseline care plan was the beginning of the comprehensive care plan and provided a person-centered approach to the resident's immediate needs and wishes upon their admission to the facility. <BR/>In an interview with RN G on 05/08/25 at 02:30 p.m. she stated she had no idea who was responsible for completing the baseline care plan. She stated she assumed it was the DON or the MDS nurse. She stated she had never received any instructions on the completion of the baseline care plan. <BR/>In an interview with LVN E on 05/08/25 at 02:35 p.m. she stated she had no idea who was responsible for the baseline care plans. She stated she assumed it was the MDS nurse. <BR/>During an interview with the DON on 05/08/25 at 03:40 p.m. she stated the admitting nurse was responsible for initiating the baseline care plan. She stated it did not have to be an RN. When asked about their policy, she stated she was unaware their policy indicated the baseline care plan had to be completed by an RN. <BR/>In an interview with the Regional Director of Clinical Services on 05/08/25 at 03:45 p.m. she stated they would need to clarify their policy which required an RN was responsible for completion of the baseline care plan. She stated the baseline care was to address the resident immediate needs which the admitting nurse would be able to determine. She stated they would have to review their process and educate accordingly. <BR/>Record review of the facility's policy titled, Comprehensive Care plan, dated January 2021, reflected, Every resident will have an individualized interdisciplinary plan of care in place. A baseline care plan of care to meet the resident's immediate needs shall be develop for each resident withing forty-eight (48) hours of admission .A Registered Nurse will complete the Baseline Care Plan in the RN's absence in the Clinical reimbursement role. An RN initiates all Care Plans. To assure that the resident's immediate care needs are met and maintained, the baseline care plan will be developed with forty-eight (48) of the resident's Admission. It will be utilized until the Comprehensive Care Plan is developed. <BR/>Record review of the facility's policy titled, Baseline Care Plan, dated November 2019, reflected, A baseline care plan is required to be completed withing 48 hours of admission .The baseline care plan must include: Initial goals based on admission orders-Physician orders-Dietary orders-Therapy Services-Social Services- PASARR ( If applicable) .The facility must provide the resident and their representative with a summary of the baseline care plan to include as a minimum- Resident's initial goals- A summary of medications and dietary instructions-Any services and treatments administered by the facility and personnel acting on behalf of the facility such as therapy or psych services-Information to properly care for the resident upon admission-Address specific health and safety concerns .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Residents #71 and Resident #62) of eighteen residents reviewed for comprehensive care plans.<BR/>1. Resident #71's care plan failed to address interventions to prevent complications related to his indwelling urinary catheter and his G-tube.<BR/>2. Resident # 62's care plan failed to address his hospice election and failed to identify services that were provided by the hospice. <BR/>These failures placed residents at risk of not receiving individualized care and services to meet their needs and interventions to prevent complications related to each individuals identified concerns. <BR/>Findings included:<BR/>1. Record review of Resident #71's quarterly MDS assessment, dated 12/21/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. The resident was unable to complete the brief interview for mental status and was coded as severely cognitively impaired by staff assessment. The resident had a foley catheter and was always incontinent of bowel. His diagnoses included dysphagia (swallowing difficulties), cerebrovascular accident (stroke), neurogenic bladder (lack of bladder control due to brain or nerve problem), and malnutrition. Resident #71 received 51% or more of total calories through tube feeding (G-tube - tube inserted through the abdomen that delivers nutrition directly to the stomach).<BR/>Record review of Resident #71's Care Plan implemented on 07/26/22 revealed it did not address the residents G-tube status or interventions to prevent complications related to the G-Tube and there was no mention of the resident's foley catheter or interventions to prevent complications with the use of a foley catheter. <BR/>Record review of Resident #71's Physician's Order Summary Report dated 02/08/23 reflected, .Check placement and residual (quantity remaining) prior to administering feeding or medication. Notify MD and hold administration if residual &gt;200 ml. Reassess hourly until residual &lt; 200 ml. or change in orders obtained every shift .with a start date of 07/11/22 . Check Foley catheter placement, ensure Foley is secured via Velcro strap to reduce friction/pulling every shift .with a start date of 08/01/22 <BR/>Record review of Resident #71's MAR for February 2023 reflected, . Check placement and residual prior to administering feeding or medication. Notify MD and hold administration if residual &gt;200 ml. Reassess hourly until residual &lt; 200 ml. or change in orders obtained every shift .Check foley catheter placement, ensure Foley is secured via Velcro strap to reduce friction/pulling. Every shift . <BR/>An observation on 02/07/23 at 01:25 p.m. revealed Resident #71 had a G-tube with continuous enteral feedings and had a foley catheter. <BR/>In an interview with the DON on 02/08/23 at 2:55 p.m. revealed any resident with a G-tube or foley catheter should have those areas care planned with interventions to prevent complications. <BR/>2. Record review of Resident #62's Quarterly MDS assessment, dated 01/11/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. He had a BIMS of 15 which indicated he was cognitively intact. His diagnoses included viral hepatis (infection that causes liver damage) and alcoholic cirrhosis of liver with ascites (late-stage liver disease). The MDS indicated the resident was receiving hospice care in the facility. <BR/>Record review of Resident #62's Care Plan dated 01/24/23 reflected no mention indicating the resident was receiving hospice services, or what services hospice was providing. <BR/>In an interview with Resident #62 on 02/07/23 at 9:00 a.m. he stated he had asked the facility to make him an appointment with the only liver doctor in town. He stated he was wanting to know how bad his liver disease had progressed. <BR/>In an Interview with LVN C on 02/08/23 at 10:25 a.m. she stated Resident #62 had requested to see the liver doctor, but stated he was on hospice. She stated he was asked if he was wanting to seek aggressive treatment, since his hospice diagnosis was cirrhosis of the liver related to alcoholism. She stated he stated he was not seeking aggressive treatment. She stated they could make him an appointment if that is what he wanted to do.<BR/>In an interview with the DON on 02/08/23 at 3:00 p.m. she stated any resident on hospice was supposed to be care planned to identify what services the facility provided and what services the hospice agency provided. She stated the MDS Coordinator was responsible for creating the comprehensive care plan. She stated the care plan had to include all the resident's identified problems and interventions to prevent complications. She stated they had been without a full time MDS Coordinator until recently and were still trying to get care plans caught up. <BR/>In an interview with MDS Coordinator B on 02/08/23 at 3:20 p.m. she stated she was responsible for creating the comprehensive care plan in conjunction with the interdisciplinary team. She stated any resident with a foley catheter, G-tube and hospice needed to be care planned for interventions to prevent complications. She stated the care plan was supposed to represent the needs of the resident while in the facility. She stated she had been part time since middle of the summer 2022 and was trying to get the care plans caught up with the limited amount of time she had. <BR/>The facility's policy, Comprehensive Care plan, revised January 2021, reflected, Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident withing forty-within (48) hours of admission. The interdisciplinary Team will continue to develop the plan in conjunction with the .MDS .completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The care plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from resident's representatives, external partners .Hospice, Therapy, Clinician and not as all inclusive

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #12) of six residents reviewed for range of motion. <BR/>The facility failed to implement interventions to prevent further decline of Resident #12's contracture to her left hand upon discharge from therapy services.<BR/>These failures could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. <BR/>Findings included:<BR/>Review of Resident #12's admission MDS Assessment, dated 3/1/25, reflected she was a [AGE] year-old female with an admission date of 4/18/23. Resident #12 had minimal cognitive impairment, and her BIMS score was 15. She had upper and lower extremity impairment on one side and required use of a wheelchair. Resident #12 required assistance in putting shoes on, lower body dressing, bathing, toileting, and personal hygiene. Resident was also fully dependent in transfers and turning in bed. Resident had the following active diagnosis: Stroke (a medical condition that occurs when blood flow to the brain is interrupted or reduced, leading to brain cell damage) (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), Arthritis (swelling or tenderness I one or more joints, causing joint pain or stiffness that often gets worse with age), Non-Alzheimer's Dementia (brain disorder that caused progressive cognitive decline), unspecified lack of coordination, unsteadiness on feet and muscle weakness. <BR/>Review of Resident #12's care plan revised 1/21/25 did not reflect interventions for her left-hand contracture or for the use of a brace on the contracted hand. <BR/>Review of Resident #12's Order Recap Report dated 5/8/25 reflected an order for 7/26/23 to 6/12/24 .may have brace to left hand to prevent contracture. Wear brace during day and off at night. Two times a day for Preventative .<BR/>Review of Discontinued Order by ADON dated 6/12/24 reflected the order for the left-hand brace had been discontinued .Reason for Discontinue: Refusal d/t non fitting.<BR/>Review of Resident #12's Order Summary Report revealed the following order on 5/7/25 .L wrist/hand brace to be worn by patient twice a day to help limit potential contracture .<BR/>Review of facility's quarterly Contracture Management Log for December 2024 reflected Resident #12 was evaluated on 11/27/24 and a contracture was observed on left hand that required a splint. <BR/>Review of facility's quarterly Contracture Management Log for April 2025 reflected Resident #12 was evaluated on 2/24/25 and a contracture was observed on left hand that required a splint. <BR/>Review of Resident #12 OT Discharge Summary dated 4/18/25 reflected Discharge Recommendations: 24 hour care . There was no mention of a splint or contracture on the discharge summary. <BR/>Observation on Resident #12 on 5/5/25 at 7:54pm revealed possible contracture on left hand without a brace or splint. Attempted to interview Resident #12 however she was unable to answer questions due to cognitive deficits. <BR/>Interview with Director of Rehabilitation on 5/7/25 at 1:14pm revealed Resident #12 had PT and OT from 2/24/25 to 4/18/25 and was discharged due plateauing in her progress. Resident #12 had a contracture on left hand and should have had a splint as there was an order on file, as he insured it was there. He stated Resident #12 was also on the Contracture Management Logs and was followed up with every quarter, last follow-up was 4/15/25. Director of Rehab was unable to provide the active order, he stated someone had cancelled the order without discussing it with him. He would have never recommended the order be discontinued, as Resident #12 needed the splint to help manager her contracture. There should always be an order for the splint and the splint/brace should be care planned. They needed to have an order to obtain the appropriate consents. He stated he would assess Resident #12 immediately and enter the order. <BR/>Observation of Resident #12 on 5/7/25 at 1:23pm revealed resident sitting in common area watching TV without a splint or brace on left hand.<BR/>Interview with CNA X on 5/7/25 at 1:24pm revealed Resident #12 had a splint on her left hand at one time but would not keep it on. CNA X had not put it on recently and had no idea where the split was at. The only thing being done for her contracture was Resident #12 uses a stress ball. <BR/>Interview with CNA J on 5/8/25 8:42am revealed she was not familiar with the resident, as she had just started working the resident's hall but stated Resident #12 had not had a splint yesterday or this morning. Residents with a contracture would normally have a splint or brace and access to toys that would help with the contracture. <BR/>Interview with LVN A on 5/8/25 at 9:16am revealed Resident #12 had a contracture and therapy had given the resident a splint, but she was unsure if it was an active order because she had not seen Resident #12 with it on. The risk of not wearing the splint if it was recommended by therapy was the risk of the contracture getting worst and causing more pain.<BR/>Interview with Director of Nursing on 5/8/25 at 12:09pm revealed she was unsure if Resident #12 had a contracture. She stated that contractures and splints would have had orders. She stated every intervention used on residents needed to have an order and be care planned, the risk of not having an order for a splint was that the hand could become more contracted. <BR/>Interview with the Executive Director on 5/8/24 at 12:45pm revealed that a splint or brace should have a physician order and be added to the care plan. The risk of not having an order for a splint was that the resident wouldn't receive everything they needed. <BR/>Interview with RN G on 5/8/25 2:30pm revealed she was aware that Resident #12 had a contracture on one and that she had received therapy multiple times. She reported Resident #12 had a brace for her contracted hand at one point and believed she still had it but no longer used it. She stated that Resident #12 did not like to use it and it was discontinued in the orders a long time ago. She stated she followed the written orders when determining whether a resident needed a splint or not. <BR/>Interview with the Director of Rehabilitation on 5/8/27 at 2:57pm revealed he no longer had access to Resident #12's OT evaluation that had the discharge recommendation for brace or splint because it was in their old electronic system, and they switched over to a new system in April. He only had the OT discharge evaluation from 4/18/25 that did not list the brace for the contracture on it. He stated that he was sure Resident #12 required a splint/brace because he had put the order in, and someone had discontinued it without discussing with him. He stated he reassessed the resident yesterday, 5/7/25 and she continued to have a contracture and needed a brace. He entered in the order for the brace. He stated Resident #12 continued to be listed on his Contracture Management log. He stated he always discussed the need of a split/brace with the IDT and will teach the nurses and CNAs how to put it on safely. the length of time to wear it, what to assess for to take it off and how many times per day it was necessary. He stated he typically did this when he entered the order and discharged the resident from therapy.<BR/>Interview with the ADON on 5/8/25 at 3:44pm revealed that she had discontinued the order for the brace Resident #12 due to Resident's family member requesting it be discontinued. She stated she had asked Resident #12 and her family member for the brace because it was in the orders and the resident's family member stated she had not used the brace for a while, because it no longer fit her. The ADON stated she did not remember if she had spoken to the Director of Therapy or the therapist about discontinuing the order because it was a long time ago. She stated she was unsure if Resident #12 still needed a brace for her contracture. <BR/>Review of Facility's policy, Restorative Nursing revised on 8/11/21 reflected .1. Restorative Nurse will be trained by therapy by each discipline, and a competency checklist is completed. Restorative nursing care consist of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. physical, occupational, or speech therapies). A. therapy will develop and implement an individualized RNA program at the resident discharge from therapy within 72 hours. Therapy will provide individualized training with the Restorative Nurse prior to discharge from therapy. B. Restorative Nurse has 7-10 days to implement the Restorative Nurse Program. 2. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. A. Restorative Nurse will report any changes to Clinical Reimbursement Coordinator and Director of nursing for further interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. <BR/>The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. Resident #1 had history of confusion, exit seeking behavior and wandering behavior. On 12/20/24, Resident #1 eloped out of the facility and the facility was not aware the resident eloped. Resident #1 was walking the streets about 3 blocks away from the facility in a residential area. <BR/>The noncompliance was identified as PNC. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began.<BR/>These failures could place residents at risk of potential accidents, injuries, harm or death. <BR/>Findings include:<BR/>Review of Resident #1's face sheet undated reflected Resident #1 was admitted to the facility on [DATE] from another skilled nursing facility with diagnoses of Muscle Wasting and Atrophy (significant shortening of the muscle fibers and loss of overall muscle mass), Syncope and Collapse (fainting), Dementia (loss of cognitive functioning that interferes with daily life and activities), Depression, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Glaucoma (eye disease that can cause vison loss and blindness and blindness), Hypertension, Osteoarthritis (chronic degenerative joint disease), Generalized Muscle Disease, Unsteadiness on feet, lack of coordination and cognitive communication deficit. Resident #1 was not her own responsible party. <BR/>Review of Resident #1's admission MDS dated [DATE] reflected Resident #1 had a BIMS of 7 indicating she was severely cognitively impaired. Resident #1 had wandering behavior daily. Resident #1 was independent with ambulation with no assistive devices. Resident #1 required supervision with ADLs except she required partial/moderate assistance with bathing. <BR/>Review of Resident #1's Admitting paperwork from previous facility discharge summary reflected: [Resident #1] has cognitive impairments and requires redirection for orientation, care and safety. [RP] would like to secure placement in a long-term care facility that can assist with redirection for wandering/exit seeking and a secure unit as needed. <BR/>Review of Resident #1's baseline care plan dated 12/06/24 reflected Resident #1 was an elopement risk. Resident #1 was cognitively impaired due to forgetfulness and dementia.<BR/>Review of Resident #1's Comprehensive Care Plan dated 12/20/24 reflected the following:<BR/>-dated 12/20/24 Resident #1 had impaired cognitive function or impaired thought processes related to impaired decision making abilities, is not always understand or able to understand verbal and non-verbal expression related to dementia. <BR/>-revised 12/31/24 Resident #1 is an elopement risk/wanderer and is at risk for possible injury [related to] impaired safety awareness and diagnosis of dementia 12/20/24 Resident had elopement event. Interventions included Distract resident from wandering ., Provide structured activities ., secure unit placement for increased monitoring.<BR/>-revised 02/06/25 Resident #1 resides on the facility security unit [due to] wander/elopement risks related to history of attempts to leave facility unattended, impaired safety awareness, resident wanders aimlessly. Interventions included Identify pattern of wandering: Is wandering purposeful, aimless or escapist? .Intervene as appropriate.<BR/>Review of Resident #1's Incident Report dated 12/20/24 reflected elopement incident for Resident #1. It reflected received phone call that resident was at a nearby house. Resident of the home was able to retrieve this resident's cell phone and call resident's[RP]. [RP] picked resident up and returned resident to facility. Resident states 'the girls and I went to a dance and got lost. Head to toe assessment performed, with no injuries noted. Resident on one-on-one monitoring until moved to secure unit on this day .Admin initiated self-report. Medical Director informed. Resident #1 was oriented to person only. Resident #1 had predisposing physiological factor s of confused and impaired memory. <BR/>Review of Resident #1's 24 Hour report dated 12/20/24 reflected Resident #1 elopement 12/20/24. One to one monitoring until moved to unit moved to 509B. <BR/>Observation and Interview on 03/12/25 at 10:28 AM revealed Resident #1 was sitting on her bed in her room on the secure unit. Resident #1 was confused and could not recall the incident. She stated she felt safe at the facility. <BR/>Review of Resident #1's progress note for December 2024 reflected the following:<BR/>Dated 12/05/24 12:45 PM by RN A resident admitted to facility ambulatory has dx of dementia and wondering alzheimers .very pleasant oriented to room .will continue to monitor and assess will update [medical doctor] family and admin prn status changes.<BR/>Dated 12/06/24 12:40 PM by LVN B Resident exit seeking and attempting to exit out of 200 hall exit door. Resident redirected to eat lunch.<BR/>Dated 12/06/24 1:55 PM by LVN B Resident continuing to attempt to exit seek. Resident pushing on exit doors. Staff attempting to redirect resident. Resident confused. [Alert and Oriented] x1. DON notified.<BR/>Review of Incident/Accident Reports December 2024 to March 2025 reflected no other elopement incidents for any other residents in the facility.<BR/>Interview on 03/12/24 at 1:54 PM with LVN C revealed Resident #1 eloped on 12/20/24 but he was not working when the incident occurred. He stated Resident #1 was confused, had wandering behavior and would ask about leaving the facility. He stated he had been in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. He was knowledgeable about his role as a charge nurse for a missing resident. He stated Resident #1 was placed on the secure unit after the elopement incident.<BR/>Interview on 03/12/24 at 3:22 PM with LVN B revealed Resident #1 had expressed desire to go home constantly, would say her family member was coming to pick her up, and asked LVN B what door do I exit from. She stated she would redirect Resident #1 when she expressed wanting to leave and go home. She stated on the morning of 12/20/24 before the incident Resident #1 was confused and did not understand why she was at facility. She stated Resident #1 required redirection and distraction from wanting to leave. She stated on 12/06/24 Resident #1 did have 2 occurrences of exit seeking on pushing on hall 200 doors and she documented it in the nurse's note. She stated she redirected Resident #1 when she attempted to exit seek and distracted her. She stated she was not aware of Resident #1's history if she was an elopement risk upon admission. She stated on 12/06/24 she was not Resident #1's charge nurse and could not recall who she notified about the exit seeking behavior for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident. She was unaware of any elopement incidents since Resident #1's elopement on 12/20/24.<BR/>Follow-up Interview on 03/13/25 at 10:15 AM with LVN B revealed on 12/20/24 Resident #1 was last seen at the facility's Christmas party at 1:45 PM or 2 PM. She stated 2:00 PM is shift change so she was not working when Resident #1 returned to the facility after the elopement. She stated she documented Resident #1's exit seeking behavior on 12/06/24 in a nurse's note since she was not Resident #1's charge nurse. <BR/>Interview on 03/12/24 at 3:40 PM with MDS Coordinator revealed Resident #1 admitted from another skilled nursing facility. She stated Resident #1 did have wandering behavior and the baseline care plan reflected she was at risk for elopement. She could not find an elopement assessment upon admission for Resident #1. She stated she was not working the day of Resident #1's elopement. She stated the charge nurse who admits a resident was responsible to ensure elopement assessment completed to determine resident's elopement risk level. She stated she was in-serviced after the incident in December 2024 on elopement policy and signs/symptoms of residents at risk for elopement.<BR/>Interview on 03/13/24 at 8:45 AM with RN A revealed Resident #1 was oriented to her self only but confused about the place. Resident #1 was ambulatory and wandered within the facility. She stated Resident #1 would go to the door but was not aware of her attempting to exit prior to the elopement. She stated Resident #1 was a risk for elopement due to confusion and wandering behavior. She stated she was the admitting nurse for Resident #1 and she could not recall why elopement assessment was not done at admission. She stated she could not recall reviewing Resident #1's discharge paperwork from the previous facility. She was not aware Resident #1 was an elopement risk. She stated she was not aware Resident #1's baseline care plan showed Resident #1 as an elopement risk. She stated the DON was the charge nurse at time of elopement incident for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. She stated after being in-serviced she was aware all residents upon admission should have elopement assessment completed to determine elopement risk. <BR/>Interview on 03/13/25 at 9:25 AM with CNA D revealed Resident #1 was confused and would misplace her phone asking for assistance from facility staff to find it. She stated Resident #1 had occasional exit seeking behavior of going towards the exit doors. She stated Resident #1 constantly wandered within the facility and would ask to go to go with Resident #1's RP. She stated nurses were aware of Resident #1's wandering, confusion and exit seeking behavior. She stated Resident #1 was placed on the secure unit after the elopement incident. <BR/>Interview on 03/13/25 at 9:32 AM with Med Aide E revealed she did could not recall Resident #1 prior to being on the secure unit and did not recall elopement incident for Resident #1 in December 2024. She stated Resident #1 was currently on the secure unit for resident safety. She stated she had been in-serviced on elopement policy and signs/symptoms of residents at risk for elopement.<BR/>Interview on 03/13/25 at 9:55 AM with Resident #1's RP revealed at the previous facility she exhibited behavior of wandering and would go to the exit doors to look out. She stated Resident #1 was confused and had dementia. She stated Resident #1 had not eloped at previous facility but they had Resident #1 moved to this facility for the resident safety and risk for elopement. She stated she had not had a care plan meeting with the facility. She stated nursing had not reached out to her prior to this incident of any exit seeking behavior for Resident #1. She stated she did not meet with facility staff to review the baseline care plan and facility had not discussed with her secure unit until after this elopement incident. She stated on 12/20/24 when she was shopping at a local store she received a phone call from a stranger using Resident#1's phone informing Resident #1 was walking the streets in a residential area. She stated she responded by telling the stranger the resident could not be there she was a resident at the facility. She stated she immediately left to go get Resident #1. She attempted to call the facility and was not able to get through but called a friend who called the facility to inform them Resident #1 was found walking the streets. She stated when she got to Resident #1 it was about like 10 minutes from when she first received the phone call. She stated she found her about 3 blocks away from the facility in a black sweatshirt with pants, socks and shoes on. Resident #1 told her she was dancing with her friends and got lost. She stated Resident #1 was cold and shivering with a blanket covering her provided by the bystander. She stated the bystander told her Resident #1 had flagged them down on the street saying she knew them and was walking the streets in residential area. She stated the facility had informed her later she must have gone out the door after the Christmas party when other visitors were exiting. She stated she took Resident #1 back to the facility in her car and nurse assessed her. She stated Resident #1 was not injured and was mad when Resident #1's RP left. She stated Resident #1 was placed on the secure unit after the elopement incident. <BR/>Interview on 03/13/25 at 10:29 AM with CNA F revealed she saw Resident #1 at the facility's Christmas party eating but she had to leave about 2 pm to transport another resident to an appointment. She stated Resident #1 did have exit seeking behavior and would express her desire to leave the facility especially after her family would visit. She stated she had been in-serviced after Resident #1's elopement on elopement policy, signs/symptoms of residents at risk for elopement, abuse/neglect.<BR/>Interview on 03/13/25 at 10:48 AM with Activity Director revealed on 12/20/24 facility had a Christmas party in the dining room including facility staff, residents and visitors from 1:30 PM to 2:00 PM. She stated she saw Resident #1 at the Christmas party but she did not recall seeing her after that. She stated she was not at the facility when Resident #1 returned to facility after elopement incident later that day. She stated Resident #1 was ambulatory on her own, had some confusion and looked like a visitor. She stated she was not aware of Resident #1 exit seeking behavior. She stated there was like 60 people at the Christmas party and maybe she had followed visitors out the door after the party. <BR/>Interview on 03/13/25 at 10:35 AM with CNA K revealed she was knowledgeable on elopement policy, signs of residents with elopement risk, abuse/neglect and would immediately report to Charge Nurse, Administrator and DON if a resident was found missing. She had been recently in-serviced on elopement protocol and abuse/neglect policy. <BR/>Interviews on 03/12/25 at 1:21 PM and 03/13/25 at 11:45 AM with CNA G revealed she had been recently in-serviced on elopement policy and signs of residents with elopement risk. She was aware she needed to notify Charge Nurse, Administrator and DON when resident is found missing. She was knowledgeable of types of abuse/neglect and had been in-serviced on abuse/neglect recently. <BR/>Interview on 03/13/25 at 11:28 AM with ADON revealed she was working today as a charge nurse and works the floor as needed as the charge nurse. She stated she was in-serviced on elopement protocol including signs of residents at risk for elopement and the nurse's role when resident is found missing. She stated she had been in-serviced on nurse responsibility to complete elopement assessment upon admission and as needed when resident exhibits exit seeking behavior. She stated when Resident #1 eloped she was at risk of injury.<BR/>Interviews on 03/13/25 at 12:10 PM with LVN L revealed she worked 2 pm to 10 pm shift on 12/20/24 but was not the charge nurse for Resident #1. She stated she was unaware of resident elopement risk and had not witnessed any exit seeking behavior from Resident #1. She stated Resident #1 was ambulatory on her own and did look like a visitor. She stated Resident #1 had confusion. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident.<BR/>Interview on 03/13/25 at 1:13 PM with DON revealed she was unable to provide any witness statements of Resident #1's elopement. She stated she was the charge nurse for Resident #1 on 2 pm to 10 pm shift on 12/20/24. She received a phone call from a friend to Resident #1's RP who also worked for the facility that Resident #1's RP had received a phone call from a stranger that Resident #1 was found at a neighboring house. The DON looked at incident report and stated she had received the phone call at 3:45 PM on 12/20/24 because this is when she initiated the incident report for Resident #1. She stated Resident #1's RP brought Resident #1 back to the facility and Resident #1 was confused saying she went dancing with her friends. She stated she assessed Resident #1 head to toe with no injury noted. She could not recall the specific vitals but stated Resident #1's vitals were within normal limits. She stated facility initiated 1:1 for resident safety when she returned and after consent placed her on the secure unit for exit seeking behavior and elopement incident. She stated when interviewing staff after the elopement Resident #1 was last seen by staff at Christmas party on 12/20/24. She stated Resident #1 did wander within the facility but she was not aware of any exit seeking behavior. She stated when she reviewed Resident #1's progress notes she found the note on 12/06/24 stating Resident #1 had exit seeking behavior and stated she was not made aware of it. She stated she completed the baseline care plan for Resident #1 and stated she put down Resident #1 was an elopement risk based on previous stay at skilled nursing facility. She stated she did not review the baseline care plan with Resident #1's RP and did not look to see if elopement assessment had been completed upon admission. She stated she completed Resident #1's elopement assessment after the incident on 12/20/24 indicating she was high elopement risk due to elopement. She could not recall discussing secure unit placement with Resident #1's RP until after she had eloped on 12/20/24. She stated nursing had been in-serviced on completing elopement assessments upon admission and as needed when residents exhibit exit-seeking behavior. She stated if she had been made aware of Resident #1's exit seeking behavior on 12/06/25 she stated an elopement assessment would have been completed to determine elopement risk and to discuss with team about secure unit placement for safety. She stated the potential risk of elopement was serious injury or accident for Resident #1. She stated Resident #1 had intermittent cognition especially after Resident #1's RP visited and did not understand why she was placed at facility. <BR/>Interview on 03/13/25 at 1:55 PM with Administrator revealed Resident #1's Previous Facility expressed she would go to the exit door asking about a car. He was not aware of Resident #1 having exit seeking behavior until after elopement incident in December 2024. He stated facility investigation revealed Resident #1 was last seen at the Christmas party on 12/20/24 and may have exited behind visitors or other people at the end of the party. He stated Resident #1 did elope and was immediately placed on 1:1 with staff until placed on secure unit for elopement and resident safety. He stated there have been no other elopements. He stated if he was aware of the exit seeking behavior prior to incident they could have assessed her with elopement assessed and review to determine if she required more supervision. He stated the potential risk to Resident #1 could be injury and serious harm. He stated the facility completed an elopement drill with facility staff to ensure staff were knowledgeable of facility policy on elopement. <BR/>Review of staff In-services reflected:<BR/>12/20/24 and 12/26/24 staff in-serviced on elopement education including elopement drill<BR/>12/26/24 nurses in-serviced on completing all admission assessments by DON included RN A, LVN B, LVN C, ADON, MDS Coordinator and other nurses.<BR/>12/20/24 and 12/28/24 staff in-serviced on abuse/neglect<BR/>Review of facility's policy Elopement dated 11/01/19 reflected To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing .6. When the patient/resident is located, the nurse completes a head-to-toe assessment. The social service designee assesses the patient/resident for emotional distress. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Examples of criteria that put a resident at higher risk of elopement .Cognitive impairment (example: those who dementia, Alzheimer's, brain injury) Exit-seeking behaviors (example: confused resident that thinks he/she needs to go pick their kids up from the school) New admission wanting desperately to leave .History of elopement at other communities<BR/>Review of facility's policy Elopement Risk assessment dated [DATE] reflected facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. PROCEDURE 1. All patients/residents are assessed on admission by a licensed nurse for elopement risk utilizing the elopement risk assessment form. 2. All patients/residents are re-assessed for elopement potential by the licensed nurse/social service designee quarterly throughout a patient's/resident's stay and with a significant change .4. The licensed nurse or social service designee completes the elopement risk assessment form and presents to the interdisciplinary team for further intervention.6. The physician and the patient/resident or the patient's/resident's representative are notified of the patient's/resident's risk for elopement and the interventions that are recommended for prevention of elopement and patient/resident safety. 7. The patient's/resident's legal representative should be contacted, if possible, to obtain all pertinent information in relation to elopement risk .10. A licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjust as needed. 11. A baseline plan of care should be completed on admission and any elopement risks should be identified. <BR/>The DON and Administrator were notified and provided the IJ template on 03/13/25 at 6:05 PM of PNC IJ for F689. The DON was provided the IJ template for PNC F689 on 03/13/25 at 6:05 PM. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of four residents (Residents #14 and Resident # 5) reviewed for pharmacy services in that-<BR/>1. RN G failed to follow the manufacturer's instructions to prime the Lispro Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #14. <BR/>2. RN D failed to follow the manufacturer's instructions to prime the Novolog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #5. <BR/>These failures placed residents at risk of not receiving full dosage of medication. <BR/>Findings included: <BR/>1. Review of Resident #14's Face sheet dated 03/14/24 reflected an [AGE] year-old female admitted to the facility on [DATE]. Active diagnoses included diabetes mellitus. <BR/>Record review of Resident #14's Physicians order summary report with a start date of 05/25/23, reflected, .Insulin Lispro 100 units/ml .Inject per sliding scale .subcutaneously (under the skin) before meals and at bedtime for diabetes . <BR/>An observation on 03/10/24 at 11:10 AM of the medication pass revealed RN G checked Resident #14's Fingerstick blood sugar and obtained a reading of 169. RN G returned to the medication cart, looked at the MAR and determined resident would need insulin according to sliding scale which indicated 151-200 give 4 units. RN G opened the medication cart and retrieved Resident #14's Lispro Flex Pen. RN G placed a needle on the insulin pen and dialed 4 units without priming the pen first. RN G then administered the Insulin to Resident #14. <BR/>Interview with RN G on 03/10/24 at 11:20 AM she stated she was unaware the insulin pen had to be primed. She stated it made sense because you might not be giving the full amount of insulin if the pen was not primed. She stated she had never been told she needed to [NAME] the insulin pen and had not checked the manufacture guidelines. <BR/>2. Record review of Resident #5's, Face sheet, dated 03/14/24 reflected a [AGE] year-old female with an admission date of 01/05/10. Resident #5 had a diagnosis which included Type 2 diabetes and dementia. <BR/>Review of the Physician Order Summary dated 03/18/24 revealed .NovoLog FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 121-150=2 units; 151-200=4 units; 201-250 = 6 units; 251-300 = 8 units; 301-350= 10 units If above 350 give 12 units and call MD, subcutaneously before meals and at bedtime .<BR/>An observation 03/10/24 at11:25 AM revealed RN D at the medication cart preparing to perform Resident #5's finger stick blood sugar. RN D performed hand hygiene and donned gloves and obtained Resident #5's blood sugar with a reading of 149. RN D checked the computer to determine the amount of insulin per sliding scale indicated 121-150 give 2 units. RN D dialed in the amount of insulin required (2 units) without priming the pen and administered the insulin. <BR/>In an interview with RN D on 03/10/24 at 11:35 AM, she stated she was not aware the insulin pen had to prime before dialing in the amount of insulin required. She stated she had not reviewed the manufacturer's instructions. She stated by not removing the air the resident could receive a less amount of insulin and wound not receive the full dose of medication. <BR/>In an interview with the DON on 03/11/24 at 01:10 PM she stated she was also unaware the insulin pen had to be primed. She stated she came from a hospital setting and they did not use insulin pens in that setting. She stated the Insulin pen needed to be primed first to ensure they removed the air and ensured the resident received the required amount of Insulin. She stated failing to follow procedures could result in residents not receiving the full amount of medication ordered. She stated their policy referred them to the manufacturers guidelines. <BR/>Review of the Facility's procedure, Injectable medication administration, dated August 2020, reflected, .Pen Devices: Dial the does as instructed by the Pen manufacture <BR/>Review of manufacture instructions for Lispro obtained from https://www.lillyinsulinlispro.com/ searched on 03/18/24 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. o prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps .<BR/>Review of manufacturer instructions for Novolog obtained from https://www.novomedlink.com/ searched on 03/18/24 reflected, .Giving the air shot before each injection .Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units .Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. A drop of Insulin should appear at the needle tip, if not .repeat the process .make sure the dose selector is set at 0. Turn the dose selector to number of units you need to inject .<BR/>

Based on observation, interview, and record review the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 2 (Medication Cart #1 and Medication Cart #2) of 2 medication carts observed for medication storage, in that:<BR/>The facility failed to ensure controlled medications in unsecure bubble packaging cards were immediately removed from Medication Cart #1 and Medication Cart #2.<BR/>These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.<BR/>Findings Included:<BR/>During an observation and record review of medication cart #1 on 02/15/25 at 2:09 PM revealed a pill bubble packaging card filled with Tramadol 50 mg tablets (controlled medication used to treat insomnia [trouble sleeping]). The seals that secured 3 pill bubbles (#6, #7, and #13) were not intact and covered with tape. A pink and blue capsule was noted inside each bubble. There were 14 pills remaining. The narcotic log count sheet reflected the appropriate count. During a continued observation of medication cart #1, a full pill bubble packaging card (30 pills) filled with Alprazolam 0.25 mg (controlled medication used to treat panic and anxiety disorders) had 1 seal (#16) that was not intact. A small white, oval tablet was inside the bubble. The narcotic log count sheet reflected the appropriate count. <BR/>During an interview, observation, and record review of medication cart #2 on 02/15/25 at 2:20 PM revealed a pill bubble packaging card filled with Lorazepam 0.5 mg (a controlled substance used to relieve anxiety) with 1 seal (#6) not intact. A white, round tablet was noted inside the bubble. There were 11 pills remaining. The narcotic log count sheet reflected the appropriate count. During an interview, RMP D indicated that controlled medications were counted at the beginning and at the end of shift. RMP D said that controlled medications must be secured in a separately locked compartment within the medication cart. RMP D stated she did not see the broken seals during the count. RMP D stated she was unaware that the bubble seal was broken or when it happened. RMP D said that best practice would be to discard the pill with a second nurse. RMP D said the risk of an exposed pill was exposure, cross-contamination, the pill could be stolen, or replaced with a similar looking pill. RMP D stated the risk of a damaged bubble seal would be a potential for drug diversion. RMP D stated the RMP's, and nurses were responsible to check the medication bubble packs for broken seals during the count of narcotics at change of the shift.<BR/>During an interview on 02/15/25 at 3:06 PM, the DON said that nurses were responsible for following the medication rights (the right resident, right medication, right dose, right form, right time) and review expiration dates. The DON said if a nurse discovered the seal of a medication bubble pack was altered (opened, torn, ripped) then the nurse should notify the DON and discard the pill with a second nurse. The DON said that the second nurse witnessed the pill disposal of controlled medications as a secure and safe method to prevent diversion.<BR/>Review of the facility's policy Pharmacy Services, revised April 2007 reflected the following: . 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observations, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure refrigerator item in walk -in refrigerator was labeled, dated and sealed.<BR/>2. The facility failed to ensure black refrigerator unit with freezer on top and drink cooler freezer had thermometers. The facility failed to document temperatures. The facility failed to ensure cleanliness of drink cooler freezer.<BR/>3. The facility failed to ensure the Dietary Manager and Food Service Manager E washed their hands when touching PPE and changing gloves during lunch preparation on 02/08/23.<BR/>4. The facility failed to ensure hamburger patties' food temperature was taken after cooked and before served to residents for lunch on 02/08/23.<BR/>5. The facility failed to ensure the low temperature dish machine was meeting the temperature of 120 degrees Fahrenheit for wash and rinse cycle.<BR/>6. The facility failed to ensure trays and bowls were allowed to air dry before use at lunch on 02/08/23. Dietary Aide G failed to ensure plates air dried before stacking plates on top of one another on 02/08/23. <BR/>These failures could place residents at risk for food-borne illness and food contamination.<BR/>Findings included:<BR/>1. Observation on 02/07/23 at 9:52 AM revealed the walk-in refrigerator had fries in a plastic bag unsealed, open about 2 inches and not dated when opened.<BR/>Interview on 02/07/23 at 9:54 AM with Dietary Aide F revealed the fries should be dated and sealed properly.<BR/>Interview on 02/07/23 at 10:13 AM with the Dietary Manager revealed refrigerated food items should be dated when opened, labeled and sealed properly .<BR/>2. Observation on 02/07/23 at 9:56 AM revealed the drink freezer had numerous food stains and debris on the bottom along with a wrapper stuck to bottom of freezer. There was a box of individual vanilla ice cream containers. There was no thermometer in the drink freezer.<BR/>Interview on 02/07/23 at 9:57 AM with Dietary Aide F revealed she did not know the ice cream was in the drink cooler freezer and did not know where the thermometer was.<BR/>Interview at 02/07/23 at 9:58 AM with Food Service Manager I revealed he thought they did not use the drink freezer and was unaware that the ice cream containers were in the freezer. He stated he did not know where thermometer was for the drink freezer.<BR/>Observations on 02/07/23 at 9:50 AM revealed the black refrigerator unit with freezer on top which contained bread in refrigerator and freezer had no temperature log or thermometer in it. Dietary Aide F could not find a thermometer in the black refrigerator.<BR/>Observation and interview on 02/07/23 at 9:59 AM revealed the Dietary Manager was unable to find a thermometer in the black refrigerator unit with freezer on top. <BR/>Interviews on 02/07/23 at 10:04 AM and 10:13 AM with the Dietary Manager revealed the black refrigerator/freezer in the dining room started to be used about a month ago so they could keep bread in it. She stated she would put a thermometer in the black freezer and refrigerator so they could know the temperatures. She stated they did not have a log for the temperatures of the refrigerator/freezer. She stated she was not aware of the drink freezer being used and did not know anyone had stored the ice cream in there. She stated the drink freezer should have a thermometer and be kept clean when in use. She stated when there was no thermometer in refrigerator or freezer they were unable to know whether cold foods were being kept within appropriate temperatures.<BR/>Review of facility's policy Food Receiving and Storage revised October 2017 reflected Food shall be received and stored in a manner that complies with safe food handling practices .Food Services, or other designated staff, will maintain clean food storage areas at all times .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date) .12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.<BR/>Review of facility's policy Refrigerators and Freezers revised December 2014 reflected facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .1. Acceptable temperature ranges are 35 F to 40 F for refrigerators and less than 0 for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.3. Monthly tracking sheets will include time, temperature, initial, and 'action taken.' 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening .7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and individual items removed from cases for storage .10. Refrigeration and freezers will be kept clean, free of debris .<BR/>Review of facility's policy Food Preparation and Service revised October 2017 reflected Thermometers will be placed in hot and cold storage areas and checked for accuracy in accordance with accepted public health standards.<BR/>3. Observation on 02/08/23 at 11:40 AM revealed Food Service Manager E touched her surgical mask with her gloved hands and then started plating food for residents with her gloved hands touching inward of the residents plates. She did not change her gloves or wash her hands. At 11:47 AM she touched her face shield with her gloved hands. She did not change her gloves or wash her hands. She continued to plate food for the residents with her gloved hands touching the inward part of the residents plates.<BR/>Observation on 02/08/23 at 11:52 AM revealed the Dietary Manger touched her face goggles with her gloved hands to adjust them on her face. She did not change her gloves or wash her hands. She continued to place plate covers over the residents plates and condiments on meal trays.<BR/>Interview on 02/08/23 at 12:35 PM with Food Service Manager E revealed she did touch her surgical mask, did not change her gloves and failed to wash her hands like she should have. <BR/>Interview on 02/08/23 at 12:37 PM with Dietary Manager revealed she and Food Service Manager E should have changed their gloves and washed their hands after touching their PPE. The Dietary Manager stated when they contaminated their gloves, they needed to change their gloves and wash their hands prior to putting on new gloves. <BR/>Review of the facility's policy Food Preparation and Service revised October 2017 reflected Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness.<BR/>Review of The US Public Health Service Food Code, dated 2017, retrieved 02/16/23, reflected the following regarding hand hygiene, 2-301.14 When to Wash Food employees shall clean their hands and exposed portions of their arms as specified under &sect; 2-301.12 immediately before engaging in food preparation including working with exposed Food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; . (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat foods; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the Hands.<BR/>4. Observation on 02/08/23 at 12:15 PM revealed frozen hamburger patties were cooking in water over the stove top. At 12:24 PM the hamburger patties' temperature were not checked prior to being placed on meal trays for residents and placed on hall trays. At 12:32 PM there were additional frozen hamburger patties cooked in water on the stove top and hamburger patties temperature was not checked. At 12:37 PM the cooked hamburger patties went out on lunch meals trays to three residents for hall trays for 300 hall and on a lunch test tray. <BR/>Observation on 02/08/23 at 12:41 PM the facility staff were passing out resident meal trays on the 300 hall. At 12:48 PM last hall meal tray for the 300 hall was served to a resident. Observation at 12:50 PM of the lunch test tray included one cooked hamburger patty in a bun . The patty was temped at 136.3 degrees F and the hamburger patty was barely warm. <BR/>Interview on 02/08/23 at 1:05 PM with the Dietary Manager revealed the hamburger patties were usually temped prior to being served to ensure the temperature was appropriate and maintained until resident meal trays were passed out. She stated they should have checked the food temperature of the hamburgers prior to serving them to ensure the hamburger patties were at the appropriate temperature of at least 160 degrees Fahrenheit .<BR/>5. Observation and interview on 02/08/23 at 3:16 PM revealed the dish machine temperature was 100 degrees Fahrenheit for wash and rinse. A 2nd observation at 3:18 PM revealed 100 degrees wash and 102 degrees Fahrenheit rinse. Interview with Dietary Aide G revealed in the morning dish machine's wash and rinse temperature was checked. He stated he did not know what the minimum temperature was for the wash and rinse since he was new and did not check the dish machine temperature.<BR/>Observation and Interview on 02/08/23 at 3:23 PM revealed the Dietary Manager checked the dish machine temperatures and it was only 101 degrees Fahrenheit for wash cycle. She stated it is supposed to be 120 degrees Fahrenheit minimum for wash and rinse for the facility's low temperature dish machine. She stated she would talk with the Dir of Plant Operations to have him look at it. She stated she told Dietary Aide G to stop using the dish machine until they got it working. She stated earlier today the dish machine was 120 degrees Fahrenheit or above for wash and rinse when it was checked.<BR/>Interview on 02/08/23 at 3:40 PM with the Administrator revealed she was informed about the dish machine temperature being too low and they would have the dish machine representative come out to look at it if the Dir of Plant Operations was unable to get it working properly, he was looking at it now. She stated they would start using Styrofoam containers if they were not able to get the dish machine working until it is fixed. <BR/>Interview on 02/09/23 at 9:10 AM with the Dir of Plant Operations revealed the dish machine was still not meeting 120 degrees Fahrenheit minimum for wash and rinse. He stated he looked at the booster for dish machine but it did not help the temperatures. He stated he was waiting for the representative from the dish machine company to look at it today.<BR/>Review of dish machine's installation and operation manual dated 12/05/07 from http://manuals.jacksonmsc.com/ecolab%20manuals/ES-2000%20&%20ES-4000%20Rev%20O.pdf reflected under section 1 the dish machine required a minimum temperature of wash and rinse of 120 degrees Fahrenheit. <BR/>6. Observations on 02/08/23 at 11:54 AM revealed resident meal lunch trays had water droplets on them and were used for resident meal trays for lunch. Bowls were stored in different directions in a plastic container with water droplets inside the bowls. Food Service Manager E used bowls from the container for food for the residents' lunch.<BR/>Interview on 02/08/23 at 12:36 PM with the Dietary Manager revealed they did not have the space in the kitchen to allow for dishware like trays, plates and bowls to air dry prior to use. She stated they had very limited counter space. <BR/>Observation on 02/08/23 at 3:15 PM revealed Dietary Aide G took plates from dish rack which just came out of the dish machine. Dietary Aide G started stacking them on top of other plates. He did not allow them to air dry.<BR/>Interview on 02/09/23 at 1:52 PM with Consultant Dietitian revealed dietary staff should change gloves and wash their hands when they touch anything that could contaminate them before putting on new gloves. She stated the refrigerator and freezers should have a thermometer in them to ensure temperatures were maintained. She stated the dish machine should have been working to meet the appropriate temperature requirements. She stated the hamburger patties' food temperature should have been checked prior to be served to ensure hamburger patties' food temperature met serving temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 6 residents (Resident #35, Resident #23, Resident #5, Resident #51, Resident #15, and Resident #45) of 8 observed for infection control. <BR/>The facility failed to ensure:<BR/>1. MA F sanitized the blood pressure cuff between uses on Resident #35 and Resident # 23 and performed hand hygiene after performing blood pressure checks. <BR/>2. RN D prevented cross contamination of Resident #5's insulin and the medication cart when she dropped the insulin pen cap onto the floor, removed her gloves after administering Resident #5's insulin and leaving Resident #5's room and opening the medication cart, retuning Resident #5's box containing the resident's glucometer and insulin pen. <BR/>3. RN G prevented cross contamination of Resident #51's wound care supplies when she failed to set up a clean field in the residents' room and failed to perform hand hygiene during wound care. <BR/>4. LVN J prevented cross contamination of Resident #15's wound care supplies when she failed to set up a clean field in the residents' room and performed hand hygiene during wound care. CNA M performed hand hygiene during incontinence care for Resident #15.<BR/>5. RN D performed hand hygiene during incontinence care for Resident #45.<BR/>Theses failure could place residents at risk for infection and cross contamination. <BR/>Findings include:<BR/>1. Record review of Resident #35's Face sheet, dated 03/14/24, reflected a [AGE] year-old male with an admission date of 11/29/23. Resident #35 had diagnoses which included diverticulitis (inflammation of the digestive tract), gastro-esophageal reflux (condition where stomach content moves up into the esophagus, and hypertension (high blood pressure).<BR/>Record review of Resident #23's Face sheet, dated 03/14/24, reflected a [AGE] year-old male with an admission date of 07/19/23. Resident #23 had diagnoses which included diabetes and hypertension (high blood pressure).<BR/>During a medication pass observation on 03/10/24 at 09:50 AM revealed MA F at the medication cart in the front lobby. MA F performed hand hygiene and retrieved a wrist blood pressure cuff and placed the cuff on Resident #35's wrist to obtain his blood pressure. MA F placed the wrist cuff on top of the medication cart without cleaning the cuff and without performing hand hygiene and proceeded to pull the resident's morning medication. After completing Resident #35's medication pass she pushed the medication cart to the dining room for her next medication pass.<BR/>Observation on 03/10/24 at 10:00 AM revealed MA F in the dining room with the medication cart. MA F performed hand hygiene and picked up the uncleaned wrist blood pressure cuff and obtained Resident # 23's blood pressure. MA F placed the wrist cuff on top of the medication cart without cleaning the cuff and without performing hand hygiene and proceeded to pull the resident's morning medication. After completing Resident #23's medication pass she pushed the medication cart to the dining room for her next medication pass.<BR/>In an interview with MA F on 03/10/24 at 10:30 AM, she stated she was supposed to sanitize the blood pressure cuff after each resident, and she failed to do that. She stated she was also required to perform hand hygiene after contact with a resident. She stated failure to sanitize the blood pressure cuff and perform hand hygiene placed residents at risk for the spread of germs. <BR/>In an Interview with the DON on 03/11/24 at 01:10 PM, she stated blood pressure cuffs had to be cleaned between resident-to-resident use and staff were to perform hand hygiene after taking a resident's blood pressure to prevent the spread of germs. She stated they did not have a policy on cleaning of resident equipment. She stated they follow CDC guidelines for the required cleaning procedure. <BR/>Record review of the CDC guideline obtained on 03/18/24 from https://www.cdc.gov/infectioncontrol/guidelines/disinfection, reflected, Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient .).<BR/>2. Record review of Resident #5's, Face sheet, dated 03/14/24 reflected a [AGE] year-old female with an admission date of 01/05/10. Resident #5 had diagnoses which included Type 2 diabetes and dementia. <BR/>An observation and interview on 03/10/24 at 11:25 AM revealed RN D at the medication cart preparing to perform Resident #5's finger stick blood sugar. RN D removed the glucometer from the Resident's box which contained a glucometer, lancets, bottle of test strips and an insulin pen. RN D stated they keep the resident's box containing her supplies on the medication cart instead of her room since she was on the secured unit. RN D performed hand hygiene and donned gloves and obtained Resident #5's blood sugar. RN D then placed the glucometer back in the box and removed her gloves and sanitized her hands. RN D checked the computer to determine the amount of insulin required, put on gloves, and assisted the resident into her room to administer the insulin. RN D removed the cap off the insulin pen and dropped it onto the floor. RN D dialed in the amount of insulin required without priming the pen and administered the insulin. RN D then picked up the cap from the floor and placed it back onto the insulin pen and left the room wearing her gloves. RN D placed the insulin pen back into the box containing the resident's glucometer and test strips and then placed the uncleaned box back into the medication cart, still wearing the gloves worn to administer the resident's insulin. <BR/>In an Interview with RN D on 03/10/24 at 11:35 AM she stated she should have removed her gloves and sanitized her hands before opining the cart to place the pen back in the box of supplies. She stated by not cleaning the cap of the insulin pen she had cross contaminated the pen as well as the supplies in the resident's box. She stated by doing this it created a risk of infections and the spread of germs to other residents. <BR/>3. Record review of Resident #51's, Face sheet dated 03/14/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #51 had a diagnosis which included hemiplegia affecting right dominant side (paralysis) and muscle weakness. <BR/>In an observation and interview of wound care on Resident #51 by RN G on 03/10/24 at 03:00 PM, revealed her at the treatment cart. RN G placed gauze, a pair of scissors, and a Xeroform dressing (mesh gauze occlusive dressing used for low drainage wounds) and a dry dressing in a plastic sack. RN G entered the resident's room and placed the sack of supplies onto the bed and then washed her hands and put on gloves. RN G pulled back the covers and revealed the dressing on Resident #51's left lower leg which had a date of 03/08/24. RN G stated she had changed the dressing on Friday 03/08/24 and it appeared no one had changed it on 03/09/24. RN G removed the old dressing slowly since it had dried and was stuck to the wound bed of the venous ulcer located on the front of the residents left lower leg. RN G reached into the plastic sack and retrieved a vial of normal saline and wet the old dressing to help facilitate removal. Once the dressing was removed the wound bed had some slough present with minimal drainage. RN G stated the wound looked a little better. RN G then removed her gloves and put on clean gloves without performing hand hygiene and again reached into the plastic bag of supplies and pulled out more vials of normal saline and gauze and cleaned the wound bed. RN G stated she needed more gauze. She removed her gloves, washed her hands, and left the room and retrieved more gauze. RN G returned to the room with gauze, put on gloves and then reached into the sack and pulled out the package containing a border dressing and opened the package and placed the opened package on the uncleaned bedside table. She then patted the wound bed dry with the gauze, removed her gloves and put on new gloves without performing hand hygiene and reached back into the sack of supplies and retrieved the Xeroform dressing and a pair of scissors. She opened the package of Xeroform and cut it to size for the wound bed and covered the wound with the Xeroform dressing and covered it with the border dressing, RN G then dated the dressing with a date of 03/10/24. RN G then removed her gloves and washed her hands. <BR/>In an interview with RN G 03/10/24 at 03:10 PM she stated she was supposed to sanitize her hands after each glove change and stated she had failed to do that. She stated she used the plastic sack as her clean field for the supplies, but then realized how this was not acceptable since the first time she reached back into the sack she had cross contaminated the other supplies. She stated failing to perform hand hygiene and set up a clean filed for her supplies created a risk of infection for the resident. <BR/>4. Record review of Resident #15's, Face sheet dated 03/14/24, reflected a [AGE] year-old-female with an admission date of 09/26/23. Resident #15 had diagnoses which included multiple sclerosis (disease in which the immune system eats away at protective coverings of nerves) and pressure ulcers. <BR/>In an observation and interview with LVN J on 03/11/24 at 09:10 AM revealed her at the treatment cart preparing supplies for wound care for Resident #15. LVN J stated the orders were: <BR/>1. Sacrum wound- Wound cleanser (contains normal saline and antimicrobial agents), apply collagen (protein used to make connective tissue) and calcium alginate (made from seaweed, absorbent dressing) and cover with dry dressing.<BR/>2. Left Lateral Malleolus (outside ankle)- wound cleanser, Santyl (enzyme used to break up and remove dead skin and tissue) and Calcium alginate and cover with dry dressing.<BR/>3. Left medial Malleolus (inside ankle) Wound cleanser, Santyl and calcium alginate and cover with dry dressing. <BR/>4. Right medal Malleolus (inside ankle) Wound cleanser, Santyl, calcium alginate and cover with dry dressing and cover with dry dressing.<BR/>5. Left heel- skin prep.<BR/>6. Left Ischial wound- Clean with Dakin's solution(a strong topical antiseptic used to clean infected wounds), apply Santyl and calcium alginate and cover with dry dressing. <BR/>7. Right gluteal fold- clean with Normal Saline, Apply Santyl, pack with kerlix moistened with Dakin's solution and cover <BR/>Observed CNA M and LVN J entered Resident #15's room to provide the residents wound care on 03/11/24 at 09:15 AM. Both staff washed their hands. LVN J cleaned the bedside table with a germicidal wipe and then placed the wound care supplies, plus a bottle of Dakin's solution and her computer on the table without placing the supplies on a barrier. CNA M put on gloves and uncovered the resident and found the resident with no brief lying on a cloth moisture resistant pad. CNA M rolled the resident on her right side revealing she had a bowel movement, which had contaminated the sacral wound dressing. CNA M provided incontinence care and changed her gloves but did not perform hand hygiene after she changed her gloves. LVN J noted the resident had 4 dressing on her right foot and stated she only had orders for her right Lateral ankle. She stated she was not sure what was going on with the resident's right foot. LVN J removed the dressing on the left outer ankle revealing a wound about the size of a golf ball with slough (yellowish white material in the wound bed consisting of dead cells) present, she stated this wound looked a little smaller since she saw it last week. LVN J cleaned the wound with normal saline, since she stated she was out of wound cleanser. LVN J removed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the wound bed and covered with a dressing. LVN J changed her gloves without performing hand hygiene and removed the dressing from the resident's left interior ankle revealing a wound about the diameter of a double D battery. The wound had slough present. LVN J cleaned the wound with normal saline, changed gloves, with no hand hygiene, and applied Santyl and Calcium alginate and covered with a dressing. LVN J then applied skin prep to the resident's left heel, which had a scab approximately the diameter of a triple A battery. LVN J changed her gloves- no hand hygiene and proceeded to remove all dressing on the outside the right ankle and revealed a wound approximately the diameter of a golf ball on the outer ankle with slough present and serous (yellow) drainage. Observed on the outer middle part of her foot a wound approximately the size of blue jean button. LVN J stated it appeared it had calcium alginate, but stated there was no order for a treatment of this wound. LVN J cleaned both wounds with normal saline, changed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the ankle and calcium alginate to the wound on her right mid foot and covered both with a dressing. LVN J changed her gloves without performing hand hygiene and proceeded to the wound on the resident's right gluteal fold. LVN J removed the dressing and revealed a wound with heavy greenish gray drainage and strong odor. Wound was approximately the diameter of a soup can and appeared to be to the bone. LVN J cleaned with normal saline, changed her gloves without performing hand hygiene and re-gloved and applied Santyl and packed with kerlix moistened with Dakin's solution and covered with a dry dressing. LVN J removed her gloves without performing hand hygiene and re-gloved and proceeded to the wound on the resident's sacrum. CNA M completed incontinence care, removing the remainder of the fecal matter after LVN J removed the soiled dressing. The sacral wound was crescent shaped and approximately the width of a tennis ball with slough present. LVN J cleaned with normal saline and applied collagen and calcium alginate and covered with a dressing. LVN J changed her gloves without performing hand hygiene and proceeded to the wound on the residents left Ischial - Wound is approximately the diameter of a drink coaster with the top part of wound having some granulation (red and moist) present. The bottom of the wound had slough and necrotic tissue present with heavy drainage and an odor. LVN J cleaned with Daikin's solution, applied Santyl to the necrotic portion of the wound and calcium alginate to the remainder of the wound bed and covered with a dressing. LVN J changed her gloves and re-gloved without performing hand hygiene and provided catheter care and both she and CNA M placed a clean brief on the resident and dressed her for the day. Resident #15 was transferred with a mechanical lift to her wheelchair. Resident #15 again stated she had asked for a Roho (air filled pressure relief cushion) cushion. Both staff removed their gloves and performed hand hygiene. <BR/>In an observation and interview with LVN J on 03/11/24 at 10:15 AM revealed she returned to the treatment cart with a full package of gauze and the bottle of Dakins solution. She stated she was throwing the gauze away since it had been in the room and was now considered contaminated. She stated she should have not carried the full bottle of Dakins. She stated she was supposed to perform hand hygiene between glove changes and stated she had failed to do that. She stated she should have placed a barrier down for her wound care supplies, but stated she was concentrating on the orders for the numerous wounds the resident had and forgot. She stated failing to perform hand hygiene after glove changes could spread infection from one site to another. <BR/>In an interview with CNA M on 03/11/24 at 10:25 AM, she stated she was supposed to perform hand hygiene between gloves changes during care. She stated she had failed to do that which could increase the risk of infection to the resident. <BR/>In an interview with the DON on 03/13/24 at 08:50 AM, she stated wound care supplies were supposed to be on a clean field and only carry in the supplies needed. She stated staff were to change their gloves and perform hand hygiene when going from dirty to clean. She stated failing to keep supplies form contamination and failing to perform hand hygiene after glove changes placed residents at risk of infection and cross contamination. <BR/>5. Record review of Resident #45's Comprehensive MDS assessment, dated 01/02/24, reflected a [AGE] year-old male with an admission date of 08/29/22 with diagnoses included injury of cervical spinal cord (permanent complete or partial loss of sensory function), muscle weakness, lack of coordination, and need for assistance with personal care. Resident #45 had a BIMS of 15 which indicated Resident #45's cognition was intact. Resident#45 required moderate assistance of one-person physical assistance with toileting hygiene, and personal hygiene. Resident #45 had limited range of motion to right lower and upper extremities. The resident was frequently incontinent of urine bowel. <BR/>Review of Resident #45's care plan, initiated on 02/03/22, reflected .[Resident #45] has mixed bladder incontinence and is at risk for skin breakdown .Interventions .clean peri-area with each incontinence episode .<BR/>In an observation and interview with Resident #45 on 03/10/24 at 10:02 AM revealed the resident in bed, he stated he needed to be changed. <BR/>In an observation and interview on 03/10/24 at 10:15 AM revealed RN D entered Resident #45's room to provide incontinences care and change the resident's clothes. RN D washed her hands and put on gloves and unfasted the brief. She took a peri-wipe and wiped down each side of the resident's groin and across his pubic area but failed to clean his penis or scrotum. RN D rolled the resident over on his side revealing he was wet. Resident #45's skin was intact. RN D removed the wet brief and with the same soiled gloves she placed a clean brief under the resident. RN D removed her gloves and put on clean gloves without performing hand hygiene. RN D cleaned the resident's buttocks with a peri-wipe from front to back. RN D removed her gloves and put on clean gloves without performing hand hygiene. RN D rolled the resident back onto his back and fastened the brief and changed his clothes. RN D removed her gloves, and she washed her hands. <BR/>In an interview on 03/10/24 at 10:25 AM, RN D stated she was supposed to clean the penis area from tip to base and then clean the peri-area and scrotum area. RN D stated she failed to do that. RN D stated she should change her gloves and perform hand hygiene when she went from dirty to clean. RN D stated failing to provide proper care exposed the resident to infections and risk of skin breakdown. <BR/>In an interview on 03/10/24 at 09:19 AM, the DON stated when providing incontinent care staff were to clean the peri area including penis and scrotum for male residents then moving toward the buttocks. She stated by not providing accurate incontinent care placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated staff were to change their gloves and perform hand hygiene when going from dirty to clean. She stated failing to perform hand hygiene after glove changes placed residents at risk of infection and [NAME] contamination. <BR/>Review of the facility policy revised Dated 8/4/2021, titled Hand Hygiene reflected, . You should always perform hand hygiene: . Before applying and after removing personal protective equipment ( . gloves, gown, mask .) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an effective pest control program was implemented so the facility is free of pests and rodents for one of twenty-four residents (Resident #2), the facility's only kitchen, the facility's only nurses' station, and one hall (100 hall) of five halls reviewed for pest control. <BR/>1. The facility failed to effectively treat Resident #2's room for gnats.<BR/>2. The facility failed to keep an effective pest control program so that the facility was free of gnats in the Kitchen.<BR/>3. The facility failed to ensure one hallway (100 hall) of 5 hallways where residents' rooms were located, were free of gnats.<BR/>4. The facility failed to ensure the nurses station was free from gnats. <BR/>These failures placed residents at risk for cross contamination, food borne illnesses, the spread of infection and disease, and a reduced quality of life.<BR/>Findings included:<BR/>1. In an observation and interview on 05/05/25 at 6:52 PM revealed Resident #2 was lying in bed with a food tray on the bedside tables, food crumbs on the bed linen and the floor, with 5 gnats flying around her and landed on the bed linen and bedside table; she stated she had noticed the gnats for a while now, was not sure what was causing them and they bothered her but she learned to live with it. She stated that the facility did treat the room for the pests, was not sure when the last time it was treated, and housekeeping cleaned her room each day. <BR/>In an observation of and interview on 05/06/25 at 3:21 PM with Housekeeper EE revealed she had cleaned Resident #2's room and floor; she stated and the residents linens were clean. At this time there was one gnat flying in the room. Housekeeper EE stated Resident #2's room did occasionally have gnats and thought it was due to Resident #2 eating in bed- the gnats were attracted to food. She stated when she saw the gnats she would write it on the pest control log and then inform the Director of Plant Operations (DPO) verbally and the room would be treated for pests. <BR/>In an interview on 05/09/25 at 11:57 AM with the Director of Environmental Services (DES) revealed Resident #2 ate her meals in bed and frequently spilled food that attracted small black bugs to her room. She stated that they clean Resident #2's room [ROOM NUMBER] days a week and an additional evening cleaning on Tuesday and Thursday and Fridays. She stated Resident #2's room was treated on 05/08/25 with fly bait spray. She stated meal trays that were not picked up on time or food spills would attract the gnats and when housekeeping observed those things, they notified nursing. She stated there are cleaning products available to the staff when housekeepers were not onsite. She stated it was important for a resident's room to be free from gnats because it was an environmental hazard and was unclean for a resident. <BR/>2. Observations in the kitchen on 5/6/25 during lunch meal service revealed the following: <BR/>*12:15pm a gnat flying around the bread rolls.<BR/>*12:18pm a gnat landed on a bread roll. <BR/>*12:25pm a gnat flying around the bread rolls.<BR/>Interview with the Director of Food Services on 5/6/25 at 12:56pm revealed she was aware of the issues with gnats flying around the kitchen and believed they had been coming from the drains. She stated they had been dumping bleach in the drains to help stop the gnats. She stated the facility had been fumigating monthly. The risk to the residents of the gnats flying around the food was they could land in the food and contaminate it. <BR/>3. Observation of the 100- hall on 05/7/2025 at 1:30pm revealed two gnats by the entryway of the conference room located in that hall. <BR/>Interview with CNA J on 5/8/25 at 8:42am revealed she had noticed gnats in the 100- hall, by the coffee makers in the dining room and trashes this week. <BR/>4. Observation of nurses' station in the middle of the building on 5/8/25 at 9:00am revealed 3 gnats flying around the desks the nurses' desks. <BR/>Review of the facility pest control service revealed Pest Management Service Agreement dated 7/2/19 .1. Services to be performed .a. perform monthly pest control service, including coordinating with Client's staff to implement an Integrated Pest Management plan, monitor and track pest issues inside and outside of the facility, addressing site issues both reported and observed .Pest control each month consists of: inspecting and treating interior pest issues including kitchen, laundry, exits, closets .e. when requested, treat a specific areas that are experiencing a particular problem .<BR/>Review of facility's Pest Logs revealed reported incidents of gnats by staff on the following dates: <BR/>*2/5/25 (room [ROOM NUMBER]),<BR/>* 2/20/25 (nurses' station), <BR/>*4/14/25 (nurses station), <BR/>*4/27/25 (room [ROOM NUMBER]), <BR/>*5/1/25 (building),<BR/>* 5/8/25 (laundry, room [ROOM NUMBER] and room [ROOM NUMBER]), <BR/>*5/8/25 (nurses station) and,<BR/>* 5/9/25 (room [ROOM NUMBER])<BR/>Review of facility invoice from Perfect Pest Control dated 4/16/25 .General Comments: Upon arrival I located logbook finding no new entries at this time. I made my way to maintenance director's office to where I was told he would out at lunch. I visited with kitchen staff stating they have seen an occasional gnat. I applied a liquid residual to cracks and crevices throughout the kitchen added a foaming agent to drains and a poly a liquid residual to the bottom sides of the dish pit tables .Material: Alpine WSG .target pests: American Roaches, Gnats/Fruit/Crane .<BR/>Review of facility invoice from Perfect Pest Control dated 3/11/25 revealed gnats were not addressed during the fumigation visit. <BR/>Review of facility invoice from Perfect Pest Control dated 2/12/25 .General Comments: Met with MD (Maintenance Director) upon arrival, he stated he knew of nothing but has told staff to utilize the log book. I located the logbook finding 104, 304, 310 and 291 with gnats. I inspected each room and restroom finding no signs of gnats and applied an aerosol bait to walls in restroom .I also met with laundry attendant stating gnats are better but still see an occasional gnat. I applied an aerosol bait to walls Material: PT alpine pressurized fly bait .target pests: Gnats/Fruit/Crane<BR/>Interview with Director of Plant Operations on 5/7/25 at 1:12pm revealed he was aware gnats being reported in the kitchen and other areas in the building and had pest control coming every time it was reported. He stated he scheduled pest control to come on 5/9/25 to spray again for gnats. <BR/>Interview with CNA P on 5/8/25 8:57am revealed she had seen a couple of gnats in several of the hallways this week. <BR/>Interview with Director of Nursing on 5/8/25 at 12:09pm revealed the facility had pest control come out routinely and pest control looked at the book showing when they had issues with gnats. She had not seen gnats until they were flying around a fast food item meal that was brought earlier in the break room. The risk of having gnats in the facility with residents present was issues with infection control and cross contamination. <BR/>Interview with Executive Director on 5/8/24 at 12:45pm revealed staff writes sightings of pest in the pest log and pest control was asked to come out immediately. Additionally, pest control would come monthly to fumigate and would check the pest logs as well to ensure they were treating for any issues. The Director of Plant Operations would also call the pest control company as needed. The risk of having pest in the facility, particularly in the kitchen would be contamination of food. <BR/>Interview with RN G on 5/8/25 at 2:30pm revealed she saw gnats on and off in patient rooms, particularly where patients were hoarding food in their room. She worked at the facility for 7 years and had seen gnats on and off. She had never seen them in the dining area. <BR/>The facility's pest control policy was requested but not provided before the date and time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three of four (Residents #15, #174 and #71) residents reviewed for pressure ulcer care.<BR/>1. The Facility failed to notify Resident #15's Physician the Wound Care Consultant was no longer providing oversight for the resident's wounds from [DATE] through [DATE] which resulted in deterioration of her Left Ischium (hip) stage 4 pressure ulcer (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone), sacrum stage 3 pressure ulcer (full thickness skin loss in which fat was visible and granulation tissues and rolled wound edges are often present), right gluteal fold (crease below the buttocks) stage 4 pressure ulcer, right lateral malleolus(outside ankle) stage 3 pressure ulcer, left medial malleolus (inside ankle) stage 3 pressure ulcer, left lateral malleolus (outside ankle) stage 3 pressure ulcer and new stage 3 pressure to her right foot.<BR/>2. The Facility failed to complete a skin and wound assessment upon Resident #15's re-admission to the facility on [DATE] until [DATE].<BR/>3. The facility failed to obtain Physician orders for Resident #15's wound care after her re-admission on [DATE], instead re-started previous wound care on [DATE] without Physician authorization.<BR/>4. The Treatment Nurse failed to consult with Resident #15's Physician or the Wound care consultant prior to changing the resident wound care orders. <BR/>5. The facility staff failed to complete a Skin assessment, Wound Care assessment or notify the physician when a wound of unknown description was identified on [DATE] on Resident #174's coccyx, which resulted in the deterioration of the wound to an unstageable pressure ulcer (obscured full -thickness skin and tissue loss) with bone exposed and a stage 1 pressure injury(non-blanchable erythema of intact skin) to her right heel upon admission to hospice on [DATE]. Resident expired in the facility on [DATE]. <BR/>6. The facility failed to obtain physician orders for treatment of Resident #174's right heel when it progressed to a stage 2 pressure ulcer (partial-thickness loss with exposed dermis) that was indicated to have drainage on [DATE]. <BR/>7. The facility failed to complete a skin assessment, wound care assessment, or notify the physician, family, and Hospice on [DATE] when a Stage 2 pressure ulcer on Resident #71's coccyx and three small blisters on her right thigh were observed on [DATE]. <BR/>An Immediate Jeopardy (IJ) was identified on [DATE] at 12:40 PM. The IJ template was provided to the facility on [DATE] at 12:45 PM and signed by the Administrator. While the IJ was removed on [DATE] at 5:17 PM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. <BR/>These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection.<BR/>Findings included:<BR/>Record Review of Resident #15's Face Sheet dated [DATE], reflected a re-admission date of [DATE] to the facility. <BR/>Record review of Resident #15's quarterly MDS, dated [DATE], reflected a [AGE] year-old female with an admission date of [DATE]. The resident had a BIMS of 13 which indicated she was cognitively intact and had not resisted care. She required extensive to dependent care with ADL. She had a foley catheter and was always incontinent of bowel. She had pressure ulcers and was at risk for pressure ulcers. Active diagnoses included diabetes, multiple sclerosis (disease in which the immune system eats away at protective coverings of nerves), paraplegia (paralysis that affects the legs) and seizure disorder. <BR/>Record review of Resident #15's care plan dated [DATE] reflected, [Resident #15] has stage 3 pressure injury to sacrum, right lateral Malleolus, left medial malleolus, stage 4 pressure injury to her left ischial and right gluteal fold and is at risk since resident chooses to stay up in wheelchair up to 8-9 hours at times .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods .<BR/>Record review of Resident #15's care plan dated [DATE] reflected, [Resident #15] has stage 3 pressure injury to sacrum, right lateral Malleolus (ankle), left medial malleolus (ankle), stage 4 pressure injury to her left ischial (hip) and right gluteal fold and is at risk since resident chooses to stay up in wheelchair up to 8-9 hours at times .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods .<BR/>Record Review of Resident #15's Hospital summary from [DATE] to [DATE] revealed resident was admitted and treated for a gastrointestinal bleed. Progress notes revealed no wound care assessment was completed during the hospital stay. <BR/>Record Review of Resident #15's Hospital Discharge orders dated [DATE], did not reflect any orders for wound care. <BR/>Record Review of Resident #15's Physician order recap report with date range from [DATE] through [DATE], reflected, <BR/>1. Left Heel- apply skin prep twice daily to scabbed area, with a start date of [DATE] ( 7 days post admission)<BR/>2. Left Ischium (hip)- Cleanse wound with Dakin's (diluted bleach)solution. Apply Hydrofera Blue(antimicrobial dressing) foam to wound bed and cover with a dry dressing every day and as needed- with a start date of [DATE]. (3 days post admission) . Order was changed on [DATE] to Cleanse wound with Dakin's solution . Apply Santyl (removes dead tissue) to wound bed and calcium alginate (used for exuding wounds). Cover with a dry dressing daily, with a start date of [DATE]. <BR/>3. Left Lateral Malleolus (outside ankle)- Apply skin prep to scabbed area twice daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of [DATE]. <BR/>4. Left Medial Malleolus (inside ankle)- Apply skin prep to scabbed area twice daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of [DATE].<BR/>5. Right Gluteal Fold (skin crease below the buttocks) - Cleanse with Normal Saline. Apply a thin layer of Santyl to wound bed. Lightly pace wound Kerlix roll moistened with Dakin's solution and cover with a super Absorbent dressing daily and as needed with a start date of [DATE]. <BR/>6. Right Lateral Malleolus(outside ankle)- Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of [DATE]- Order was changed on [DATE] to Cleanse wound with wound cleanser and pat dry. Apply Collagen and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of [DATE]. <BR/>7. Right Lateral (outside )side of foot- Cleanse with wound cleanser, apply a small amount of Santyl to wound bed, then apply Calcium Alginate, cover with dry dressing daily with a start date of [DATE]. <BR/>8. Right Medial Malleolus (inside ankle) Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of [DATE]- Order was changed on [DATE] to Cleanse wound with wound cleanser and pat dry. Apply Santyl and Calcium alginate to wound bed and cover with a dry dressing daily and as needed with a start date of [DATE]. <BR/>9. Sacral wound- Cleanse with wound cleanser. Apply Hydrofera Blue Foam to wound cand cover with a dry dressing daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound cleanser. Apply Collagen(protein used to make connective tissue), and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of [DATE]. <BR/>Record Review of Resident #15's TAR for [DATE] reflected no wound care was documented for [DATE], [DATE], [DATE], [DATE]. <BR/>Record review of Resident #15's Braden scales for predicting pressure sore risk, dated [DATE] reflected a score of 15 which indicated risk for pressure ulcers. <BR/>Record Review of the facility's Pressure Skin/Wound Log, dated [DATE], (most current) reflected one resident with pressure ulcers. Resident #15 was listed with the following wound descriptions and treatments:<BR/>admitted with- Stage 4 left Ischium- 11.0 x6.0 x 1.5 cm- treatment-hydofera blue and foam dressing.<BR/>admitted with- Stage 3 sacrum- 2.0 x2.5 x1.3 cm treatment-hydofera blue and foam dressing.<BR/>Facility acquired- Stage 4 right gluteal fold- 6.5 x7.0x 4.5 cm. treatment- Santyl, kerlix/dakin, foam dressing.<BR/>Facility acquired- Stage 2 right Lateral Malleolus 2.0x 2.5 x 0.1 cm- treatment-Collagen foam dressing. <BR/>Facility acquired- Deep tissue injury left heel- 2.0 x 1.0 x 0 cm- Treatment- skin prep.<BR/>Facility acquired-Stage 3 left medial Malleolus 2.0 x 0 x 0 cm- treatment- Skin prep.<BR/>Facility acquired- Stage 2 Left Lateral Malleolus- 1.5 x1.5 x 0 cm- Treatment- skin prep. <BR/>Record Review of Wound Care Consultant Report dated [DATE] for Resident #15 reflected:<BR/>1. <BR/>Left Ischium- 5x8x0.6 cm - stage 4 pressure- improving.- post debridement- 5x8x0.7 cm- Bone palpated.<BR/>2. <BR/>Sacrum- 2x2.5x1 cm-stage 3 pressure-stable- post debridement- 2x2.5x1.1 cm<BR/>3. <BR/>Right gluteal fold-5x8x5.3 cm-pressure- heavy exudate, slough, strong odor-post debridement- 5x8x5.4 cm. Bone palpated.<BR/>4. <BR/>Right Lateral Malleolus- 2.4x2x0.2 cm- Stage 2 pressure<BR/>5. <BR/>Left heel- 1.5x1.5x0.1 cm- deep tissue pressure injury- improving.<BR/>6. <BR/>Left Medial Malleolus- 1.5x2x0.1 cm-Stage 3 pressure- improving.<BR/>7. <BR/>Left Lateral Malleolus- 2x1.5x0.1 cm - improving. <BR/>Record review of the electronic record for Resident #15 reflected no additional Wound Care Consultant reports. A visit was attempted by the Wound Care Consultant on [DATE]- Resident was involved in activities and declined assessment. <BR/>Record review of Resident #15's admission assessment dated [DATE], completed by LVN J reflected, Skin integrity- was left blank- Under comment section- stated - See wound assessments. <BR/>Record review of Resident #15's electronic record reflected no Wound Care assessment was completed until [DATE], which deferred to the Wound Care Consultants assessment completed on [DATE].<BR/>In an interview with the LVN Treatment Nurse on [DATE] at 02:00 PM, she stated she was the one doing the wound care assessments and measuring the wounds on Resident #15. She stated there had not been anyone from the Wound Care consultant company coming to the building for over a month. She stated even before that they were not coming consistently on a weekly basis. She stated the Wound care Nurse Practitioner had told her since Resident #15 was the only one in the building she thought they would just do Telehealth. She stated she told the NP due to the extensive nature of Resident #15's wounds she did not think that was going to be adequate, so the Nurse Practitioner stated she would get someone else to come. She stated another Nurse Practitioner from the wound care company came out, but she only came one time and they never sent anyone else. She stated at some point, Resident #15's wounds had started having more slough, so she added Santyl back to the wound care order. She stated the Nurse Practitioner had taken it off at one time. She stated she had not called the Primary care physician or his NP about any of the resident wounds. She stated Resident #15 was sent to the hospital a few weeks ago unrelated to her wounds, and stated she was told the hospital had not done wound care on her for the 3 days she was in the hospital. She stated she thought the wound on her coccyx had been improving. She stated once Resident #15 gets up she will refuse to lay back down until bedtime which makes healing very difficult. <BR/>In an interview and observation with Resident #15 on [DATE] at 08:55 AM she stated she knew this Surveyor was going to watch her wound care this morning ([DATE]) and she was OK with that. She stated once she got up mid-morning she does not go back to be until around 8 or 9 PM. She stated she knew it was not good for the healing of her pressure injuries, but stated there was not enough staff to lay her down and get her back up throughout the day and she did not want to miss her smoke breaks. She stated part of the problem was the cushion in her wheelchair. She stated she had been asking the facility to get her a Roho cushion ( air filled cushion) but the facility had not provided one. Observation of the cushion in her wheelchair revealed a memory foam cushion that was concaved in the middle of the cushion. <BR/>In an observation and interview with LVN J on [DATE] at 09:10 AM revealed her at the treatment cart preparing supplies for wound care for Resident #15. Observed CNA M and LVN J entered Resident #15's room to provide the residents wound care on [DATE] at 09:15 AM. Both staff washed their hands. LVN J cleaned the bedside table with a germicidal wipe and then placed the wound care supplies, plus a bottle of Dakin's solution and her computer on the table without placing the supplies on a barrier. CNA M put on gloves and uncovered the resident and found the resident with no brief lying on a cloth moisture resistant pad. CNA M rolled the resident on her right side revealing she had a bowel movement, which had contaminated the sacral wound dressing. CNA M provided incontinence care and changed her gloves but did not perform hand hygiene after she changed her gloves. LVN J noted the resident had 4 dressing on her right foot and stated she only had orders for her right Lateral ankle. She stated she was not sure what was going on with the resident's right foot. LVN J removed the dressing on the left outer ankle revealing a wound about the size of a golf ball with slough (yellowish white material in the wound bed consisting of dead cells) present, she stated this wound looked a little smaller since she saw it last week. LVN J cleaned the wound with normal saline, since she stated she was out of wound cleanser. LVN J removed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the wound bed and covered with a dressing. LVN J changed gloves without performing hand hygiene and removed the dressing from the resident's left interior ankle revealing a wound about the diameter of a double D battery. The wound had slough present. LVN J cleaned the wound with normal saline, changed gloves, with no hand hygiene, and applied Santyl and Calcium alginate and covered with a dressing. LVN J then applied skin prep to the resident's left heel, which had a scab approximately the diameter of a triple A battery. LVN J changed gloves, no hand hygiene and proceeded to remove all dressing on the outside the right ankle and revealed a wound approximately the diameter of a golf ball on the outer ankle with slough present and serous (yellow) drainage. Observed on the outer middle part of her foot a wound approximately the size of blue jean button. LVN J stated it appeared it had calcium alginate, but stated there was no order for a treatment of this wound. LVN J cleaned both wounds with normal saline, changed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the ankle and calcium alginate to the wound on her right mid foot and covered both with a dressing. LVN J changed gloves without performing hand hygiene and proceeded to the wound on the resident's right gluteal fold. LVN J removed the dressing and revealed a wound with heavy greenish gray drainage and strong odor. Wound was approximately the diameter of a soup can and appeared to be to the bone. LVN J cleaned with normal saline, changed gloves with no hand hygiene and re-gloved and applied Santyl and packed with kerlix moistened with Dakin's solution and covered with a dry dressing. LVN J removed gloves- no hand hygiene and re-gloved and proceeded to the wound on the resident's sacrum. CNA M completed incontinence care, removing the remainder of the fecal matter after LVN J removed the soiled dressing. The sacral wound was crescent shaped and approximately the width of a tennis ball with slough present. LVN J cleaned with normal saline and applied collagen and calcium alginate and covered with a dressing. LVN J changed gloves- no hand hygiene and proceeded to the wound on the residents left Ischial. The wound was approximately the diameter of a orange with the top part of wound having some granulation (red and moist) present. The bottom of the wound had slough and necrotic tissue present with heavy drainage and an odor. LVN J cleaned with Daikin's solution, applied Santyl to the necrotic portion of the wound and calcium alginate to the remainder of the wound bed and covered with a dressing. LVN J changed her gloves and re-gloved without performing hand hygiene and provided catheter care and both she and CNA M placed a clean brief on the resident and dressed her for the day. Resident #15 was transferred with mechanical lift to her wheelchair. Wheelchair was noted to have a memory foam cushion that was concaved in the middle. Resident #15 again stated she had asked for a Roho (air filled pressure relief cushion) cushion. Both staff removed their gloves and performed hand hygiene. <BR/>In an interview with LVN J on [DATE] at 10:15 AM she stated Resident #15's ankle wounds looked about the same since she saw them last week, but her wound on her gluteal fold was much worse as well as the sacrum and Ischium wound which appeared to be tunneling (opening under the skin). She stated she worked Monday through Friday on the 06:00 AM to 02:00 PM shift. She stated Resident #15 returned from the hospital on [DATE]. She stated there were no wound care orders from the hospital. She stated when she got report from the hospital, they stated they had done wound care on Saturday, but not Sunday stating the resident had refused. She stated she did not assess the wound when she returned to the facility on [DATE], since the Treatment Nurse did the Wound care assessments. She stated she did not find out until this week ([DATE]) the treatment nurse had stepped down from that position. She stated she thought the 2:00 PM to 10:00 PM nurse did her wound care on [DATE]. She stated she had asked the MDS Nurse if she could put in the wound care orders. She stated they were just using the previous wound care orders. She stated she had not contacted the MD to clarify the wound care orders. She stated she did the wound care on Tuesday [DATE] and the wounds were not draining like they were today ([DATE]) but stated they did have a lot more slough. She stated she had not contacted the primary care physician about the wounds, stating she assumed the treatment nurse wound be doing that. She stated she had not signed off on the wound care because the orders had still not been put in the system when she did the wound care on Tuesdays [DATE].<BR/>In an interview with Resident #15's NP DD on [DATE] at 11:40 AM who was in the building making rounds, she stated she had not been contacted about Resident #15's wounds since her return from the hospital. She stated she was on call last weekend. She stated the facilities usually had a wound care doctor that comes weekly. She stated she was not aware that no one was coming for wound care manage for Resident #15. She stated she did not re-call ordering any wound cultures on the resident, but stated if she were having signs and symptoms of infections, she would order them today ([DATE]). She stated anyone with the extensive nature of Resident #15's wounds needed to be seen weekly by a wound care specialist. She stated the risk of failing to manage Resident #15's wounds could lead to sepsis, further decline of the wound and loss of limbs. She stated they needed to contact the Primary Care physician or herself anytime there was a significant change. <BR/>Attempted to contact Resident #15's Primary care physician on [DATE] at 11:51 AM and was told he was out of the office on vacation. <BR/>In an interview with the DON on [DATE] at 12:45 PM stated she knew the Wound Care management company had not sent anyone out for several weeks. She stated they originally had wound care NP AA coming weekly, but her visits became less consistent. She stated NP AA had told the Treatment Nurse that she did not want to come for just one resident and wanted to do Telehealth, but the Treatment Nurse and herself felt Resident #15's wounds needed to be seen weekly, so NP AA arranged for someone else to come. She stated wound care NP EE came out about a month ago and had not been back. She stated she was planning on getting with the Treatment Nurse to see what was going on with Resident #15's wounds but stated due to the shortage of staff the Treatment Nurse had been working the floor covering shifts for the last 3 weeks. She stated due to this they had an in-service with the staff sometime in February 2024 letting them know the Treatment Nurse would no longer be doing the weekly skin assessments and the Nurses would be responsible for their assigned residents, but the Treatment Nurse would still be doing the wound care assessments weekly. She stated the staff were also told they would be responsible for doing the wound care if the Treatment Nurse was working the floor. She stated it was her expectation that anytime there was a new skin issues they were to complete a skin assessment, notify the physician and family and get orders. She stated the nurse who identified the issue needed to be the one who reached out to the physician. She stated she was not sure what they were going to do about a wound care physician at this time. She stated wound care orders could only be changed by the physician. She stated it was outside the scope of practice for the nurse to implement her own wound care orders. She stated the risk could be making the wound worse, risk of infection. She stated she had not considered who would complete the wound care assessments if the Treatment Nurse was unavailable, and stated after this week, the Treatment Nurse had stepped down from the position. <BR/>In an interview with the MDS Coordinator on [DATE] at 12:50 PM she stated when Resident #15 returned to the facility on [DATE] she helped put in the hospital discharge medication orders but stated she had told the Treatment Nurse she needed to put in the wound care orders. She stated she was not aware of who the facility Wound care management company was or who to contact about wound care. <BR/>In an interview with the Treatment Nurse on [DATE] at 10:05 PM she stated she was called in at 6:30 PM today to help on the floor as CNA. She stated she had told the nurse's back in January they were going to have to do the wound care when she was off or working the hall. She stated they were also supposed to be doing the skin assessment, but that was not happening, so they did an in-service on [DATE] on the requirement of for the weekly skin assessment. She stated the nurses were supposed to complete the skin assessment for any skin condition and if it was pressure or deep tissue injury, they were to report to her, and she would complete the Wound care assessment. She stated the nurse however was to contact the physician, family and obtain any treatment order needed. She stated she had been doing Resident #15's Skin assessment and wound assessment up until she went to the hospital on [DATE] and was trying to do the treatments when she could. She stated her wound assessments were scheduled for Thursdays and she was off on Thursday. She stated when Resident #15 came back to the facility on [DATE], the admitting nurse should have done a skin assessment and called the doctor for orders for the wound. She stated she was not surprised wounds were not getting documented as being done. She stated she was so frazzled by the time she leaves she was not sure what she did and did not do. She stated she did Resident #15's wound care on Wednesday[DATE] but did not do the wound care assessment. She stated she off on [DATE] the day the assessment was due. She stated there was a little bit of odor and drainage. She stated the wounds did not have an odor or drainage before she went to the hospital. She stated she probably could have reached out to the Wound care company, but stated she felt like the wounds had been stable prior to her going to the hospital. She stated when she started in [DATE], she received no training on wound care and was not aware of the facility's policy for wound care. She stated she had previous experience as a treatment nurse in another facility, but stated she was not wound care certified. <BR/>In an interview with CNA L on [DATE] at 01:00 PM she stated she worked the day Resident #15 returned to the facility. She stated her wounds had a very foul smell. She stated the nurse was aware of the smell. She stated if she saw a new skin issue, she would put it in the electronic record and tell the nurse. <BR/>In an interview with RN G on [DATE] at 02:45 PM stated when she arrived at work on [DATE] for her 2-10 PM shift, Resident #15 had been readmitted to the facility. She stated LVN J had re-admitted her but had not had a chance to do her wound care, so she stated she did the wound care that evening. She stated the wounds were terrible and smelled bad. She stated she assumed the Treatment Nurse was taking care of the wound care orders. She stated the wounds on the residents' ankles looked worse to her and she had a new place on the middle of her right foot. She stated she thought she contacted the physician about the new place on the resident right foot but stated she had deleted all her old calls and was not sure what day she called him. She stated she should have written the order and signed the TAR when she did the wounds on [DATE], [DATE] and [DATE]. She stated it was so crazy last week she was doing good just to get the care done. She stated she did not feel like she had enough experience to complete the wound care assessments and would need more training before she felt comfortable staging or measuring a wound. <BR/>2. Record Review of Resident #174's Significant Change MDS assessment dated on [DATE] reflected a [AGE] year-old female with an admission date of [DATE]. Resident had a BIMS of 2 which indicated she was severely cognitively impaired. She required extensive assistance with all ADLs and was frequently incontinent of bladder and always incontinent of bowel. Resident had a one unstageable pressure injury listed and was receiving Hospice services. Active diagnoses included heart failure and dementia. <BR/>Record Review of Resident #174's care plan initiated on [DATE] reflected, [Resident #174] is at increased risk for pressure sores due to immobility .Interventions Administer treatments as ordered .Follow facility policies/protocols for the prevention/treatment of skin breakdown .Inform the resident /family/caregivers of any new area of skin breakdown .<BR/>Record review of Resident #174's Braden assessment completed on [DATE] by MDS Coordinator indicated the resident had a score of 14 which placed her at moderate risk of pressure ulcers. <BR/>Record Review of Resident #174's progress note dated [DATE] at 07:35 PM by RN EE reflected, resident found with medium sized wound to buttocks. Resident denies pain at this time. barrier cream applied and brief changed. [Treatment Nurse], notified of wound and stated she would look into it tomorrow morning. <BR/>Record Review of Resident #174's progress note dated [DATE] at 07:58 PM by RN EE, reflected, resident assessed coughing up green, thick, productive sputum and lung sounds are wet and wheezy. Vitals are stable at this time. resident remains afebrile. [NP CC] notified of cough and sputum . Further review of the progress noted reviewed there was no documentation the NP was notified of the wound to the residents' buttocks. <BR/>Record review of Resident #174's progress noted dated [DATE] at 10:22 AM by RN E reflected, pressure area to coccyx wound nurse is performing dressing changes to area day 4 for zpack (Azithromycin)) and prednisone will continue to monitor, air mattress present on bed with controls available as well as call light and water pitcher. Denies needs or pains at present time will continue to monitor and update md, family and admin(sic) prn status changes. <BR/>Record review of Resident #174's progress note dated [DATE] at 08:15 PM by LVN Treatment nurse, reflected, Unstageable pressure ulcer to sacrum d/t slough present. 5cm x 3cm x 2cm. New order received from Hospice Cleanse with<BR/>wound cleanser, Apply Santyl to wound bed then apply Hydrofera Blue foam and a dry dressing daily and as needed. Family and MD notified.<BR/>Resident admitted [company name] Hospice today.<BR/>Record review of Resident #174's Physician order Summary report date [DATE] reflected, <BR/> Sacrum- Cleanse wound with wound cleanser. Apply Santyl to wound bed. Then lightly pack with Hydrofera Blue and apply Supers absorbent Dressing daily and as needed every day shift with a start date of [DATE]. <BR/>Order was changed to Cleanse wound with wound cleanser. Apply Silver Alginate to wound bed and cover with a super absorbent dressing daily and as needed, with a start date of [DATE]. There were no orders for the Pressure ulcer to the Resident's right heel. There were no orders for [DATE] for wound care to the resident's sacrum.<BR/>Record review of Resident #174's TAR for [DATE] reflected no documentation of wound care to the residents' sacral wound. <BR/>Record review of Resident #174's TAR for February 2024, reflected no documentation of wound care from [DATE] through [DATE], [DATE] through [DATE], and [DATE] for the Resident sacral wound. Further review revealed there was no documentation for wound care to the resident right heel from [DATE] through [DATE]. <BR/>Record review of Hospice GG's admission assessment dated [DATE] reflected Resident #174 had an unstageable 4x4 cm to her coccyx with bone exposed and bleeding. In addition, she had a Stage 1 pressure injury to her right heel that was red, mushy with a black center. Will follow up for wound care orders.<BR/>Record review of Hospice GG's assessment dated [DATE] reflected, Wound #1 Sacral is a [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status for three of six residents (Resident Residents#15, #174, #71) reviewed for notification of changes.<BR/>1. Treatment Nurse and DON failed to notify Resident #15's Primary Physician when the wound care consultant had stopped seeing the resident on a weekly basis and failed to notify the Physician in a change of condition of the wounds. <BR/>2. LVN J failed to notify the Physician for wound care orders when Resident #15 re-admitted to the facility on [DATE]. <BR/>2. RN EE failed to notify the Physician and responsible party on 01/25/24 when Resident #174 developed a wound on her buttocks. <BR/>3. The ADON failed to notify the physician and responsible party of Resident #71's change of condition when a new pressure ulcer on her coccyx and blisters were observed on her leg on 03/10/24.<BR/>An Immediate Jeopardy (IJ) was identified on 03/12/24 at 12:40 PM. The IJ template was provided to the facility on [DATE] at 12:45 PM and signed by the Administrator. While the IJ was removed on 03/14/24 at 5:17 PM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. <BR/>This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death.<BR/>Findings included:<BR/>Record Review of Resident #15's Face Sheet dated 03/14/24, reflected a re-admission date of 03/04/24 to the facility. <BR/>Record review of Resident #15's quarterly MDS, dated [DATE], reflected a [AGE] year-old female with an admission date of 09/26/23. The resident had a BIMS of 13 which indicated she was cognitively intact and had not resisted care. She required extensive to dependent care with ADL. She had a foley catheter and was always incontinent of bowel. She had pressure ulcers and was at risk for pressure ulcers. Active diagnoses included diabetes, multiple sclerosis (disease in which the immune system eats away at protective coverings of nerves), paraplegia (paralysis that affects the legs) and seizure disorder. <BR/>Record review of Resident #15's care plan dated 12/13/24 reflected, [Resident #15] has stage 3 pressure injury to sacrum, right lateral Malleolus, left medial malleolus, stage 4 pressure injury to her left ischial and right gluteal fold and is at risk since resident chooses to stay up in wheelchair up to 8-9 hours at times .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods .<BR/>Record review of Resident #15's care plan revised on 03/14/24 reflected, The resident had a stage 3 pressure ulcer to right foot, deep tissue injury to left heal, and left lateral malleolus .Interventions .[Wound Care provider] consultation 03/13/24 .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods .<BR/>Record Review of Resident #15's Hospital Discharge orders dated 03/04/24, did not reflect any orders for wound care. <BR/>Record Review of Resident #15's Physician order recap report with date range from 02/01/24 through 03/31/24, reflected, <BR/>1. Left Heel- apply skin prep twice daily to scabbed area, with a start date of 03/11/24 ( 7 days post admission)<BR/>2. Left Ischium (hip)- Cleanse wound with Dakin's (diluted bleach)solution. Apply Hydrofera Blue(antimicrobial dressing) foam to wound bed and cover with a dry dressing every day and as needed- with a start date of 03/07/24. (3 days post admission) . Order was changed on 03/10/24 to Cleanse wound with Dakin's solution . Apply Santyl (removes dead tissue) to wound bed and calcium alginate (used for exuding wounds). Cover with a dry dressing daily, with a start date of 03/11/24. <BR/>3. Left Lateral Malleolus (outside ankle)- Apply skin prep to scabbed area twice daily with a start date of 03/07/24. Order was changed on 03/10/24 to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of 03/11/24. <BR/>4. Left Medial Malleolus (inside ankle)- Apply skin prep to scabbed area twice daily with a start date of 03/07/24. Order was changed on 03/10/24 to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of 03/11/24.<BR/>5. Right Gluteal Fold (skin crease below the buttocks) - Cleanse with Normal Saline. Apply a thin layer of Santyl to wound bed. Lightly pace wound Kerlix roll moistened with Dakin's solution and cover with a super Absorbent dressing daily and as needed with a start date of 03/07/24. <BR/>6. Right Lateral Malleolus(outside ankle)- Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of 03/07/24- Order was changed on 03/10/24 to Cleanse wound with wound cleanser and pat dry. Apply Collagen and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of 03/11/24. <BR/>7. Right Lateral (outside )side of foot- Cleanse with wound cleanser, apply a small amount of Santyl to wound bed, then apply Calcium Alginate, cover with dry dressing daily with a start date of 03/12/24. <BR/>8. Right Medial Malleolus (inside ankle) Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of 03/07/24- Order was changed on 03/10/24 to Cleanse wound with wound cleanser and pat dry. Apply Santyl and Calcium alginate to wound bed and cover with a dry dressing daily and as needed with a start date of 03/11/24. <BR/>9. Sacral wound- Cleanse with wound cleanser. Apply Hydrofera Blue Foam to wound cand cover with a dry dressing daily with a start date of 03/07/24. Order was changed on 03/10/24 to Cleanse with wound cleanser. Apply Collagen(protein used to make connective tissue), and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of 03/11/24. <BR/>Record Review of Resident #15's TAR for March 2024 reflected no wound care was documented for 03/04/24, 03/05/24, 03/06/24, 03/08/24. <BR/>Record review of the electronic record for Resident #15 reflected visit was attempted by the Wound Care Consultant on 02/13/24- Resident was involved in activities and declined assessment. There were no additional Wound Care Consultant reports.<BR/>Record review of Resident #15's admission assessment dated [DATE], completed by LVN J reflected, Skin integrity- was left blank- Under comment section- stated - See wound assessments. <BR/>Record review of Resident #15's electronic record reflected no Wound Care assessment was completed until 03/13/24, which deferred to the Wound Care Consultants assessment completed on 03/13/24.<BR/>In an interview with the LVN Treatment Nurse on 03/10/24 at 02:00 PM, she stated she was the one doing the wound care assessments and measuring the wounds on Resident #15. She stated there had not been anyone from the Wound Care consultant company coming to the building for over a month. She stated even before that they were not coming consistently on a weekly basis. She stated the Wound care Nurse Practitioner had told her since Resident #15 was the only one in the building she thought they would just do Telehealth. She stated she told the NP due to the extensive nature of Resident #15's wounds she did not think that was going to be adequate, so the Nurse Practitioner stated she would get someone else to come. She stated another Nurse Practitioner from the wound care company came out, but she only came one time and they never sent anyone else. She stated at some point, Resident #15's wounds had started having more slough, so she added Santyl back to the wound care order. She stated the Nurse Practitioner had taken it off at one time. She stated she had not called the Primary care physician or his NP about any of the resident wounds. She stated Resident #15 was sent to the hospital a few weeks ago unrelated to her wounds, and stated she was told the hospital had not done wound care on her for the 3 days she was in the hospital. She stated she thought the wound on her coccyx had been improving. She stated once Resident #15 gets up she will refuse to lay back down until bedtime which makes healing very difficult. <BR/>In an interview and observation with Resident #15 on 03/11/24 at 08:55 AM she stated once she got up mid-morning she does not go back to be until around 8 or 9 PM. She stated she knew it was not good for the healing of her pressure injuries, but stated there was not enough staff to lay her down and get her back up throughout the day and she did not want to miss her smoke breaks. She stated part of the problem was the cushion in her wheelchair. She stated she had been asking the facility to get her a Roho cushion ( air filled cushion) but the facility had not provided one. Observation of the cushion in her wheelchair revealed a memory foam cushion that was concaved in the middle of the cushion. <BR/>In an observation and interview with LVN J on 03/11/24 at 09:10 AM revealed her at the treatment cart preparing supplies for wound care for Resident #15. Observed CNA M and LVN J entered Resident #15's room to provide the residents wound care on 03/11/24 at 09:15 AM. Both staff washed their hands. LVN J cleaned the bedside table with a germicidal wipe and then placed the wound care supplies, plus a bottle of Dakin's solution and her computer on the table without placing the supplies on a barrier. CNA M put on gloves and uncovered the resident and found the resident with no brief lying on a cloth moisture resistant pad. CNA M rolled the resident on her right side revealing she had a bowel movement, which had contaminated the sacral wound dressing. CNA M provided incontinence care and changed her gloves but did not perform hand hygiene after she changed her gloves. LVN J noted the resident had 4 dressing on her right foot and stated she only had orders for her right Lateral ankle. She stated she was not sure what was going on with the resident's right foot. LVN J removed the dressing on the left outer ankle revealing a wound about the size of a golf ball with slough (yellowish white material in the wound bed consisting of dead cells) present, she stated this wound looked a little smaller since she saw it last week. LVN J cleaned the wound with normal saline, since she stated she was out of wound cleanser. LVN J removed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the wound bed and covered with a dressing. LVN J changed gloves without performing hand hygiene and removed the dressing from the resident's left interior ankle revealing a wound about the diameter of a double D battery. The wound had slough present. LVN J cleaned the wound with normal saline, changed gloves, with no hand hygiene, and applied Santyl and Calcium alginate and covered with a dressing. LVN J then applied skin prep to the resident's left heel, which had a scab approximately the diameter of a triple A battery. LVN J changed gloves, no hand hygiene and proceeded to remove all dressing on the outside the right ankle and revealed a wound approximately the diameter of a golf ball on the outer ankle with slough present and serous (yellow) drainage. Observed on the outer middle part of her foot a wound approximately the size of blue jean button. LVN J stated it appeared it had calcium alginate, but stated there was no order for a treatment of this wound. LVN J cleaned both wounds with normal saline, changed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the ankle and calcium alginate to the wound on her right mid foot and covered both with a dressing. LVN J changed gloves without performing hand hygiene and proceeded to the wound on the resident's right gluteal fold. LVN J removed the dressing and revealed a wound with heavy greenish gray drainage and strong odor. Wound was approximately the diameter of a soup can and appeared to be to the bone. LVN J cleaned with normal saline, changed gloves with no hand hygiene and re-gloved and applied Santyl and packed with kerlix moistened with Dakin's solution and covered with a dry dressing. LVN J removed gloves- no hand hygiene and re-gloved and proceeded to the wound on the resident's sacrum. CNA M completed incontinence care, removing the remainder of the fecal matter after LVN J removed the soiled dressing. The sacral wound was crescent shaped and approximately the width of a tennis ball with slough present. LVN J cleaned with normal saline and applied collagen and calcium alginate and covered with a dressing. LVN J changed gloves- no hand hygiene and proceeded to the wound on the residents left Ischial. The wound was approximately the diameter of a orange with the top part of wound having some granulation (red and moist) present. The bottom of the wound had slough and necrotic tissue present with heavy drainage and an odor. LVN J cleaned with Daikin's solution, applied Santyl to the necrotic portion of the wound and calcium alginate to the remainder of the wound bed and covered with a dressing. LVN J changed her gloves and re-gloved without performing hand hygiene and provided catheter care and both she and CNA M placed a clean brief on the resident and dressed her for the day. Resident #15 was transferred with mechanical lift to her wheelchair. Wheelchair was noted to have a memory foam cushion that was concaved in the middle. Resident #15 again stated she had asked for a Roho (air filled pressure relief cushion) cushion. Both staff removed their gloves and performed hand hygiene. <BR/>In an interview with LVN J on 03/11/24 at 10:15 AM she stated Resident #15's ankle wounds looked about the same since she saw them last week, but her wound on her gluteal fold was much worse as well as the sacrum and Ischium wound which appeared to be tunneling. She stated she worked Monday through Friday on the 06:00 AM to 02:00 PM shift. She stated Resident #15 returned from the hospital on [DATE]. She stated there were no wound care orders from the hospital. She stated when she got report from the hospital, they stated they had done wound care on Saturday, but not Sunday stating the resident had refused. She stated she did not assess the wound when she returned to the facility on [DATE], since the Treatment Nurse did the Wound care assessments. She stated she did not find out until this week the treatment nurse had stepped down from that position. She stated she thought the 2:00 PM to 10:00 PM nurse did her wound care on 03/04/24. She stated she had asked the MDS Nurse if she could put in the wound care orders. She stated they were just using the previous wound care orders to provide wound care. She stated she had not contacted the MD to clarify the wound care orders. She stated she did the wound care on Tuesday 03/05/24 and the wounds were not draining like they were today (03/11/24) but stated they did have a lot more slough. She stated she had not contacted the primary care physician about the wounds, stating she assumed the treatment nurse wound be doing that. She stated she had not signed off on the wound care because the orders had still not been put in the system when she did the wound care on Tuesday 03/05/24. <BR/>In an interview with Resident #15's NP DD on 03/11/24 at 11:40 AM , she stated she had not been contacted about Resident #15's wounds since her return from the hospital. She stated she was on call last weekend. She stated the facility usually had a wound care doctor that comes weekly. She stated she was not aware no one was coming for wound care manage for Resident #15. She stated she did not re-call ordering any wound cultures on the resident, but stated if she were having signs and symptoms of infections, she would order them today (03/11/24). She stated anyone with the extensive nature of Resident #15's wounds needed to be seen weekly by a wound care specialist. She stated the risk of failing to manage Resident #15's wounds could lead to sepsis, further decline of the wound and loss of limbs. She stated they needed to contact the Primary Care physician or herself anytime there was a significant change. <BR/>Attempted to contact Resident #15's Primary care physician on 03/11/24 at 11:51 AM and was told he was out of the office on vacation. <BR/>In an interview with the DON on 03/11/24 at 12:45 PM she stated she knew the Wound Care management company had not sent anyone out for several weeks. She stated they originally had wound care NP AA coming weekly, but her visits became less consistent. She stated NP AA had told the Treatment Nurse that she did not want to come for just one resident and wanted to do Telehealth, but the Treatment Nurse and herself felt Resident #15's wounds needed to be seen weekly, so NP AA arranged for someone else to come. She stated wound care NP EE came out about a month ago and had not been back. She stated she was planning on getting with the Treatment Nurse to see what was going on with Resident #15's wounds but stated due to the shortage of staff the Treatment Nurse had been working the floor covering shifts for the last 3 weeks. She stated due to this they had an in-service with the staff sometime in February 2024 letting them know the Treatment Nurse would no longer be doing the weekly skin assessments and the Nurses would be responsible for their assigned residents, but the Treatment Nurse would still be doing the wound care assessments weekly. She stated the staff were also told they would be responsible for doing the wound care if the Treatment Nurse was working the floor. She stated it was her expectation that anytime there was a new skin issues they were to complete a skin assessment, notify the physician and family and get orders. She stated the nurse who identified the issue needed to be the one who reached out to the physician. She stated she was not sure what they were going to do about a wound care physician at this time. She stated wound care orders could only be changed by the physician. She stated it was outside the scope of practice for the nurse to implement her own wound care orders. She stated the risk could be making the wound worse, risk of infection. She stated she had not considered who would complete the wound care assessments if the Treatment Nurse was unavailable, and stated after this week, the Treatment Nurse had stepped down from the position. She stated nurses were not allowed to stage the wounds, only measure them. <BR/>In an interview with the MDS Coordinator on 03/11/24 at 12:50 PM she stated when Resident #15 returned to the facility on [DATE] she helped put in the hospital discharge medication orders but stated she had told the Treatment Nurse she needed to put in the wound care orders. She stated she was not aware of who the facility Wound care management company was or who to contact about wound care. <BR/>In an interview with the Treatment Nurse on 03/11/24 at 10:05 PM she stated she was called in at 6:30 PM today to help on the floor as CNA. She stated she had told the nurse's back in January they were going to have to do the wound care when she was off or working the hall. She stated they were also supposed to be doing the skin assessment, but that was not happening, so they did an in-service on 02/21/24 on the requirement of for the weekly skin assessment. She stated the nurses were supposed to complete the skin assessment for any skin condition and if it was pressure or deep tissue injury, they were to report to her, and she would complete the Wound care assessment. She stated the nurse however was to contact the physician, family and obtain any treatment order needed. She stated she had been doing Resident #15's Skin assessment and wound assessment up until she went to the hospital on [DATE] and was trying to do the treatments when she could. She stated her wound assessments were scheduled for Thursdays and she was off on Thursday. She stated when Resident #15 came back to the facility on [DATE], the admitting nurse should have done a skin assessment and called the doctor for orders for the wound. She stated she was not surprised wounds were not getting documented as being done. She stated she was so frazzled by the time she leaves she was not sure what she did and did not do. She stated she did Resident #15's wound care on Wednesday03/06/24 but did not do the wound care assessment. She stated she off on 03/07/24 the day the assessment was due. She stated there was a little bit of odor and drainage. She stated the wounds did not have an odor or drainage before she went to the hospital. She stated she probably could have reached out to the Wound care company, but stated she felt like the wounds had been stable prior to her going to the hospital. She stated when she started in October 2024, she received no training on wound care and was not aware of the facility's policy for wound care. She stated she had previous experience as a treatment nurse in another facility, but stated she was not wound care certified. <BR/>In an interview with CNA L on 03/12/24 at 01:00 PM she stated she worked the day Resident #15 returned to the facility. She stated her wounds had a very foul smell. She stated the nurse was aware of the smell. She stated if she saw a new skin issue, she would put it in the electronic record and tell the nurse. <BR/>In an interview with RN G on 03/12/24 at 02:45 PM she stated when she arrived at work on 03/04/24 for her 2-10 PM shift, Resident #15 had been readmitted to the facility. She stated LVN J had re-admitted her but had not had a chance to do her wound care, so she stated she did the wound care that evening. She stated the wounds were terrible and smelled bad. She stated she assumed the Treatment Nurse was taking care of the wound care orders. She stated she just used the previous orders. She stated the wounds on the residents' ankles looked worse to her and she had a new place on the middle of her right foot. She stated she thought she contacted the physician about the new place on the resident right foot but stated she had deleted all her old calls and was not sure what day she called him. She stated she should have written the order and signed the TAR when she did the wounds on 03/4/24, 03/08/24 and 3/10/24. She stated it was so crazy last week she was doing good just to get the care done. She stated she did not feel like she had enough experience to complete the wound care assessments and would need more training before she felt comfortable staging or measuring a wound. <BR/>2. Record Review of Resident #174's Significant Change MDS assessment dated on 02/08/24 reflected a [AGE] year-old female with an admission date of 04/17/20. Resident had a BIMS of 2 which indicated she was severely cognitively impaired. She required extensive assistance with all ADLs and was frequently incontinent of bladder and always incontinent of bowel. Resident had a one unstageable pressure injury listed and was receiving Hospice services. Active diagnoses included heart failure and dementia. <BR/>Record Review of Resident #174's care plan initiated on 11/20/20 reflected, [Resident #174] is at increased risk for pressure sores due to immobility .Interventions Administer treatments as ordered .Follow facility policies/protocols for the prevention/treatment of skin breakdown .Inform the resident /family/caregivers of any new area of skin breakdown .<BR/>Record review of Resident #174's Braden assessment completed on 01/15/24 by MDS Coordinator indicated the resident had a score of 14 which placed her at moderate risk of pressure ulcers. <BR/>Record Review of Resident #174's progress note dated 01/25/24 at 07:35 PM by RN EE reflected, resident found with medium sized wound to buttocks. Resident denies pain at this time. barrier cream applied and brief changed. [Treatment Nurse], notified of wound and stated she would look into it tomorrow morning. <BR/>Record Review of Resident #174's progress note dated 01/25/24 at 07:58 PM by RN EE, reflected, resident assessed coughing up green, thick, productive sputum and lung sounds are wet and wheezy. Vitals are stable at this time. resident remains afebrile. [NP CC] notified of cough and sputum . Further review of the progress noted reviewed there was no documentation the NP was notified of the wound to the residents' buttocks. <BR/>Record review of Resident #174's progress noted dated 01/31/24 at 10:22 AM by RN E reflected, pressure area to coccyx wound nurse is performing dressing changes to area day 4 for zpack (Azithromycin)) and prednisone will continue to monitor, air mattress present on bed with controls available as well as call light and water pitcher. Denies needs or pains at present time will continue to monitor and update md, family and admin(sic) prn status changes. <BR/>Record review of Resident #174's progress note dated 02/02/24 at 08:15 PM by LVN Treatment nurse, reflected, Unstageable pressure ulcer to sacrum d/t slough present. 5cm x 3cm x 2cm. New order received from Hospice Cleanse with<BR/>wound cleanser, Apply Santyl to wound bed then apply Hydrofera Blue foam and a dry dressing daily and as needed. Family and MD notified.<BR/>Resident admitted [company name] Hospice today.<BR/>Record review of Resident #174's Physician order Summary report date 03/10/24 reflected, <BR/> Sacrum- Cleanse wound with wound cleanser. Apply Santyl to wound bed. Then lightly pack with Hydrofera Blue and apply Supers absorbent Dressing daily and as needed every day shift with a start date of 02/06/24. <BR/>Order was changed to Cleanse wound with wound cleanser. Apply Silver Alginate to wound bed and cover with a super absorbent dressing daily and as needed, with a start date of 02/17/24. There were no orders for the Pressure ulcer to the Resident's right heel. There were no orders for January 2024 for wound care to the resident's sacrum.<BR/>Record review of Resident #174's TAR for January 2024 reflected no documentation of wound care to the residents' sacral wound. <BR/>Record review of Resident #174's TAR for February 2024, reflected no documentation of wound care from 02/02/24 through 02/09/21, 02/11/24 through 02/14/24, and 02/16/24 for the Resident sacral wound. Further review revealed there was no documentation for wound care to the resident right heel from 02/02/24 through 02/17/24. <BR/>Record review of Hospice GG's admission assessment dated [DATE] reflected Resident #174 had an unstageable 4x4 cm to her coccyx with bone exposed and bleeding. In addition, she had a Stage 1 pressure injury to her right heel that was red, mushy with a black center. Will follow up for wound care orders.<BR/>Record review of Hospice GG's assessment dated [DATE] reflected, Wound #1 Sacral is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Closed. Measurements are 5cm length x 6cm width x 1.5 cm depth, with an area of 30 sq cm and a volume of 45 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining (erosion under the skin) has been noted. There is a Moderate amount of drainage noted. Wound bed has 76-100%, granulation, 1-25% slough (yellow/white material in wound bed), no eschar(dry, scab) , and no epithelialization (development of new tissue) present . Wound #2 Right Heel is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Closed. Measurements are 2.5cm length x 2cm width x 0 cm depth, with an area of 5 sq cm and a volume of 0 cubic cm. No tunneling (opening under the skin) has been noted. No sinus tract has been noted. No undermining has been noted. There is a Moderate amount of drainage noted. Wound bed has 26-50%, granulation, 26-50% epithelialization, no slough, and no eschar present .<BR/>Further record review of Hospice GG's assessment dated [DATE] reflected, Wound Orders- Sacral wound- Cleanse per protocol, pat dry, apply silver alginate and cover with dressing daily and prn. Caregiver or facility nurse to change on days that hospice nurse not present. There was no recommendation documented for the pressure wound to the resident's right heel. <BR/>Record review of Resident #174's skin assessment completed by LVN Treatment nurse: <BR/>01/01/24- no skin issues<BR/>01/08/24- no skin issues<BR/>01/15/24- no skin issues <BR/>01/22/24- no skin issues<BR/>01/29/24- 4 cm x 4 cm non blanchable deep tissue area to sacrum. Skin intact. <BR/>02/02/21- see wound assessment.<BR/>02/09/24-pressure ulcer to buttocks/sacral area.- See wound assessment for details. ( No documentation of the pressure ulcer to her right heel)<BR/>02/16/24- pressure ulcer to buttocks/sacral area that has turned into Kennedy ulcer (sores that appear during someone's final hours or days of living.)<BR/>Review of Resident #174's Wound care assessments completed by LVN Treatment Nurse revealed the following:<BR/>*02/02/24-Location- Sacrum- 5.0 x 2.0 x2.0 cm Unstageable pressure- Undermining was present- date of onset 2/02/24- wound was open with slough and heavy bloody exudate but no odor. Current wound care orders- Cleanse with wound cleanser. Apply Santyl to wound bed then apply Hydroferra Blue foam and as super absorbent silicone dressing daily and as needed. Physician notified. Responsible party notified. There was no documentation about the resident's right heel.<BR/>*02/09/24- Location- Sacrum- 6 x 3.5x2 cm Pressure- Kennedy terminal ulcer- undermining present, open, wound bed is red, yellow, and gray with slough and moderate bloody exudate and a mild odor- . Current wound care orders- Cleanse with wound cleanser. Apply Santyl to wound bed then apply Hydroferra Blue foam and as super absorbent silicone dressing daily and as needed- declining wound-Primary physician notified on 02/09/24. There was no documentation about the resident's right heel. <BR/>In an interview with the LVN Treatment Nurse on 03/10/24 at 02:00 PM, she stated when she was first notified about Resident #174's wound on her bottom it was barely open. She stated RN FF had called her at home about the wound. She stated prior to this the resident had an air mattress, but stated the Administrator had instructed them to remove all the air mattress for anyone who did not currently have a wound. She stated they had taken Resident #174 off the air mattress and within 2 weeks she had a breakdown on her bottom. She stated RN FF should had completed a skin assessment and notified the physician and family when she found the wound. She they were not providing any type of wound care other than barrier cream, offloading her heels, and repositioning her frequently. She stated they day the resident was placed on Hospice the wound had declined. She stated the Hospice stated they had their own wound care and would be taking care of the wound, so she did not contact anyone else about the wound. She stated someone came out one time and stated he would be coming once a week, but then he never came back. She stated the wound progressed rapidly and had a foul odor and drainage toward the end. She stated Hospice did bring out an air mattress for the resident. She stated she was not sure if the family had been notified about the severity of the wound, but stated one of the family members was present one day when she was doing the wound care. She stated she did not stage the wound as a Kennedy ulcer but stated someone [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident has a right to a safe, clean, comfortable and homelike environment for 9 (Residents #1, #5, #20, #21, #39, #41, #59, #67, #69) of 24 residents reviewed for safe and sanitary environment.<BR/>1. The facility failed to ensure Resident #20, #21, #41 and #59 had bed sheets in good condition without holes in them.<BR/>2. The facility failed to ensure Resident #39's curtain was without food stains. <BR/>3. The facility failed to ensure sheet rock behind toilet was in good condition not exposing pipes in Resident #69's bathroom. <BR/>4. The facility failed to ensure Resident #67's room had a curtain over the window. The facility failed to ensure Resident #67's bathroom had a toilet paper holder, a mirror, and sheet rock in bathroom wall did not expose pipes.<BR/>5. The facility failed to ensure residents in secure unit (500 hall) were comfortable with room temperature.<BR/>These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.<BR/>Findings include: <BR/>1. Record Review of Resident #21's admission MDS assessment dated [DATE] reflected Resident #21 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of closed fracture of left femur with routine healing, heart failure and hypertension. Resident #21 required substantial/maximal assistance with most ADLs except partial/moderate assistance with mobility. Resident #21 had a BIMS of 15 indicating she was cognitively intact. <BR/>Observation on 03/10/24 at 9:53 AM revealed Resident #21 was lying in bed with about 4 dime sized holes in her white fitted sheet above her head to the left of her pillow, about 3 dime sized holes in her fitted sheet to the left of her arm and a large tear on bottom corner about 4 inches length by 2 inches height exposing resident's mattress. <BR/>Interview on 03/10/24 at 9:54 AM with Resident # 21 revealed her bed sheets had holes in them and staff changed her sheets yesterday. She stated she noticed the holes in her bed sheets.<BR/>Interview on 03/10/24 at 11:20 AM with ADON revealed Resident #21's fitted sheet should not have holes in it but she stated it was difficult for the facility staff to find fitted sheets that are right size to cover the mattress and without holes in it especially on the corners of the bedding. She stated the staff should not be putting bed linen with holes on it on resident's beds. <BR/>Record review of Resident #41's quarterly MDS assessment dated [DATE] reflected Resident #41 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diabetes, coronary artery disease, dementia, generalized muscle weakness and lack of coordination. Resident #41 required partial/moderate assistance with showering. Resident #41 had a BIMS of 14 indicating he was cognitively intact. <BR/>Observation and Interview on 03/11/24 at 9:56 AM with Resident #41 revealed he was lying in bed with bed sheets with five small dime sized holes on top of bed sheet near his head. He stated he had noticed holes in the sheets since admitting to the facility.<BR/>Record Review of Resident #59's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of early onset Alzheimer's disease, depression, generalized anxiety disorder, and hypertension. Resident #58 had a BIMS score of 0 indicating she was severely cognitively impaired.<BR/>Observation on 03/11/24 at 9:54 AM of Resident #59's room revealed 5 small holes on the fitted bed sheet at the foot of the bed.<BR/>Record Review of Resident #20's quarterly MDS assessment dated [DATE] reflected Resident #20 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of bipolar disorder (mood disorder with extreme mood swings), recurrent depressive disorder, encephalopathy (brain dysfunction), nontraumatic subdural hemorrhage (bleeding in the layer of tissue around the brain), arthritis (disorder causing joint pain and stiffness). Resident #20 had a BIMS score of 6 indicating he was severely cognitively impaired. <BR/>Observation on 03/11/24 at 10:00 AM revealed Resident #20's fitted sheet had 8 small holes in her sheets at the head of the bed and 5 small holes at the foot of the bed. <BR/>Interview with CNA B on 03/11/24 at 10:05 AM revealed that she was aware of the holes on Resident #5, #20, and #59's sheets. CNA B stated the facility has been in need of linens and facility had not gotten new bed sheets. CNA B stated that she had no choice but to use the sheets with holes and that it was better than having no sheets for residents. CNA B stated that risk to resident for not having clean and comfortable environment was an infection risk if not cleaned and reduced psychosocial outcomes.<BR/>Observation of the linen closet and interview on 03/14/24 at 12:04 PM, with Housekeeping and Laundry Supervisor revealed 4 fitted sheets with holes. She removed them from the closet. The Housekeeping and Laundry Supervisor revealed her expectation of facility staff was to remove and discard any stained linen or linen having holes. She stated stained linen and linen with holes should not go to the floor. She stated the risk would be resident dignity and residents have the right to have clean and intact linen.<BR/>2. Record review of Resident # 39's Comprehensive MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of malignant melanoma, dementia (loss of cognitive functioning), depression, and anxiety disorder. Resident #39 had a BIMS score of 4 indicating she was severely cognitively impaired.<BR/>Observation and interview on 03/10/24 at 10:10 AM revealed Resident #39's curtain in between the door and her bed had dark brown and black splatters. Resident #39 revealed she had not noticed curtain because it was not facing her side of the bed. <BR/>Interview on 03/10/24 at 10:11 AM with CNA W revealed she saw Resident #39's curtain yesterday and forgot to take it down and believed it was food smears from another resident that wanders into rooms. CNA W stated that housekeeping was responsible for looking at curtains when they check resident rooms. CNA W stated not having clean curtains in resident rooms would put residents at risk of infections or negatively impact their mood.<BR/>3. Review of Resident #69's quarterly MDS assessment dated [DATE] reflected Resident #69 was an [AGE] year old male admitted to the facility on [DATE] with diagnose of frontotemporal neurocognitive disorder (result of damage to neurons in the frontal and temporal lobes of the brain), atherosclerosis heart disease(the buildup of plaque in and on the artery walls of the heart), peripheral vascular disease (systematic disorder that involves narrowing of vessels situated away from the heart or the brain), diabetes, stroke, dementia and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). Resident #69 had a BIMS of 11 indicating he was moderately cognitively impaired. <BR/>Observation on 03/10/24 at 10:14 AM revealed in Resident # 69 and Resident #30's bathroom had a square of sheeting rock sitting to the right of the toilet next to wall and a hole size of the sheet rock square (12 in x 12 in) behind the toilet seat exposing pipes in the wall.<BR/>Interview on 3/10/24 at 10:15 AM with Resident # 69 revealed the hole in bathroom wall behind toilet had been there since he was admitted to the facility. He stated Maintenance Director was aware of it.<BR/>Interview on 03/11/24 at 5:45 PM with Maintenance Director revealed in Resident #69's bathroom wall sheet rock was off due to past issues with plumbing but he had not replaced the sheet rock yet exposing plumbing pipes behind toilet. He stated he did not know exactly how long the sheet rock had been off. He stated he did not document it in the Maintenance log and had difficulty getting facility staff to document maintenance requests in the maintenance log so he could keep track of them. <BR/>4 . Record review of Resident #67's quarterly MDS dated [DATE] reflected Resident #67 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of metabolic encephalopathy (brain dysfunction due to disease or toxins in body), dementia (loss of cognition), hypotension (low blood pressure). Resident #67 had a BIMS score of 11 indicating she was moderately cognitively impaired. <BR/>Observation on 03/10/24 at 11:00 AM revealed Resident #67's window had a privacy curtain for her side of the bed pinned to window with a thumbtack with no curtain. Observation of Resident #67 bathroom revealed no toilet paper towel holder on wall and toilet paper sat on top of back of toilet. Observation of Resident #67's bathroom revealed a large hole about 2 feet by 2 feet across underneath sink and at top right corner of bathroom wall above sink exposing plumbing. Resident #67's bathroom had no mirror. <BR/>Interview on 03/10/24 at 11:01 AM with Resident #67 revealed that she wanted to go home and did not feel like her room was home-like.<BR/>Interview with CNA B on 03/11/24 at 10:05 AM revealed she did not know about Resident #67's window curtain and would look into it. CNA B stated that risk to resident for not having clean and comfortable environment was an infection risk if not cleaned and reduced psychosocial outcomes.<BR/>Interview on 03/11/2024 at 1:50 PM with Maintenance Director regarding Resident #67's bathroom revealed there had been a leak and the holes in the drywall were to identify the leak and repair it. Maintenance Supervisor was unable to say how long ago the holes were made or when he was going to repair the holes. Maintenance Supervisor was not aware Resident #67's privacy curtain was pinned to window.<BR/>5. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of anoxic brain injury (brain deprived of oxygen), altered mental status, anemia (low iron), hypothyroidism (decreased production of thyroid hormone), and congestive heart failure. Resident #1 had a BIMS score of 14 indicating she was cognitively intact. <BR/>Observation and interview on 03/10/24 at 2:49 PM of Resident #1's room revealed Resident #1 in bed wearing a long sleeve shirt and sweatshirt, covered with 2 blankets, and a blanket over her head. Observation of Resident #1's room revealed it to be cold and the air conditioner was running with cold air coming from vent above Resident #59's bed. <BR/>Interview on 03/10/24 at 2:50 PM with Resident #1 revealed she was not sure why her room was so cold and it seemed like the air conditioning was always on even now. <BR/>Interview on 03/10/24 at 2:55 PM with RN D revealed she was aware Resident #1's room was cold and stated they keep the door open to try to help the cold air escape. RN D stated she was not sure why Resident #1's room was so cold. <BR/>Observation and Interview on 03/11/24 at 2:18 PM revealed Resident #1 lying in bed with two blankets and head covered with blanket stated she was cold and cold all the time. Observation of Maintenance Director using a digital thermometer revealed Resident #1's vent room temperature was 55 degrees Fahrenheit and wall was 63 degrees Fahrenheit.<BR/>Record review of Resident #5's quarterly MDS assessment dated [DATE] reflected Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of traumatic subarachnoid hemorrhage (burst blood vessel in the brain), need for assistance with personal care, mild intellectual disabilities, bipolar type schizoaffective disorder (mood disorder with periods of intense feelings), diabetes. Resident #5 had a BIMS score of 9 indicating she was moderately cognitively impaired.<BR/>Observation and interview on 03/11/24 at 9:49 AM revealed Resident #5 lying in bed on her left side wearing a long sleeve shirt, covered with 3 blankets and wearing a bow on the top of her hair. Interview with Resident #5 revealed she was a poor historian and was not sure how long she had been at facility. <BR/>Observation on 03/11/24 at 2:21 PM of Resident #5's room revealed Resident #5 lying in bed covered with two blankets wearing a long sleeve sweater. Interview with Resident #5 revealed she was cold and she did not like feeling cold. <BR/>Observation of Resident #5's room revealed air conditioner is on and blowing cold air from vent, which was shut, temperature at vent measured 52 degrees Fahrenheit and 63 degrees Fahrenheit on wall. <BR/>Observation on 03/11/24 at 10:00 AM revealed Resident #20 sitting in her wheelchair in her room in front of her bed wearing long sleeve shirt and pants with non-slip socks. <BR/>Record review of Resident # 47's Quarterly MDS dated [DATE] revealed Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke), dementia (loss of cognitive functioning), and lack of coordination. She had a BIMS score of 99 indicated she was not interviewable and was severely impaired in cognitive skills for decision making. <BR/>Observations on 03/11/24 at 2:16 PM revealed Maintenance Director used a digital thermometer to measure Resident #47's room revealed air conditioner blowing cold air from vent with temperature from vent measuring 60 degrees Fahrenheit and 65 degrees Fahrenheit at wall. <BR/>Observation on 03/11/24 at 2:22 PM of Resident #39's room revealed air conditioner was on and blowing cold air from vent. Observation of Maintenance Director using a digital thermometer revealed room temperature at vent measured 60 degrees Fahrenheit and 66 degrees Fahrenheit on wall. <BR/>Observation on 03/11/24 at 2:23 PM of Resident #20's room revealed air conditioner is on and blowing cold air from vent. Observation of Maintenance Director using a digital thermometer revealed room temperature at vent measured 52 degrees Fahrenheit and 62 degrees Fahrenheit on wall.<BR/>Interview on 03/12/24 at 2:25 PM with Maintenance Director revealed temperature of resident rooms should be 71 degrees Fahrenheit at a minimum. He stated the risk to residents if the temperature was under 71 degrees Fahrenheit would be discomfort. Maintenance Director stated the staff were responsible for ensuring the temperature was not below a comfortable level for residents. He stated the facility used to have locked boxes on the thermostats, but they were broken off not being replaced.<BR/>Interview on 03/14/24 at 9:40 AM with Administrator revealed she had in-serviced facility staff including to put maintenance repairs in maintenance log at nurses' station. She stated it was difficult on the Maintenance Director to keep up with needed maintenance requests if not documented in the log. <BR/>Review of facility's maintenance log from January to March 2024 did not reflect repairs needed in Resident #69's bathroom sheet rock. <BR/>Review of facility's In-service dated 12/28/23 to all facility staff included maintenance log location and maintenance Director telephone number.<BR/>Review of facility's policy Quality of Life - Homelike Environment last revised May 2017 reflected Residents are provided with a safe, clean, comfortable and homelike environment .1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment .e. clean bed and bath linens that are in good condition .h. comfortable and safe temperatures (71 F - 81 F) .<BR/>Review of facility's policy Maintenance Service last revised December 2009 reflected Maintenance service shall be provided to all areas of the building, grounds and equipment. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide residents with an ongoing program of activities for 5 out of 5 residents (Resident #67, #46, #48, #70 and #5) reviewed for activities.<BR/>The facility did not provide routine activities for Residents #67, #46, #48, #70 and #5.<BR/>The failure could affect residents by placing them at risk for depression, boredom, and decreased quality of life. <BR/>Findings included:<BR/>1. Record Review of Resident #67's Quarterly MDS dated [DATE] revealed resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #67 diagnoses included: Metabolic Encephalopathy (brain dysfunction due to disease or toxins in body), Dementia (loss of cognition), Hypotension (low blood pressure), and a BIMS score of 11 (moderately impaired cognition).<BR/>Record review of Resident #67's Care Plan dated 11/28/2023 revealed resident would maintain involvement in cognition stimulation and social activities.<BR/>Interview on 03/10/2024 at 11:00 a.m. with Resident #67 revealed she used to enjoy walking the most and group activities. Resident #67 stated she had not participated in group activities lately and felt isolated and sad. Resident #67 cried and stated that she felt forgotten and was not sure why the activities had not occurred.<BR/>Interview on 3/11/24 at 11:00 a.m. with Resident Council revealed 5/5 said they have Bingo on Thursdays for activities, but no other activities.<BR/>Interview and observation on 3/11/24 at 12:40 p.m. with Administrator of the activity calendar (located down the 300-hall going towards the dining hall). The Administrator stated a smaller copy was placed inside each resident's room. She stated the receptionist was taking over for the activity director while she was out on FMLA. The Activity Director has been out 1 week and will be back in 5 weeks. The Administrator said the receptionist was not certified as an activities director and she will check to see if she needs to be while she was covering.<BR/>Observed Activity Calendar on 3/11/24 at 12:41 p.m. in the 300-hallway going towards dining hall revealed there are three activities listed for each day at 10:30 a.m., 11 a.m. and 1, 2 or 3 p.m. during the week. Also, activities listed on Saturdays at 8 a.m. and 11 a.m. or 2 p.m. and Sundays at 8 a.m. and Church at 10 a.m. The Bingo activity was list at 2 p.m. on Mondays, Wednesdays, and Fridays.<BR/>2. <BR/>Record Review of Resident #46 revealed a [AGE] year-old female with an initial admission date of 3/17/22 and a readmission date of 3/22/23. Resident #46's diagnoses included: Major Depressive Disorder, Anxiety Disorder, Altered Mental Status, Dementia w/o Behavior, Psychotic or Mood disturbances and Cognitive Communication Deficit.<BR/>Record Review of Resident #46's MDS dated [DATE], indicated she had a BIMS of 10 which indicated she was slightly impaired.<BR/>Record Review of Resident #46's Care Plan dated 1/10/24, showed the resident attends activities of choice and needs invitation to large group activities due to cognitive loss and her goal was to enjoy activities three times per week. Also, the Care Plan stated resident preferred Activities outside, Cooking Class, Bingo, Exercise, and tv-radio. Resident #46 attends Resident Council and Gardening.<BR/>Interview and observation on 3/11/24 at 12:50 p.m. Resident #46was showed the list of calendar activities in her room. She knew the calendar was there but was not aware of any activities occurring except Bingo. She used to work outside and be outside all the time, but there are no outside activities other than smokers going out to smoke. She said there has never been popcorn as listed on the calendar and she has been at the facility 1 &frac12; year.<BR/>3. <BR/>Record Review of Resident #48 revealed a [AGE] year-old female with an admission date of 11/10/23. Resident #48's diagnoses included: Cognitive Communication Deficit, Major Depressive Disorder and Bipolar Disorder.<BR/>Record Review of Resident #48's MDS dated [DATE], indicated she had a BIMS score of 13 which indicated she was cognitively intact.<BR/>Record Review of Resident #48's Care Plan dated 2/20/24, showed the resident attends activities of choice and her goal was to enjoy activities three times a week. Also, the care plan stated the resident preferred activities outside, Party/social, exercise, family visits, and tv/radio. Resident #48 attends Resident council and Gardening.<BR/>Interview on 3/11/24 at 12:55 p.m. Resident #48 said the facility only does Bingo and that was only once a week. She does not like Bingo. Resident #48 said the facility only did Bingo when the activity director was here. Resident said they used to have outings and take people to the store in the van, but they do not do that anymore. She would like to go on outings if they still did them.<BR/>4. <BR/>Review of Resident #70's face sheet revealed a [AGE] year-old female with an admission date of 1/23/24. Resident #70's diagnoses included: Cerebral Infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Altered Mental Status and Depression.<BR/>Review of Resident #70's MDS dated [DATE], indicated she had a BIMS of 15 (cognitively intact).<BR/>Review of Resident # 70's Care Plan dated 1/31/24, showed the resident is independent on staff for meeting emotional, intellectual, physical, and social needs. Resident # 70's goal is: the resident will maintain involvement in cognitive stimulation, social activities as desired through review date.<BR/>Interview on 3/13/24 at 11:47 a.m. Resident #70, stated they usually did Bingo for activities but since the activities director was out on leave, they have not been doing bingo. She said they would usually do bingo two times a week but not anymore. She gave suggestions for coloring if people wanted to, but they never did anything but bingo. She said the staff make sure the residents go outside to smoke every two hours and that takes a priority. She said they are not doing any activities since the activities director left. Resident #70 was not aware the facility did bingo yesterday and announced over the speaker. She stated she could not hear the announcements in her room.<BR/>5. <BR/>Record Review of Resident #5's was a [AGE] year-old female with an initial admission date of 12/17/2020 and a readmission date of 12/15/2023. Resident #5's diagnoses included: Traumatic Subarachnoid Hemorrhage (burst blood vessel in the brain), Need for assistance with personal care, Mild Intellectual Disabilities, Bipolar type schizoaffective disorder (mood disorder with periods of intense feelings), and Type-1 Diabetes (autoimmune disease that attacks cells in the pancreas). Review of Resident #5's MDS dated [DATE], indicated a BIMS score of 9 (moderately impaired).<BR/>Record review of Resident #5's Care Plan dated 02/01/2021 and revised on 01/17/2024 revealed resident needed invitation to large group activities due to cognitive loss and was to be provided a program of activities that is of interest and empowers resident.<BR/>Interview on 03/13/2024 at 1:51 PM with Resident #5 revealed she wanted to play bingo and liked that activity the most. Resident #5 asked CNA B for a coloring book and CNA B assisted resident to common area. Resident #5 told CNA B that she wanted to play bingo. CNA B told Resident #5 she was not sure if bingo was going to happen today and would find out.<BR/>Interview on 03/13/2024 at 1:55 PM with CNA B revealed Fun Time Fitness and Christian Music was on the calendar for earlier in the day but had not yet occurred. CNA B stated that yesterday, 03/12/2024, the only activity that occurred on 500 hall was coloring sometime after 9 AM.<BR/>Interview on 3/13/24 at 3:02 p.m. the Receptionist said she was the receptionist and her last day in that position was Friday, 3/15/24. She was waiting to hear if she will be covering for the activity director who has been gone for about 2 weeks and will be back in May. The receptionist retired early and was only off 2 months and came back as a receptionist for Focus. Before she retired early, she was an activities director for 22 years at another facility.<BR/>Interview on 3/13/24 at 3:05 p.m. with Administrator/Admin said she checked with her corporate office and was told the receptionist did not need to be certified to cover for the activity director. She said if the activities director did not come back, then she would need to have a certified person be activities director. Administrator said the receptionist did Bingo today and yesterday. Admin said AD would do morning exercises, have church services and Hospice would come in and do things with the residents. Admin verified activities were announced over the intercom system. She said she would make sure CNAs are asking resident about going to activities. <BR/>Interview on 3/14/24 at 11:20 a.m. with receptionist said Admin told her she would be covering for the activity director while she was on leave. She was doing both jobs this week; she goes to the locked unit to do exercises with them from 9:30 - 10, comes back and watches the front door and then at 10:30 a.m. - 11, she does exercises with the other residents. Then, it was smoke break time for residents, so she was back up front. Admin let her know some residents cannot hear the intercom system and the nurses will be letting her know who needs 1:1 activity. Also, she was getting staff to help her get residents out of their rooms.<BR/>Review of facility's policy Life Enrichment Activity Guidelines dated 04/2020 reflected the facility will provide based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident encouraging both independence and interaction in the community .6. Individualized and group activities are provided that: Reflect the schedules, choices and rights of the residents. b. Are offered at hours convenient to the residents .c. Reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of four (Resident #51) residents reviewed for wound care.<BR/>RN D failed to provide Resident #51 her prescribed wound care on 03/09/24. <BR/>This failure could place residents at risk for a decline in the resident's condition, increased risk of infection and decline in wound healing. <BR/> Findings Included:<BR/>Review of Resident #51's Quarterly MDS assessment dated 12/2924 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident was cognitively intact with a BIMS of 14. She was always incontinent of bladder and frequently incontinent of bowel, required substantial to extensive assistance with ADL care and was high risk for pressure ulcer/injury. She had no skin issues at the time of assessment. Resident #51 had active diagnoses which included hemiplegia affecting right dominant side (paralysis), muscle weakness, cerebrovascular accident (stroke), and seizure disorder. <BR/>Review of Resident #51's care plan updated 03/13/24, reflected, The resident has a venous/stasis ulcer of the left lower extremity .Interventions .Document progress in wound healing on an ongoing basis. Notify physician as indicated .Weekly treatment documentation to include measurement of each area of skin breakdown .<BR/>Review of Resident #51's Physician order Summary with a start date of 03/01/24, reflected, .Left lower extremity: Cleanse with normal saline, pat dry, apply Xeroform (mesh gauze occlusive dressing used for low drainage wounds) to fit wound bed, cover with dry dressing. Perform daily and PRN for soiling and dislodgement every day shift for [sic]promote healing .<BR/>Review of Resident #51's March 2024 TAR reflected no documentation that wound care had been completed on 03/09/24.<BR/>In an interview with Resident #51 on 03/10/24 at 10:40 AM she stated she had a wound on her left lower leg due to lymphoedema (swelling caused by blocked lymph nodes). She stated the staff had been changing the bandage daily but had missed yesterday. She stated she should had let someone know but had forgot about it. <BR/>In an observation and interview of wound care on Resident #51 by RN G on 03/10/24 at 03:00 PM, revealed her at the treatment cart. RN G placed gauze, a pair of scissors, and a Xeroform dressing (mesh gauze occlusive dressing used for low drainage wounds) and a dry dressing in a plastic sack. RN G entered the resident's room and placed the sack of supplies onto the bed and then washed her hands and put on gloves. RN G pulled back the covers and revealed the dressing on Resident #51's left lower leg revealed a date of 03/08/24. RN G stated she had changed the dressing on Friday 03/08/24 and it appeared no one had changed it on 03/09/24. RN G removed the old dressing slowly since it had dried and was stuck to the wound bed of the venous ulcer located on the front of the residents left lower leg. RN G reached into the plastic sack and retrieved a vial of normal saline and wet the old dressing to help facilitate removal. Once the dressing was removed the wound bed had some slough present with minimal drainage. RN G stated the wound looked a little better. She opened the package of Xeroform and cut it to size for the wound bed and covered the wound with the Xeroform dressing and covered it with the border dressing, RN G then dated the dressing with a date of 03/10/24. <BR/>In an interview with RN G on 03/10/24 at 03:10 PM, she stated she did not work yesterday and thought RN D had worked this hall yesterday (03/09/24). She stated Resident #51's dressing was to be changed daily and was not sure why the wound care had not been done. She stated they had been very short handed for several weeks. She stated failing to provide daily wound care could also cause the wound to worsen and become infected. <BR/>In an interview with RN D on 03/10/24 at 03:45 PM, she stated she was the charge nurse for hall 100 on 03/09/24. She stated she did not change the dressing on Resident #51's leg yesterday but had completed Resident #15's wound care and shower. She stated they were doing their best to get patient care done since they were so shorthanded. She stated there had been only 2 nurses, when they usually had 3 for several months and they had really been short on aides, which required the Nursing staff to help more on the floor. She stated she knew it was important for the daily wound care to be done to prevent further decline in the wound, she just did not get it done and failed to alert the oncoming shift. <BR/>In an interview with the DON on 03/11/24 at 12:45 PM, she stated due to the shortage of staff the Treatment nurse had been working the floor covering shifts for the last 3 weeks. She stated due to this they had an in-service with the staff sometime in February letting them know they would be responsible for the wound care on their assigned halls. She stated they had double weekend staff and they had always been responsible for the wound care on the weekend. She stated she was not aware the wound care had not been completed on Resident #51. She stated if the nurse had not been able to complete it, the following shift should have completed it. She stated it was the expectation all wound care was to be completed and documented as ordered to prevent further decline of the wound. <BR/>In an interview with the Administrator on 03/12/24 at 09:30 AM she stated she knew the Treatment nurse was stepping down and had been filling in on the floor a lot but was not aware of the number of calls in they were having. She stated it was her understanding they had instructed the nurses they were to be doing their own wound care. She stated she would have expected the DON to be monitoring the MAR and TAR to ensure wound care was being completed. She stated failing to provide wound care and failing to notify the physician about changes in the residents, and delays in care were a form of neglect which could lead to a decline of the resident's well-being. <BR/>Review of the facility's policy titled, Skin Management: Prevention and Treatment of wounds, dated, November 2019, reflected, The purpose of this procedure is for prevention, and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds .Treatment .A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto the resident's treatment record for follow up .Wound care dressing are dated and initialed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication error rate was not 5% or greater. The facility had a medication error rate of 6.45%, based on 2 errors of 31 opportunities, which involved two of four residents (Residents #35 and #23) and one of three staff observed during medication administration for medication errors in that-. <BR/>1. MA F failed to administer Resident #35's Pantoprazole 40 mg on 03/10/24 as ordered by the physician. <BR/>2. MA F failed to administer Resident #23's Omeprazole 20 mg on 03/10/24 as ordered by the physician. <BR/>This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>The findings include:<BR/>1. Record review of Resident #35's Face sheet, dated 03/14/24, reflected a [AGE] year-old male with an admission date of 11/29/23. Resident #33 had a diagnoses which included diverticulitis (inflammation of the digestive tract), gastro-esophageal reflux (condition where stomach content moves up into the esophagus, and hypertension (high blood pressure).<BR/>A record review of Resident #35's admission MDS assessment, dated 12/14/23, revealed a BIMS score of 14, which indicated he was cognitively intact. <BR/>A record review of Resident #35's Physician's order Summary report dated 03/14/24, reflected Resident #35 was to receive the following medications daily: <BR/>Pantoprazole (acid inhibitor) 40 mg 1 tablet. <BR/>During a medication pass observation on 03/10/24 at 09:50 AM revealed MA F administered the following medications: Amiodarone (antiarrhythmic) 200 mg 1 tablet, Cetirizine( antihistamine)10 mg 1 tablet, Stool Softener 100 mg 1 capsule, Divalproex (anticonvulsant) Delayed release 500 mg 1 tablet, Eliquis (blood thinner) 5 mg 1 tablet, Ferrous Sulfate (iron supplement) 325 mg 1 tablet, Vit B-12 (mineral)1000 mcg 1 tablet, Cholecalciferol 1000 units (Vit D3-50) 1 tablet, Multivitamin (mineral) 1 tablet, Hydrochlorothiazide (diuretic) 12.5 mg 1 tablet, Lamotrigine (anticonvulsant) 25 mg 1 tablet, Metoprolol (blood pressure) 25 mg 2 tablets. <BR/>In an interview with MA F on 03/10/24 at 09:55 AM, she stated the Pantoprazole 40 mg was on order and had not arrived at the facility for her to give this morning.<BR/>2. Record review of Resident #23's Face sheet, dated 03/14/24, reflected a [AGE] year-old male with an admission date of 07/19/23. Resident #23 had a diagnosis which included diabetes and hypertension (high blood pressure) .<BR/>A record review of Resident #23's Quarterly MDS assessment, dated 01/10/24, revealed a BIMS score of 11, which indicated he was moderately cognitively impaired. <BR/>A record review of Resident #35's Physician's order Summary report dated 03/14/24, reflected Resident #23 was to receive the following medications daily: Omeprazole (acid inhibitor) 20 mg capsule delayed release. <BR/>During a medication pass observation on 03/10/24 at 10:00 AM revealed MA F administered the following medications: Atorvastatin (statin) 40 mg 1 tablet, Lorazepam (antianxiety) 1 mg 1 tablet, Stool Softener 100 mg 1 capsule, Divalproex (anticonvulsant) Delayed release 500 mg 2 tablet, Benztropine (Anti tremor) 1 mg 1 tablet, Hydrochlorothiazide (diuretic) 25 mg 1 tablet, Carvedilol (blood pressure) 12.5 mg 1 tablet, Fluphenazine (antipsychotic) 5 mg 2 tablets, Paliperidon extended release (antipsychotic) 6 mg 1 tablet, Levetiracetam (anticonvulsant) 1000 mg 1 tablet, Metformin (diabetes) 500 mg 1 tablet, Venlafaxine (antidepressant) extended release, 75 mg 1 tablet, Losartan (blood pressure) 25 mg 1 tablet, Sertraline (Antidepressant) 50 mg 1 tablet, Sertraline (Antidepressant) 50 mg 1/2 tablet. <BR/>In an interview with MA F on 03/10/24 at 10:30 AM, she stated she did not give the Omeprazole because it was a house stock medication and there was none in the medication room. She stated she assumed it had been ordered and had not come in. <BR/>Interview with the DON on 03/11/24 at 01:10 PM, she stated it was the expectation the Medication aides alert the Nurse if they were out of a medication, so they could get it from the Emergency-Kit. If the medication was not available in the Emergency-kit, then they had to notify the doctor for further instructions. She stated if it was an Over-the-Counter medication or facility stock medication then they would go locally and pick up the necessary medications. She stated she ordered stock medications every week and was certain they had Omeprazole on hand. She stated failure to administer the medications could impact the resident's health depending on which medication had been omitted. <BR/>Medication room observation with RN G on 03/11/24 at 02:10 PM revealed 5 bottles of omeprazole in the cabinet. RN G checked the Emergency- Kit system and determined Pantoprazole 40 mg extended release was available. RN K stated MA F never told her yesterday (03/10/24) she did not give a medication to Resident #35 and Resident #23. She stated they were always to let her know so she could check the Emergency-Kit or if it was an Over the Counter they did not have on hand, she could send out for the medication. She stated if they were not able to get the medication then they had to call the physician for further instructions. <BR/>In a follow up Interview with MA F on 03/13/24 at 11:50 AM, she stated she had never been told she was to let the nurse know when she did not have a medication available and was not aware they could get medication from the Emergency-Kit. She stated she just overlooked the omeprazole when she had checked the medication room. She stated she had been told by one of medication aides who trained her, all she was supposed to do was document why it was not given and reorder the medication if it had not already been re-ordered. She stated in the future she would notify the nurse. <BR/>Record review of the facility policy titled Administration Procedure for All Medications, dated August 2020, reflected, .Notify the attending physician and /or prescriber of .Persistent refusals .Held medication .<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Residents #18) reviewed for dental services.<BR/>The facility failed to provide timely dental services for Resident #18 and follow up on dental referral. <BR/>This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.<BR/>Findings included: <BR/>Record review of Resident #18's Quarterly MDS dated [DATE] revealed she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of bi-polar type schizoaffective disorder (episodes of extreme mood swings including delusions), encephalopathy, dementia (loss of cognitive function), hypertension (high blood pressure) and a BIMS score of 99 indicating resident was unable to complete interview.<BR/>Record review of Resident #18's nurse's progress note dated 02/16/2024 by SSD revealed Resident #18 requested a dental referral because it was difficult for her to chew some foods. <BR/>Interview with Resident #18's family member on 03/11/2024 at 12:00 PM revealed Resident #18 was non-responsive to questions for the past 2 weeks due to depression, which was typical of resident's bi-polar disorder. The family member stated he thinks that sometimes Resident #18's teeth will hurt and thinks Resident #18 would need to have remaining teeth pulled and use dentures. <BR/>Observation and interview on 03/11/2024 at 12:05 PM of Resident #18 teeth revealed the top and bottom jaw were missing many teeth, with black, brown, and yellowed areas on the remaining teeth. <BR/>Interview on 03/13/2024 at 1:51 PM with CNA B revealed when Resident #18 was not in a depressive state she will ask for a dentist and wanted to have dentures. CNA B stated she had told the previous Social Services Director (SSD) and was not sure if the new SSD was aware. <BR/>Interview on 03/14/2024 at 10:21 AM with the SSD revealed that she was aware Resident #18 was in need of dental services because she had discussed it during a meeting with resident on 02/16/2024. The SSD stated that she sent referral on 02/19/2024 to dental services through email. The SSD stated the process for dental referrals was to send the name of residents that needed to be seen and include resident face sheet. The SSD stated she did not have a good system for tracking referrals. The SSD stated she wouldn't know if a resident had been seen unless she saw it happen or if she asked resident. The SSD stated she was not sure if Resident #18 had received dental services yet. The SSD stated dental visited at facility 03/13/24 for a different resident and didn't think they saw Resident #18. The SSD stated she sent another referral via email to dental services on 03/10/2024 because Resident #18 was not seen for their February 2024 visit. The The SSD stated she planned to email dental services and ask for Resident #18 to be seen sooner and was not sure if they would accommodate. <BR/>Interview on 03/14/2024 at 4:45 PM with the Administrator revealed she was unaware Resident #18 was in need of dental services and had not been seen. The Administrator stated that the expectation was for residents to receive timely dental referrals and the SSD was responsible for referrals and ensuring follow up was done. The Administrator stated SSD was new and they were still figuring out a system. The Administrator stated risk to resident was pain or infection from missed dental visits. <BR/>Record review on 03/14/2024 at 4:55 PM of Social Services policy dated 12/21/2021 revealed the SSD was responsible for making referrals to social service, maintaining regular progress, and follow up notes.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one (Dietary Manager) of three dietary staff reviewed for qualifications. <BR/>The facility failed to employ a qualified Dietary Manager.<BR/>This failure could place the residents at risk of not being provided a nutritional well-balanced diet and not have their dietary needs identified and addressed.<BR/>Findings included:<BR/>Review of the Dietary Manager's employee file revealed a hire date of 12/30/21 and she had food handlers' training certificate dated 08/04/22 with expiration date of 08/04/24. She did not have certified dietary manager certificate or ServeSafe Manager certification in her file. The Dietary Manager did not have an associate degree or higher in food service management or in hospitality. The Dietary Manager's job description was not in the employee's file. <BR/>Interview on 02/07/23 at 10:13 AM revealed the Dietary Manager stated she started working at the facility as the Dietary Manager since August 2022.<BR/>Interview on 02/09/23 at 12:50 and 1:18 PM with the Dietary Manager revealed she was in the process of completing modules in an online course for the Dietary Manager Certification which she started the online course in October 2022 and had 13 months to complete getting certified. She stated the Consultant Dietitian visited the facility twice a month. She stated she was not aware she had to complete ServeSafe Manager training and did not know anything about this training. <BR/>Interview on 02/09/23 at 1:12 PM with the Administrator revealed she thought the Dietary Manager's job description was in her file and signed by the Dietary Manager. She stated the Consultant Dietitian was overseeing the Dietary Manger while she worked on her dietary manager certificate. She stated she was not aware the Dietary Manager needed to complete ServeSafe Manager training prior to working in the kitchen. She stated she was not aware if the Dietary Manager had taken the ServeSafe Manager training. She stated the consultant dietitian came to facility twice a month and was not full time at the facility. <BR/>Interview on 02/09/23 at 1:52 PM with Consultant Dietitian revealed the Dietary Manager did have a food handlers license and was not aware the Dietary Manger had to complete the ServeSafe Manager training prior to working in the kitchen. She stated she was available for the Dietary Manager to consult with her and came to facility twice a month. She stated she had provided the Dietary Manger a food manager booklet and the Dietary Manager was working on her online course work to get her certification as a dietary manager. She stated she did go over kitchen sanitation issues with the Dietary Manager and the Administrator when she visited twice a month. <BR/>Review of facility's job description for the Director of Food and Nutrition Services revised March 2022 reflected one of the primary purposes of the job was directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility. Under qualifications it reflected ServeSafe Manager Certification required to be presented during orientation/before working in the kitchen if not CDM (Certified Dietary Manager) and holds a current and valid Food Service Manager/Dietary Manager Certificate or CDM Certification or CDM Exam eligibility .If verifiable proof of CDM Credential or CDM Exam eligibility is not provided, applicant will be required to enroll in an ANFP approved CDM course within 30 days of hire and complete all course work and testing within 12 months of hire.<BR/>Review of the facility's policy Food and Nutrition Services Staff revised October 2017 reflected The food Services Department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department .

Based on observations, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure refrigerator item in walk -in refrigerator was labeled, dated and sealed.<BR/>2. The facility failed to ensure black refrigerator unit with freezer on top and drink cooler freezer had thermometers. The facility failed to document temperatures. The facility failed to ensure cleanliness of drink cooler freezer.<BR/>3. The facility failed to ensure the Dietary Manager and Food Service Manager E washed their hands when touching PPE and changing gloves during lunch preparation on 02/08/23.<BR/>4. The facility failed to ensure hamburger patties' food temperature was taken after cooked and before served to residents for lunch on 02/08/23.<BR/>5. The facility failed to ensure the low temperature dish machine was meeting the temperature of 120 degrees Fahrenheit for wash and rinse cycle.<BR/>6. The facility failed to ensure trays and bowls were allowed to air dry before use at lunch on 02/08/23. Dietary Aide G failed to ensure plates air dried before stacking plates on top of one another on 02/08/23. <BR/>These failures could place residents at risk for food-borne illness and food contamination.<BR/>Findings included:<BR/>1. Observation on 02/07/23 at 9:52 AM revealed the walk-in refrigerator had fries in a plastic bag unsealed, open about 2 inches and not dated when opened.<BR/>Interview on 02/07/23 at 9:54 AM with Dietary Aide F revealed the fries should be dated and sealed properly.<BR/>Interview on 02/07/23 at 10:13 AM with the Dietary Manager revealed refrigerated food items should be dated when opened, labeled and sealed properly .<BR/>2. Observation on 02/07/23 at 9:56 AM revealed the drink freezer had numerous food stains and debris on the bottom along with a wrapper stuck to bottom of freezer. There was a box of individual vanilla ice cream containers. There was no thermometer in the drink freezer.<BR/>Interview on 02/07/23 at 9:57 AM with Dietary Aide F revealed she did not know the ice cream was in the drink cooler freezer and did not know where the thermometer was.<BR/>Interview at 02/07/23 at 9:58 AM with Food Service Manager I revealed he thought they did not use the drink freezer and was unaware that the ice cream containers were in the freezer. He stated he did not know where thermometer was for the drink freezer.<BR/>Observations on 02/07/23 at 9:50 AM revealed the black refrigerator unit with freezer on top which contained bread in refrigerator and freezer had no temperature log or thermometer in it. Dietary Aide F could not find a thermometer in the black refrigerator.<BR/>Observation and interview on 02/07/23 at 9:59 AM revealed the Dietary Manager was unable to find a thermometer in the black refrigerator unit with freezer on top. <BR/>Interviews on 02/07/23 at 10:04 AM and 10:13 AM with the Dietary Manager revealed the black refrigerator/freezer in the dining room started to be used about a month ago so they could keep bread in it. She stated she would put a thermometer in the black freezer and refrigerator so they could know the temperatures. She stated they did not have a log for the temperatures of the refrigerator/freezer. She stated she was not aware of the drink freezer being used and did not know anyone had stored the ice cream in there. She stated the drink freezer should have a thermometer and be kept clean when in use. She stated when there was no thermometer in refrigerator or freezer they were unable to know whether cold foods were being kept within appropriate temperatures.<BR/>Review of facility's policy Food Receiving and Storage revised October 2017 reflected Food shall be received and stored in a manner that complies with safe food handling practices .Food Services, or other designated staff, will maintain clean food storage areas at all times .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date) .12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.<BR/>Review of facility's policy Refrigerators and Freezers revised December 2014 reflected facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .1. Acceptable temperature ranges are 35 F to 40 F for refrigerators and less than 0 for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.3. Monthly tracking sheets will include time, temperature, initial, and 'action taken.' 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening .7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and individual items removed from cases for storage .10. Refrigeration and freezers will be kept clean, free of debris .<BR/>Review of facility's policy Food Preparation and Service revised October 2017 reflected Thermometers will be placed in hot and cold storage areas and checked for accuracy in accordance with accepted public health standards.<BR/>3. Observation on 02/08/23 at 11:40 AM revealed Food Service Manager E touched her surgical mask with her gloved hands and then started plating food for residents with her gloved hands touching inward of the residents plates. She did not change her gloves or wash her hands. At 11:47 AM she touched her face shield with her gloved hands. She did not change her gloves or wash her hands. She continued to plate food for the residents with her gloved hands touching the inward part of the residents plates.<BR/>Observation on 02/08/23 at 11:52 AM revealed the Dietary Manger touched her face goggles with her gloved hands to adjust them on her face. She did not change her gloves or wash her hands. She continued to place plate covers over the residents plates and condiments on meal trays.<BR/>Interview on 02/08/23 at 12:35 PM with Food Service Manager E revealed she did touch her surgical mask, did not change her gloves and failed to wash her hands like she should have. <BR/>Interview on 02/08/23 at 12:37 PM with Dietary Manager revealed she and Food Service Manager E should have changed their gloves and washed their hands after touching their PPE. The Dietary Manager stated when they contaminated their gloves, they needed to change their gloves and wash their hands prior to putting on new gloves. <BR/>Review of the facility's policy Food Preparation and Service revised October 2017 reflected Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness.<BR/>Review of The US Public Health Service Food Code, dated 2017, retrieved 02/16/23, reflected the following regarding hand hygiene, 2-301.14 When to Wash Food employees shall clean their hands and exposed portions of their arms as specified under &sect; 2-301.12 immediately before engaging in food preparation including working with exposed Food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; . (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat foods; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the Hands.<BR/>4. Observation on 02/08/23 at 12:15 PM revealed frozen hamburger patties were cooking in water over the stove top. At 12:24 PM the hamburger patties' temperature were not checked prior to being placed on meal trays for residents and placed on hall trays. At 12:32 PM there were additional frozen hamburger patties cooked in water on the stove top and hamburger patties temperature was not checked. At 12:37 PM the cooked hamburger patties went out on lunch meals trays to three residents for hall trays for 300 hall and on a lunch test tray. <BR/>Observation on 02/08/23 at 12:41 PM the facility staff were passing out resident meal trays on the 300 hall. At 12:48 PM last hall meal tray for the 300 hall was served to a resident. Observation at 12:50 PM of the lunch test tray included one cooked hamburger patty in a bun . The patty was temped at 136.3 degrees F and the hamburger patty was barely warm. <BR/>Interview on 02/08/23 at 1:05 PM with the Dietary Manager revealed the hamburger patties were usually temped prior to being served to ensure the temperature was appropriate and maintained until resident meal trays were passed out. She stated they should have checked the food temperature of the hamburgers prior to serving them to ensure the hamburger patties were at the appropriate temperature of at least 160 degrees Fahrenheit .<BR/>5. Observation and interview on 02/08/23 at 3:16 PM revealed the dish machine temperature was 100 degrees Fahrenheit for wash and rinse. A 2nd observation at 3:18 PM revealed 100 degrees wash and 102 degrees Fahrenheit rinse. Interview with Dietary Aide G revealed in the morning dish machine's wash and rinse temperature was checked. He stated he did not know what the minimum temperature was for the wash and rinse since he was new and did not check the dish machine temperature.<BR/>Observation and Interview on 02/08/23 at 3:23 PM revealed the Dietary Manager checked the dish machine temperatures and it was only 101 degrees Fahrenheit for wash cycle. She stated it is supposed to be 120 degrees Fahrenheit minimum for wash and rinse for the facility's low temperature dish machine. She stated she would talk with the Dir of Plant Operations to have him look at it. She stated she told Dietary Aide G to stop using the dish machine until they got it working. She stated earlier today the dish machine was 120 degrees Fahrenheit or above for wash and rinse when it was checked.<BR/>Interview on 02/08/23 at 3:40 PM with the Administrator revealed she was informed about the dish machine temperature being too low and they would have the dish machine representative come out to look at it if the Dir of Plant Operations was unable to get it working properly, he was looking at it now. She stated they would start using Styrofoam containers if they were not able to get the dish machine working until it is fixed. <BR/>Interview on 02/09/23 at 9:10 AM with the Dir of Plant Operations revealed the dish machine was still not meeting 120 degrees Fahrenheit minimum for wash and rinse. He stated he looked at the booster for dish machine but it did not help the temperatures. He stated he was waiting for the representative from the dish machine company to look at it today.<BR/>Review of dish machine's installation and operation manual dated 12/05/07 from http://manuals.jacksonmsc.com/ecolab%20manuals/ES-2000%20&%20ES-4000%20Rev%20O.pdf reflected under section 1 the dish machine required a minimum temperature of wash and rinse of 120 degrees Fahrenheit. <BR/>6. Observations on 02/08/23 at 11:54 AM revealed resident meal lunch trays had water droplets on them and were used for resident meal trays for lunch. Bowls were stored in different directions in a plastic container with water droplets inside the bowls. Food Service Manager E used bowls from the container for food for the residents' lunch.<BR/>Interview on 02/08/23 at 12:36 PM with the Dietary Manager revealed they did not have the space in the kitchen to allow for dishware like trays, plates and bowls to air dry prior to use. She stated they had very limited counter space. <BR/>Observation on 02/08/23 at 3:15 PM revealed Dietary Aide G took plates from dish rack which just came out of the dish machine. Dietary Aide G started stacking them on top of other plates. He did not allow them to air dry.<BR/>Interview on 02/09/23 at 1:52 PM with Consultant Dietitian revealed dietary staff should change gloves and wash their hands when they touch anything that could contaminate them before putting on new gloves. She stated the refrigerator and freezers should have a thermometer in them to ensure temperatures were maintained. She stated the dish machine should have been working to meet the appropriate temperature requirements. She stated the hamburger patties' food temperature should have been checked prior to be served to ensure hamburger patties' food temperature met serving temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs and preferences for three (Residents #26, #4 and #5) of nine residents reviewed for call lights. <BR/>1. Facility failed to ensure Resident #26's call button was within reach of Resident #26 while she was lying in bed.<BR/>2. Facility failed to ensure Resident #4's call button was within reach of Resident #4 while she was lying in bed. <BR/>3. Facility failed to ensure Resident #5's call button was within reach of Resident #5 while she was lying in bed.<BR/>These failures could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity.<BR/>Findings included:<BR/>1. Review of Resident #26's Annual MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinsons disease, stroke, diabetes, seizures and chronic obstructive pulmonary disease. Resident #26 had a BIMS of 8 indicating she was moderately cognitively impaired. She required extensive assistance with ADLs of bed mobility, dressing, toileting, hygiene with one to two person assistance .<BR/>Observations on 02/07/23 at 11:21 AM and 11:25 AM revealed Resident # 26 was lying in bed with the call button not within reach. The call button was located about 3 feet away from Resident #26's bed on a pile of stuff.<BR/>Interview on 02/07/23 at 11:21 AM with Resident #26 revealed her call button was not within reach and she used it when it was in reach to get assistance from staff. She stated she would fall out of the bed trying to reach for the call button and had fallen before in her room. <BR/>Interview on 02/07/23 at 11:26 AM with the ADON revealed Resident #26's call button should have been within reach and she would talk to the aides about ensuring call lights were within reach of residents. She stated Resident #26 did use the call button to ask for assistance. <BR/>2. Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of heart failure, hypertension, Alzheimer's disease, Parkinson's disease, schizophrenia and chronic obstructive pulmonary disease. Resident #4 had a BIMS of 11 indicating she was moderately cognitively impaired. She required extensive assistance with most ADLs except limited assistance with transfers. <BR/>Review of Resident #4's Comprehensive Care Plan last revised 01/24/23 reflected Resident #4 was at an increased risk for falls as evidenced by a history of falls, cognitive impairment, physical impairment, unsteady gait, generalized weakness. Interventions included to Anticipate needs, provide prompt assistance and Ensure call light in in reach and answer promptly.<BR/>Observation and interview on 02/07/23 at 11:34 AM revealed Resident # 4 was lying in bed with the call button about 3 feet away from her. Resident #4 stated her call light was not working for the last 2 days and was not within reach for her to use. <BR/>Interview on 02/07/23 at 11:37 AM with the Director of Plant Operations revealed he had to replaced the bulb (light in the hallway) since it was not lighting up when Resident #4 pressed her call button. At 11:43 AM the Director of Plant Operations stated he was not aware of residents in room [ROOM NUMBER]'s call light not working and was unaware the bulb went out until when he just looked at it. He stated he checked the resident call lights monthly.<BR/>3. Review of Resident #5's significant change MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of kidney failure, hypertension, arthritis, stroke and hemiplegia/hemiparesis on right side (weakness on side which caused paralysis). She had a BIMS of 9 indicating she was moderately cognitively impaired. She required extensive assistance with ADLs except eating was supervision and toileting was total dependence. <BR/>Observation and interview on 02/07/23 at 11:38 AM revealed Resident #5 was lying in bed with the call button not within reach. The call button was about 4 feet away from her bed, hanging down vertically from the wall. Resident #5 stated she would use the call button if it was within reach of her while in her bed .<BR/>Interview on 02/07/23 at 11:39 AM with the ADON revealed the call buttons should be within reach of the residents while in bed so they could use it to ask for assistance. She stated not having a call button within reach can place residents at risk for falls and a delay in getting assistance from staff when needed. She stated Resident #4 and #5's call buttons were not within reach of the residents and both residents used their call buttons. She told the CNAs on her hall to check and ensure call buttons are within reach of residents. She stated she was not aware of Resident room [ROOM NUMBER]'s light bulb in the hallway not working to alert staff in the hallway 600 about the call light being on.<BR/>Interview on 02/07/23 at 2:40 PM with the Administrator revealed call buttons should be within reach of residents and working properly. She stated the staff had been in-serviced recently on call lights. <BR/>Interview on 02/08/23 at 11:00 AM with LVN C revealed they had a recent in-service about ensuring call buttons are within reach of residents when in their room. <BR/>Interview on 02/08/23 at 11:42 AM with the Director of Plant Operations revealed he did not have a log he kept checking resident call buttons to ensure they were working. He stated he checked call buttons monthly to ensure they were working and checked different resident rooms on different hallways. <BR/>Interview on 02/09/23 at 10:45 AM with the Administrator revealed the Director of Plant Operations stated he would start a log documenting checking residents' call buttons to ensure they are in working order. She stated focused care partners. which are department heads assigned to resident rooms. would start checking their assigned residents' call buttons to ensure they were working and within reach of residents when they do their resident rounds. <BR/>Review of facility's policy Quality of Life/Accommodation of Needs revised August 2009 reflected the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being .1. The resident's individual needs and preferences shall be accommodated to the extent possible .<BR/>Review of facility's policy Nurse Call effective 08/08/2022 reflected All facilities must ensure that nurse call cords are installed and functioning properly in all patient rooms. The nurse call cords must be easily accessible to patients and located within reach from the patient's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for two (Resident #2 and an unknown Resident) of four residents reviewed for abuse.<BR/>The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 12/13/24 between Resident #2 and an unknown Resident. <BR/>This deficient practice could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings included:<BR/>Record review of the facility policy titled Abuse revised on 01/01/2023, reflected, Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation .All events that involve an allegation of abuse or involved a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of the alleged violation .Protection: It is of utmost importance that a resident(s) suspected of being abused, and other residents must be protected during the initial identification, and investigation process . <BR/>Record review of Resident #2's face sheet, dated 03/12/25, reflected Resident #2 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included traumatic subarachnoid hemorrhage (stroke caused by bleeding on the surface of the brain), oropharyngeal phase (difficulty swallowing), altered mental status and dementia.<BR/>Record review of Resident #2's quarterly MDS assessment, dated 01/08/25, reflected Resident #2 had a BIMS of 8, which indicated her cognition was moderately impaired. The MDS reflected Resident #2 had physical and verbal behaviors directed toward others. <BR/>Record review of Resident #2's comprehensive care plan revised 12/31/24, reflected Resident #2 had a Focused area of behavior problem related to low frustration tolerance .history of hitting, propelling wheelchair at a fast pace and running into other residents, grabbing, and screaming at staff, takes off colostomy bag (medical device that collects stool from the body)) and throws it on the floor. The care plan interventions included: administer medications as ordered, monitor and document for side effects and effectiveness, if reasonable, discuss resident's behaviors, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, psych notification for PRN evaluation for increased behaviors, and remove from the situation and take to alternate location as needed. <BR/>Record review of the facility incident reports for 3 months (12/12/24-3/12/25), did not reveal any incidents involving Resident #2 and an unknown Resident on 12/13/24.<BR/>Record review of LVN H written nurse's notes dated 12/13/24 reflected, LVN H was standing out at the med cart in the hall when we heard shouting. Get off me! shouted [Resident #2.] LVN H turned around and witnessed [Resident #2 ] hitting another resident . LVN H immediately walked over to [Resident #2] and educated her about keeping her hands to herself. [Resident #2] started repeating I'm sorry. LVN H asked [Resident #2] to apologize to the resident she hit. [Resident #2] did. In addition, review of LVN H notes revealed no assessed for Resident #2.<BR/>In an interview on 03/12/25 at 11:18 a.m. with Resident #2 revealed she denied she hit anyone. She denied she was in an altercation with anyone. <BR/>In an attempted phone interview on 03/13/25 at 1:50 p.m. with LVN H, left voice message for LVN H to call back the writer . The writer received no returned call prior to the survey exit. <BR/>In an interview on 03/13/25 at 2:49 p.m. with RN J, revealed she had no knowledge of the 12/13/24 incident that involved Resident #2 and an unknown resident. RN J revealed she knew what the abuse reporting policy was. RN J revealed any abuse is to be reported to the abuse coordinator/administrator within 24 hours unless it involves serious bodily injury, then you would report it within 2 hours. <BR/>In an interview on 03/13/25 at 3:06 p.m. with CNA I, revealed she had no knowledge of the 12/13/24 incident that involved Resident #2 and an unknown resident . CNA I revealed any abuse or neglect is to be reported to the charge nurse and administrator immediately. <BR/>In an interview on 03/13/25 at 3:36 p.m. the DON stated she was unaware of the unreported incident. She stated the incident should have been reported per the facility policy. She stated her expectations is for her staff to report all incidents of abuse and neglect within the timeframes per the policy. She stated facility staff is aware of the facility's reporting protocols , which was provided in their trainings. She stated she is responsible for staff trainings on abuse and neglect and reporting policy. She stated failure to report could place other residents at risk for injury or harm. <BR/>In a phone interview on 03/13/25 at 4:28 p.m., the Administrator stated he was the abuse coordinator for the facility. The Administrator stated he was unaware of the unreported incident. The Administrator stated his expectations is for his staff to report all incidents of abuse and neglect within the timeframes per the facility policy. The Administrator stated it was important to report any allegations of abuse and neglect for safety and protection of the residents and try to circumvent other incidents of abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 9 (Resident #4, Resident #26, Resident #16, Resident #2, Resident #36, Resident #41, Resident #52, Resident #5, Resident #47) of 24 residents reviewed for ADLs. <BR/>The facility failed to ensure:<BR/>1- Resident #4, who required extensive assistance, was provided with timely incontinence care on 03/10/24 from 6:30 a.m. to 3:15 p.m.<BR/>2- Resident #26 had her fingernails cleaned and trimmed.<BR/>3- Resident #16 was shaved and not having facial hair.<BR/>4- Resident #2 was shaved and not having facial hair.<BR/>5- Residents #36, #41 and #52 received showers on shower days.<BR/>6- Resident #5 her fingernails cleaned and teeth brushed.<BR/>7- Resident #47 had her fingernails cleaned<BR/>These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>1. Record review of Resident #4's annual MDS assessment, dated 01/25/24, reflected a [AGE] year-old female with an admission dated of 07/10/20. She had a BIMS of 1, indicating she was severely cognitively impaired. Resident #4 required extensive assistance with toileting and personal hygiene and was always incontinent of urinary bladder and bowel. Resident #4 was at risk of pressure ulcers with no current skin issues. Her active diagnoses included dementia, chronic kidney disease and cerebrovascular accident (stroke) and seizure disorder. <BR/>Record review of Resident #4's Comprehensive Care Plan dated 06/17/21, reflected, . [Resident #4] has frequent bladder incontinence and is at risk for skin breakdown Interventions .Change with each incontinent episode and as needed . <BR/>In an observation and interview with Resident #4 on 03/10/24 at 10:35 a.m. revealed the resident in bed with particles of food on her gown and her lips. Resident #4 has no use of her left hand, and her thumb nails appear thick and dark in color. Fall mat in place and bed was in low position. Resident #4 stated she does not get up but would like to get up but stated the staff did not want to get her up. <BR/>In an observation and interview on 03/10/24 at 03:15 p.m. revealed MA A entered Resident #4's room to provide incontinence care and change the resident's gown, which still had food on it. MA A stated this was the first time she had been in to do peri care on the resident since coming on duty at 6 a.m. Resident #4 stated she had not been changed since last night. MA A washed her hands and put on gloves and unfasted the brief and provided peri-care from front to back. MA A assisted the resident onto her left side revealing she was wet but not saturated. Resident #4's skin was intact but had deep crease on the back of her legs from the brief and the wrinkles in the sheet. MA A removed the wet brief and with the same soiled gloves and placed a clean brief under the resident and then cleaned the resident's buttocks with a peri-wipe from front to back. MA A removed her gloves and put on clean gloves without performing hand hygiene and opened a package of barrier cream and applied the cream to the residents' buttocks. MA A rolled the resident back onto her back and fastened the brief and changed her gown. MA A removed her gloves and the washed her hands. <BR/>In an Interview with MA A on 03/10/24 at 03:25 p.m. she stated she had not had time to check the resident before now, since she had been the only aide for 4 halls. She stated the ADON had come in after the survey team had arrived and was helping on the floor. She stated she was not sure if someone else had changed the resident any other time today. She stated incontinent resident were supposed to be changed as soon as possible to prevent skin breakdown. <BR/>Interview with the Weekend Supervisor, RN H on 03/10/24 at 03:32 p.m. she stated she had not provided any incontinences care on any of the residents. <BR/>Interview with MA F on 03/10/24 at 03:36 p.m. stated she had not provided any incontinences care on any of the residents this morning. <BR/>Interview with RN G on 03/10/24 at 03:40 PM stated she had provided incontinent care on residents a few of the residents, but not on Resident #4. <BR/>Interview with the ADON on 03/10/24 at 03:55 PM stated she got to facility between 9:30 AM to 10:00 AM today. She stated she had provided incontinences care to several residents but stated she had not provided any care to Resident #4. She stated they usually did not get Resident #4 up, but if she wanted to get up, they would make sure she was gotten up. She stated they had been very short staffed, and she had worked the floor numerous times in the last week. <BR/>2. Record review of Resident #26's Quarterly MDS assessment dated [DATE] reflected Resident #26 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning), lack of coordination, and cognitive decline. Resident #26's BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #26 required maximal assistance with dressing and personal hygiene. <BR/>Record review of Resident #26's Comprehensive Care Plan, initiated 04/13/21, reflected the following: Focus: Resident at risk for an ADL self-care performance deficit. Goal: Resident will maintain current level of function through the review date. Intervention: personal hygiene/oral care - supervision .<BR/>In an observation and interview on 03/10/24 at 09:25 AM revealed Resident #26 was sitting in bed. The nails on the left hand were approximately 0.2cm in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #26 was confused and the answers to questions did not make sense.<BR/>3. Record review of Resident #16's Comprehensive MDS assessment, dated 01/10/24, reflected Resident #16 was a [AGE] year-old female admitted to the facility on [DATE] with readmission date of 01/08/24. Diagnoses included dementia, muscle weakness, cognitive communication deficit, and parkinson's disease. Resident #16 BIMS score of 9, which indicated her cognition was moderately impaired. Resident #9 required maximal assistance of one-person physical assistance with dressing, and personal hygiene.<BR/>Record review of Resident #16's Comprehensive Care Plan initiated 02/21/23, reflected the following: Focus: I [Resident #16] have an ADL self-care performance deficit related to disease processes. Goal: The resident will improve current level of function in all ADL's Interventions: Encourage the resident to participate to the fullest extent possible with each interaction .<BR/>Observation and interview on 03/10/24 at 9:34 AM revealed Resident #16 was sitting in her bed. she had facial hair on her chin. Resident #16 stated she did not like hair on her face because it was itching, she stated she did not remember when the last time staff shaved her chin. <BR/>4. Record review of Resident #2's Quarterly MDS assessment, dated 12/08/23, reflected Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia, cognitive communication deficit, muscle weakness, and lack of coordination. Resident #2 had a BIMS score of 11 which indicated Resident #2's cognition was moderately altered. Resident#2 required moderate assistance of one-person physical assistance with dressing, and personal hygiene.<BR/>Record review of Resident #2's Comprehensive Care Plan initiated 11/07/23, reflected the following: Focus: I [Resident #2] have an ADL self-care performance deficit related to disease processes. Goal: The resident will maintain current level of function in all ADL's Interventions: . the resident requires extensive assistive by 1 staff member with encouragement to maximize independence .<BR/>Observation and interview on 03/10/24 at 9:41 AM revealed Resident #2 was lying in her bed. she had facial hair on her chin. Resident #2 stated she did not ask anybody to shave her because the staff were very busy. <BR/>In an interview on 03/10/24 at 10:34 AM, MA A stated CNAs were allowed to cut the residents' nails if they were not diabetic and to shave resident faces. MA A stated she was busy she did not get to get to do the shaving and the nail care for residents. She stated she would do it right then. <BR/>In an Interview on 03/12/24 9:19 AM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. The DON stated CNAs were responsible to shave residents and remove facial hair for female residents, as needed. The DON stated she was responsible to do routine rounds for monitoring. <BR/>5. Review of Resident #52's annual assessment dated [DATE] reflected Resident #52 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of coronary artery disease, heart failure, arthritis and chronic obstructive pulmonary disease. Resident #52 required partial/moderate assistance with showering. Resident #52 had a BIMS of 15 indicating he was cognitively intact. <BR/>Review of Resident #52's comprehensive care plan last revised on 01/17/24 reflected Resident #52 had an ADL self-care performance deficit related to disease process including activity intolerance, impaired balance and limited mobility. Resident #52's intervention included resident requires partial by 1 staff with bathing/showering 3 times per week and as necessary.<BR/>Record Review of Resident #52's ADL shower revealed Resident #52 was a Tuesday, Thursday and Saturday 6am to 2pm shower. It reflected Resident #52 received showers on his shower days on 02/01/24, 02/08/24, 02/10/24, 02/13/24, 02/15/24, 02/17/24, 02/20/24, 02/22/24, 02/24/24, 02/27/24, 02/29/24 and 03/05/24.<BR/>Interview on 03/10/24 at 11:00 AM with Resident #52 revealed he had not had a shower in 2 weeks. He stated his shower days were on Tuesdays, Thursdays and Saturdays. He stated he asked the CNAs about getting a shower but CNAs would tell him they are short staffed.<BR/>Interview on 03/12/24 at 9:32 AM with CNA L revealed Resident #52 maybe had gone about a week without a shower since CNA P had been off. She stated she tried to ensure residents got their showers but not having enough staff could affect resident in getting showers. <BR/>Interviews on 03/13/24 at 10:01 AM and 1:07 PM with CNA P revealed she had been off since 03/01/24 and showered Resident # 52 on 02/29/24. She stated Resident #52 was happy to see her because he told her he had not been showered since she last worked on the hall due to staffing. She stated Resident #52 told her he was ripe and needed a shower. She stated she showered Resident #52 after breakfast this morning. <BR/>6.Review of Resident #36's quarterly MDS assessment dated [DATE] reflected Resident #36 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, seizure disorder, anxiety disorder, depression, generalized muscle weakness, lack of coordination and unsteadiness on feet. Resident #36 required partial/moderate assistance with showering ADLs. Resident #36 had a BIMS of 15 indicating he was cognitively intact. <BR/>Review of Resident #36's comprehensive care plan last revised on 01/17/24 reflected Resident #36 had an ADL self-care performance deficit related to disease processes. Intervention included bathing/showering: physical help in bathing x1.<BR/>Review of Resident #36's ADL bathing documentation dated 03/12/24 from 02/01/24 to 03/08/24 reflected Resident #36 was a Monday, Wednesday and Friday 6 am to 2 pm shower. Resident #36 received showers on 02/02/24, 02/05/24, 02/07/24, 02/09/24, 02/12/24, 02/14/24, 02/16/24, 02/19/24, 02/21/24, 03/01/24, and 03/04/24.<BR/>Observation and Interview on 03/11/24 at 9:55 AM with Resident #36 revealed his hair was greasy. He stated he did not get showers but once a week . He stated they are short staffed and he was lucky if he gets a shower once a week. He stated the last time he was showered was sometime last week.<BR/>Interview on 03/11/24 at 5:07 PM Resident #36 stated he was not showered today even though his shower was on Mondays, Wednesdays, and Friday. He stated he should have been showered today but they were short staffed and unable to shower him.<BR/>Interview on 03/12/24 at 9:45 AM with Resident #36 revealed he was showered yesterday evening and he stated it was nice to feel clean again. <BR/>7.Review of Resident #41's quarterly MDS assessment dated [DATE] reflected Resident #41 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diabetes, coronary artery disease, dementia, generalized muscle weakness and lack of coordination. Resident #41 required partial/moderate assistance with showering. Resident #41 had a BIMS of 14 indicating he was cognitively intact. <BR/>Record Review of Resident #41's ADL bathing documentation dated 03/12/24 for 02/01/24 to 03/11/24 reflected Resident #41 was a Monday, Wednesday and Friday 2 pm to 10 pm shower. He received showers on 02/07/24, 02/09/24, 02/12/24, 02/14/24, 02/16/24, 02/19/24, 02/21/24, 03/01/24, 03/04/24 and 03/07/24. <BR/>Observation and Interview on 03/11/24 at 10:00 AM with Resident # 41 revealed his hair and beard appeared greasy. He stated he got a shower last Thursday only because he asked for it on the night shift. He stated he only got showers once a week if lucky. He stated they are too short of staff. He stated this has been going on since he admitted to the facility about 2 months. <BR/>Interview on 03/11/24 at 5:06 PM with Resident #41 revealed he was not showered today yet.<BR/>Interview on 03/11/24 at 5:30 PM with RN G revealed staffing issues were affecting residents getting showers because the facility did not have enough staff to ensure all residents were getting showers on their shower days. Last week Residents #41 mentioned to her about not getting showered but he was unable to be showered due to short staff. She was aware Resident #41 had to ask the night shift to shower him so he could get showered. She stated she was aware of Resident #36 missing showers due to short staff. She stated she would ensure both Residents #36 and #41 got showered today. RN G was not aware how to look up in PCC if residents getting showered. <BR/>Interview on 03/12/24 at10:28 AM with DON revealed she expected residents to be offered and provided a shower three times a week on their shower days if preferred by the resident. She stated residents had the right to be showered and could affect their quality of life if not provided the opportunity to be showered. She stated she was not aware of resident showers being affected by staffing issues until now. She stated residents have a specific shower date and shift depending on their room assignment. She stated she had not been monitoring residents' ADLs to ensure residents were getting showered. <BR/>8. Review of Resident #5 Quarterly MDS dated [DATE] revealed Resident #5 was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of traumatic subarachnoid hemorrhage (burst blood vessel in the brain), need for assistance with personal care, and diabetes. Resident #5 had a BIMS score of 9 indicating she was moderately cognitively impaired.<BR/>Observation and interview on 3/11/2024 at 9:49 AM revealed Resident #5 was lying in bed. Resident #5's teeth did not appear to be brushed recently with thick yellow substance along her bottom teeth and top teeth. Resident was unable to say when she had her teeth brushed last. Observation of Resident #5's fingernails revealed nails were painted a dark pink with some chips, cracks, and dents in the nail polish and with a dark brown thick substance underneath her nails on her left-hand index finger, second finger, and thumb. Resident #5 nails on both hands had sharp, jagged, and broken edges on the index finger, second finger, and thumb.<BR/>7. Review of Resident # 47's quarterly MDS dated [DATE] revealed she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), dementia (loss of cognitive functioning), and lack of coordination. Resident #47 had a BIMS score of 99 (indicating resident was not able to complete interview). <BR/>Observation on 03/11/2024 at 9:51 AM revealed Resident #47 was lying in bed sleeping on her right side. Observation of Resident #47's nails revealed a thick dark brown substance underneath her index finger, second finger, and ring finger of her right hand. <BR/>Interview on 03/11/2024 at 9:52 AM with CNA B revealed that she believed the brown substance to be food. CNA B stated the expectation was that resident's nails are cleaned during their shower unless they have diabetes or some other condition that requires a nurse to clean their nails. CNA B stated the risk to the resident with dirty nails would be increase infection risk to mucus membranes or skin when scratching with the dirty nails. <BR/>Interview on 03/12/2024 at 9:54 AM with CNA Q revealed she had worked on the secure unit at the facility for 3 days and was not sure if residents on the secure unit had their teeth brushed on 03/12/2024 or on 03/11/2024. CNA Q stated she gives every resident a warm towel in the morning to wipe off their faces and did not brush any resident's teeth today. CNA Q stated risk to residents would be infection or tooth pain. <BR/>Interview on 03/12/2024 at 10:00 AM with CNA B revealed she did not brush any resident's teeth today because she was too busy to get it to it. CNA B stated resident's teeth should be brushed every other day and she was not sure when the resident's had their teeth brushed last on the secure unit. CNA B stated she does not check resident's teeth every shift and would if they complained of pain. CNA B stated risk to resident would be infection or tooth pain. <BR/>Review of facility's policy Quality of Life - Homelike Environment last revised May 2017 reflected Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. <BR/>The facility did not have a policy on Activities of Daily Living per the Administrator on 03/13/24 at 3:50 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three of four (Residents #15, #174 and #71) residents reviewed for pressure ulcer care.<BR/>1. The Facility failed to notify Resident #15's Physician the Wound Care Consultant was no longer providing oversight for the resident's wounds from [DATE] through [DATE] which resulted in deterioration of her Left Ischium (hip) stage 4 pressure ulcer (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone), sacrum stage 3 pressure ulcer (full thickness skin loss in which fat was visible and granulation tissues and rolled wound edges are often present), right gluteal fold (crease below the buttocks) stage 4 pressure ulcer, right lateral malleolus(outside ankle) stage 3 pressure ulcer, left medial malleolus (inside ankle) stage 3 pressure ulcer, left lateral malleolus (outside ankle) stage 3 pressure ulcer and new stage 3 pressure to her right foot.<BR/>2. The Facility failed to complete a skin and wound assessment upon Resident #15's re-admission to the facility on [DATE] until [DATE].<BR/>3. The facility failed to obtain Physician orders for Resident #15's wound care after her re-admission on [DATE], instead re-started previous wound care on [DATE] without Physician authorization.<BR/>4. The Treatment Nurse failed to consult with Resident #15's Physician or the Wound care consultant prior to changing the resident wound care orders. <BR/>5. The facility staff failed to complete a Skin assessment, Wound Care assessment or notify the physician when a wound of unknown description was identified on [DATE] on Resident #174's coccyx, which resulted in the deterioration of the wound to an unstageable pressure ulcer (obscured full -thickness skin and tissue loss) with bone exposed and a stage 1 pressure injury(non-blanchable erythema of intact skin) to her right heel upon admission to hospice on [DATE]. Resident expired in the facility on [DATE]. <BR/>6. The facility failed to obtain physician orders for treatment of Resident #174's right heel when it progressed to a stage 2 pressure ulcer (partial-thickness loss with exposed dermis) that was indicated to have drainage on [DATE]. <BR/>7. The facility failed to complete a skin assessment, wound care assessment, or notify the physician, family, and Hospice on [DATE] when a Stage 2 pressure ulcer on Resident #71's coccyx and three small blisters on her right thigh were observed on [DATE]. <BR/>An Immediate Jeopardy (IJ) was identified on [DATE] at 12:40 PM. The IJ template was provided to the facility on [DATE] at 12:45 PM and signed by the Administrator. While the IJ was removed on [DATE] at 5:17 PM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. <BR/>These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection.<BR/>Findings included:<BR/>Record Review of Resident #15's Face Sheet dated [DATE], reflected a re-admission date of [DATE] to the facility. <BR/>Record review of Resident #15's quarterly MDS, dated [DATE], reflected a [AGE] year-old female with an admission date of [DATE]. The resident had a BIMS of 13 which indicated she was cognitively intact and had not resisted care. She required extensive to dependent care with ADL. She had a foley catheter and was always incontinent of bowel. She had pressure ulcers and was at risk for pressure ulcers. Active diagnoses included diabetes, multiple sclerosis (disease in which the immune system eats away at protective coverings of nerves), paraplegia (paralysis that affects the legs) and seizure disorder. <BR/>Record review of Resident #15's care plan dated [DATE] reflected, [Resident #15] has stage 3 pressure injury to sacrum, right lateral Malleolus, left medial malleolus, stage 4 pressure injury to her left ischial and right gluteal fold and is at risk since resident chooses to stay up in wheelchair up to 8-9 hours at times .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods .<BR/>Record review of Resident #15's care plan dated [DATE] reflected, [Resident #15] has stage 3 pressure injury to sacrum, right lateral Malleolus (ankle), left medial malleolus (ankle), stage 4 pressure injury to her left ischial (hip) and right gluteal fold and is at risk since resident chooses to stay up in wheelchair up to 8-9 hours at times .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods .<BR/>Record Review of Resident #15's Hospital summary from [DATE] to [DATE] revealed resident was admitted and treated for a gastrointestinal bleed. Progress notes revealed no wound care assessment was completed during the hospital stay. <BR/>Record Review of Resident #15's Hospital Discharge orders dated [DATE], did not reflect any orders for wound care. <BR/>Record Review of Resident #15's Physician order recap report with date range from [DATE] through [DATE], reflected, <BR/>1. Left Heel- apply skin prep twice daily to scabbed area, with a start date of [DATE] ( 7 days post admission)<BR/>2. Left Ischium (hip)- Cleanse wound with Dakin's (diluted bleach)solution. Apply Hydrofera Blue(antimicrobial dressing) foam to wound bed and cover with a dry dressing every day and as needed- with a start date of [DATE]. (3 days post admission) . Order was changed on [DATE] to Cleanse wound with Dakin's solution . Apply Santyl (removes dead tissue) to wound bed and calcium alginate (used for exuding wounds). Cover with a dry dressing daily, with a start date of [DATE]. <BR/>3. Left Lateral Malleolus (outside ankle)- Apply skin prep to scabbed area twice daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of [DATE]. <BR/>4. Left Medial Malleolus (inside ankle)- Apply skin prep to scabbed area twice daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of [DATE].<BR/>5. Right Gluteal Fold (skin crease below the buttocks) - Cleanse with Normal Saline. Apply a thin layer of Santyl to wound bed. Lightly pace wound Kerlix roll moistened with Dakin's solution and cover with a super Absorbent dressing daily and as needed with a start date of [DATE]. <BR/>6. Right Lateral Malleolus(outside ankle)- Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of [DATE]- Order was changed on [DATE] to Cleanse wound with wound cleanser and pat dry. Apply Collagen and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of [DATE]. <BR/>7. Right Lateral (outside )side of foot- Cleanse with wound cleanser, apply a small amount of Santyl to wound bed, then apply Calcium Alginate, cover with dry dressing daily with a start date of [DATE]. <BR/>8. Right Medial Malleolus (inside ankle) Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of [DATE]- Order was changed on [DATE] to Cleanse wound with wound cleanser and pat dry. Apply Santyl and Calcium alginate to wound bed and cover with a dry dressing daily and as needed with a start date of [DATE]. <BR/>9. Sacral wound- Cleanse with wound cleanser. Apply Hydrofera Blue Foam to wound cand cover with a dry dressing daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound cleanser. Apply Collagen(protein used to make connective tissue), and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of [DATE]. <BR/>Record Review of Resident #15's TAR for [DATE] reflected no wound care was documented for [DATE], [DATE], [DATE], [DATE]. <BR/>Record review of Resident #15's Braden scales for predicting pressure sore risk, dated [DATE] reflected a score of 15 which indicated risk for pressure ulcers. <BR/>Record Review of the facility's Pressure Skin/Wound Log, dated [DATE], (most current) reflected one resident with pressure ulcers. Resident #15 was listed with the following wound descriptions and treatments:<BR/>admitted with- Stage 4 left Ischium- 11.0 x6.0 x 1.5 cm- treatment-hydofera blue and foam dressing.<BR/>admitted with- Stage 3 sacrum- 2.0 x2.5 x1.3 cm treatment-hydofera blue and foam dressing.<BR/>Facility acquired- Stage 4 right gluteal fold- 6.5 x7.0x 4.5 cm. treatment- Santyl, kerlix/dakin, foam dressing.<BR/>Facility acquired- Stage 2 right Lateral Malleolus 2.0x 2.5 x 0.1 cm- treatment-Collagen foam dressing. <BR/>Facility acquired- Deep tissue injury left heel- 2.0 x 1.0 x 0 cm- Treatment- skin prep.<BR/>Facility acquired-Stage 3 left medial Malleolus 2.0 x 0 x 0 cm- treatment- Skin prep.<BR/>Facility acquired- Stage 2 Left Lateral Malleolus- 1.5 x1.5 x 0 cm- Treatment- skin prep. <BR/>Record Review of Wound Care Consultant Report dated [DATE] for Resident #15 reflected:<BR/>1. <BR/>Left Ischium- 5x8x0.6 cm - stage 4 pressure- improving.- post debridement- 5x8x0.7 cm- Bone palpated.<BR/>2. <BR/>Sacrum- 2x2.5x1 cm-stage 3 pressure-stable- post debridement- 2x2.5x1.1 cm<BR/>3. <BR/>Right gluteal fold-5x8x5.3 cm-pressure- heavy exudate, slough, strong odor-post debridement- 5x8x5.4 cm. Bone palpated.<BR/>4. <BR/>Right Lateral Malleolus- 2.4x2x0.2 cm- Stage 2 pressure<BR/>5. <BR/>Left heel- 1.5x1.5x0.1 cm- deep tissue pressure injury- improving.<BR/>6. <BR/>Left Medial Malleolus- 1.5x2x0.1 cm-Stage 3 pressure- improving.<BR/>7. <BR/>Left Lateral Malleolus- 2x1.5x0.1 cm - improving. <BR/>Record review of the electronic record for Resident #15 reflected no additional Wound Care Consultant reports. A visit was attempted by the Wound Care Consultant on [DATE]- Resident was involved in activities and declined assessment. <BR/>Record review of Resident #15's admission assessment dated [DATE], completed by LVN J reflected, Skin integrity- was left blank- Under comment section- stated - See wound assessments. <BR/>Record review of Resident #15's electronic record reflected no Wound Care assessment was completed until [DATE], which deferred to the Wound Care Consultants assessment completed on [DATE].<BR/>In an interview with the LVN Treatment Nurse on [DATE] at 02:00 PM, she stated she was the one doing the wound care assessments and measuring the wounds on Resident #15. She stated there had not been anyone from the Wound Care consultant company coming to the building for over a month. She stated even before that they were not coming consistently on a weekly basis. She stated the Wound care Nurse Practitioner had told her since Resident #15 was the only one in the building she thought they would just do Telehealth. She stated she told the NP due to the extensive nature of Resident #15's wounds she did not think that was going to be adequate, so the Nurse Practitioner stated she would get someone else to come. She stated another Nurse Practitioner from the wound care company came out, but she only came one time and they never sent anyone else. She stated at some point, Resident #15's wounds had started having more slough, so she added Santyl back to the wound care order. She stated the Nurse Practitioner had taken it off at one time. She stated she had not called the Primary care physician or his NP about any of the resident wounds. She stated Resident #15 was sent to the hospital a few weeks ago unrelated to her wounds, and stated she was told the hospital had not done wound care on her for the 3 days she was in the hospital. She stated she thought the wound on her coccyx had been improving. She stated once Resident #15 gets up she will refuse to lay back down until bedtime which makes healing very difficult. <BR/>In an interview and observation with Resident #15 on [DATE] at 08:55 AM she stated she knew this Surveyor was going to watch her wound care this morning ([DATE]) and she was OK with that. She stated once she got up mid-morning she does not go back to be until around 8 or 9 PM. She stated she knew it was not good for the healing of her pressure injuries, but stated there was not enough staff to lay her down and get her back up throughout the day and she did not want to miss her smoke breaks. She stated part of the problem was the cushion in her wheelchair. She stated she had been asking the facility to get her a Roho cushion ( air filled cushion) but the facility had not provided one. Observation of the cushion in her wheelchair revealed a memory foam cushion that was concaved in the middle of the cushion. <BR/>In an observation and interview with LVN J on [DATE] at 09:10 AM revealed her at the treatment cart preparing supplies for wound care for Resident #15. Observed CNA M and LVN J entered Resident #15's room to provide the residents wound care on [DATE] at 09:15 AM. Both staff washed their hands. LVN J cleaned the bedside table with a germicidal wipe and then placed the wound care supplies, plus a bottle of Dakin's solution and her computer on the table without placing the supplies on a barrier. CNA M put on gloves and uncovered the resident and found the resident with no brief lying on a cloth moisture resistant pad. CNA M rolled the resident on her right side revealing she had a bowel movement, which had contaminated the sacral wound dressing. CNA M provided incontinence care and changed her gloves but did not perform hand hygiene after she changed her gloves. LVN J noted the resident had 4 dressing on her right foot and stated she only had orders for her right Lateral ankle. She stated she was not sure what was going on with the resident's right foot. LVN J removed the dressing on the left outer ankle revealing a wound about the size of a golf ball with slough (yellowish white material in the wound bed consisting of dead cells) present, she stated this wound looked a little smaller since she saw it last week. LVN J cleaned the wound with normal saline, since she stated she was out of wound cleanser. LVN J removed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the wound bed and covered with a dressing. LVN J changed gloves without performing hand hygiene and removed the dressing from the resident's left interior ankle revealing a wound about the diameter of a double D battery. The wound had slough present. LVN J cleaned the wound with normal saline, changed gloves, with no hand hygiene, and applied Santyl and Calcium alginate and covered with a dressing. LVN J then applied skin prep to the resident's left heel, which had a scab approximately the diameter of a triple A battery. LVN J changed gloves, no hand hygiene and proceeded to remove all dressing on the outside the right ankle and revealed a wound approximately the diameter of a golf ball on the outer ankle with slough present and serous (yellow) drainage. Observed on the outer middle part of her foot a wound approximately the size of blue jean button. LVN J stated it appeared it had calcium alginate, but stated there was no order for a treatment of this wound. LVN J cleaned both wounds with normal saline, changed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the ankle and calcium alginate to the wound on her right mid foot and covered both with a dressing. LVN J changed gloves without performing hand hygiene and proceeded to the wound on the resident's right gluteal fold. LVN J removed the dressing and revealed a wound with heavy greenish gray drainage and strong odor. Wound was approximately the diameter of a soup can and appeared to be to the bone. LVN J cleaned with normal saline, changed gloves with no hand hygiene and re-gloved and applied Santyl and packed with kerlix moistened with Dakin's solution and covered with a dry dressing. LVN J removed gloves- no hand hygiene and re-gloved and proceeded to the wound on the resident's sacrum. CNA M completed incontinence care, removing the remainder of the fecal matter after LVN J removed the soiled dressing. The sacral wound was crescent shaped and approximately the width of a tennis ball with slough present. LVN J cleaned with normal saline and applied collagen and calcium alginate and covered with a dressing. LVN J changed gloves- no hand hygiene and proceeded to the wound on the residents left Ischial. The wound was approximately the diameter of a orange with the top part of wound having some granulation (red and moist) present. The bottom of the wound had slough and necrotic tissue present with heavy drainage and an odor. LVN J cleaned with Daikin's solution, applied Santyl to the necrotic portion of the wound and calcium alginate to the remainder of the wound bed and covered with a dressing. LVN J changed her gloves and re-gloved without performing hand hygiene and provided catheter care and both she and CNA M placed a clean brief on the resident and dressed her for the day. Resident #15 was transferred with mechanical lift to her wheelchair. Wheelchair was noted to have a memory foam cushion that was concaved in the middle. Resident #15 again stated she had asked for a Roho (air filled pressure relief cushion) cushion. Both staff removed their gloves and performed hand hygiene. <BR/>In an interview with LVN J on [DATE] at 10:15 AM she stated Resident #15's ankle wounds looked about the same since she saw them last week, but her wound on her gluteal fold was much worse as well as the sacrum and Ischium wound which appeared to be tunneling (opening under the skin). She stated she worked Monday through Friday on the 06:00 AM to 02:00 PM shift. She stated Resident #15 returned from the hospital on [DATE]. She stated there were no wound care orders from the hospital. She stated when she got report from the hospital, they stated they had done wound care on Saturday, but not Sunday stating the resident had refused. She stated she did not assess the wound when she returned to the facility on [DATE], since the Treatment Nurse did the Wound care assessments. She stated she did not find out until this week ([DATE]) the treatment nurse had stepped down from that position. She stated she thought the 2:00 PM to 10:00 PM nurse did her wound care on [DATE]. She stated she had asked the MDS Nurse if she could put in the wound care orders. She stated they were just using the previous wound care orders. She stated she had not contacted the MD to clarify the wound care orders. She stated she did the wound care on Tuesday [DATE] and the wounds were not draining like they were today ([DATE]) but stated they did have a lot more slough. She stated she had not contacted the primary care physician about the wounds, stating she assumed the treatment nurse wound be doing that. She stated she had not signed off on the wound care because the orders had still not been put in the system when she did the wound care on Tuesdays [DATE].<BR/>In an interview with Resident #15's NP DD on [DATE] at 11:40 AM who was in the building making rounds, she stated she had not been contacted about Resident #15's wounds since her return from the hospital. She stated she was on call last weekend. She stated the facilities usually had a wound care doctor that comes weekly. She stated she was not aware that no one was coming for wound care manage for Resident #15. She stated she did not re-call ordering any wound cultures on the resident, but stated if she were having signs and symptoms of infections, she would order them today ([DATE]). She stated anyone with the extensive nature of Resident #15's wounds needed to be seen weekly by a wound care specialist. She stated the risk of failing to manage Resident #15's wounds could lead to sepsis, further decline of the wound and loss of limbs. She stated they needed to contact the Primary Care physician or herself anytime there was a significant change. <BR/>Attempted to contact Resident #15's Primary care physician on [DATE] at 11:51 AM and was told he was out of the office on vacation. <BR/>In an interview with the DON on [DATE] at 12:45 PM stated she knew the Wound Care management company had not sent anyone out for several weeks. She stated they originally had wound care NP AA coming weekly, but her visits became less consistent. She stated NP AA had told the Treatment Nurse that she did not want to come for just one resident and wanted to do Telehealth, but the Treatment Nurse and herself felt Resident #15's wounds needed to be seen weekly, so NP AA arranged for someone else to come. She stated wound care NP EE came out about a month ago and had not been back. She stated she was planning on getting with the Treatment Nurse to see what was going on with Resident #15's wounds but stated due to the shortage of staff the Treatment Nurse had been working the floor covering shifts for the last 3 weeks. She stated due to this they had an in-service with the staff sometime in February 2024 letting them know the Treatment Nurse would no longer be doing the weekly skin assessments and the Nurses would be responsible for their assigned residents, but the Treatment Nurse would still be doing the wound care assessments weekly. She stated the staff were also told they would be responsible for doing the wound care if the Treatment Nurse was working the floor. She stated it was her expectation that anytime there was a new skin issues they were to complete a skin assessment, notify the physician and family and get orders. She stated the nurse who identified the issue needed to be the one who reached out to the physician. She stated she was not sure what they were going to do about a wound care physician at this time. She stated wound care orders could only be changed by the physician. She stated it was outside the scope of practice for the nurse to implement her own wound care orders. She stated the risk could be making the wound worse, risk of infection. She stated she had not considered who would complete the wound care assessments if the Treatment Nurse was unavailable, and stated after this week, the Treatment Nurse had stepped down from the position. <BR/>In an interview with the MDS Coordinator on [DATE] at 12:50 PM she stated when Resident #15 returned to the facility on [DATE] she helped put in the hospital discharge medication orders but stated she had told the Treatment Nurse she needed to put in the wound care orders. She stated she was not aware of who the facility Wound care management company was or who to contact about wound care. <BR/>In an interview with the Treatment Nurse on [DATE] at 10:05 PM she stated she was called in at 6:30 PM today to help on the floor as CNA. She stated she had told the nurse's back in January they were going to have to do the wound care when she was off or working the hall. She stated they were also supposed to be doing the skin assessment, but that was not happening, so they did an in-service on [DATE] on the requirement of for the weekly skin assessment. She stated the nurses were supposed to complete the skin assessment for any skin condition and if it was pressure or deep tissue injury, they were to report to her, and she would complete the Wound care assessment. She stated the nurse however was to contact the physician, family and obtain any treatment order needed. She stated she had been doing Resident #15's Skin assessment and wound assessment up until she went to the hospital on [DATE] and was trying to do the treatments when she could. She stated her wound assessments were scheduled for Thursdays and she was off on Thursday. She stated when Resident #15 came back to the facility on [DATE], the admitting nurse should have done a skin assessment and called the doctor for orders for the wound. She stated she was not surprised wounds were not getting documented as being done. She stated she was so frazzled by the time she leaves she was not sure what she did and did not do. She stated she did Resident #15's wound care on Wednesday[DATE] but did not do the wound care assessment. She stated she off on [DATE] the day the assessment was due. She stated there was a little bit of odor and drainage. She stated the wounds did not have an odor or drainage before she went to the hospital. She stated she probably could have reached out to the Wound care company, but stated she felt like the wounds had been stable prior to her going to the hospital. She stated when she started in [DATE], she received no training on wound care and was not aware of the facility's policy for wound care. She stated she had previous experience as a treatment nurse in another facility, but stated she was not wound care certified. <BR/>In an interview with CNA L on [DATE] at 01:00 PM she stated she worked the day Resident #15 returned to the facility. She stated her wounds had a very foul smell. She stated the nurse was aware of the smell. She stated if she saw a new skin issue, she would put it in the electronic record and tell the nurse. <BR/>In an interview with RN G on [DATE] at 02:45 PM stated when she arrived at work on [DATE] for her 2-10 PM shift, Resident #15 had been readmitted to the facility. She stated LVN J had re-admitted her but had not had a chance to do her wound care, so she stated she did the wound care that evening. She stated the wounds were terrible and smelled bad. She stated she assumed the Treatment Nurse was taking care of the wound care orders. She stated the wounds on the residents' ankles looked worse to her and she had a new place on the middle of her right foot. She stated she thought she contacted the physician about the new place on the resident right foot but stated she had deleted all her old calls and was not sure what day she called him. She stated she should have written the order and signed the TAR when she did the wounds on [DATE], [DATE] and [DATE]. She stated it was so crazy last week she was doing good just to get the care done. She stated she did not feel like she had enough experience to complete the wound care assessments and would need more training before she felt comfortable staging or measuring a wound. <BR/>2. Record Review of Resident #174's Significant Change MDS assessment dated on [DATE] reflected a [AGE] year-old female with an admission date of [DATE]. Resident had a BIMS of 2 which indicated she was severely cognitively impaired. She required extensive assistance with all ADLs and was frequently incontinent of bladder and always incontinent of bowel. Resident had a one unstageable pressure injury listed and was receiving Hospice services. Active diagnoses included heart failure and dementia. <BR/>Record Review of Resident #174's care plan initiated on [DATE] reflected, [Resident #174] is at increased risk for pressure sores due to immobility .Interventions Administer treatments as ordered .Follow facility policies/protocols for the prevention/treatment of skin breakdown .Inform the resident /family/caregivers of any new area of skin breakdown .<BR/>Record review of Resident #174's Braden assessment completed on [DATE] by MDS Coordinator indicated the resident had a score of 14 which placed her at moderate risk of pressure ulcers. <BR/>Record Review of Resident #174's progress note dated [DATE] at 07:35 PM by RN EE reflected, resident found with medium sized wound to buttocks. Resident denies pain at this time. barrier cream applied and brief changed. [Treatment Nurse], notified of wound and stated she would look into it tomorrow morning. <BR/>Record Review of Resident #174's progress note dated [DATE] at 07:58 PM by RN EE, reflected, resident assessed coughing up green, thick, productive sputum and lung sounds are wet and wheezy. Vitals are stable at this time. resident remains afebrile. [NP CC] notified of cough and sputum . Further review of the progress noted reviewed there was no documentation the NP was notified of the wound to the residents' buttocks. <BR/>Record review of Resident #174's progress noted dated [DATE] at 10:22 AM by RN E reflected, pressure area to coccyx wound nurse is performing dressing changes to area day 4 for zpack (Azithromycin)) and prednisone will continue to monitor, air mattress present on bed with controls available as well as call light and water pitcher. Denies needs or pains at present time will continue to monitor and update md, family and admin(sic) prn status changes. <BR/>Record review of Resident #174's progress note dated [DATE] at 08:15 PM by LVN Treatment nurse, reflected, Unstageable pressure ulcer to sacrum d/t slough present. 5cm x 3cm x 2cm. New order received from Hospice Cleanse with<BR/>wound cleanser, Apply Santyl to wound bed then apply Hydrofera Blue foam and a dry dressing daily and as needed. Family and MD notified.<BR/>Resident admitted [company name] Hospice today.<BR/>Record review of Resident #174's Physician order Summary report date [DATE] reflected, <BR/> Sacrum- Cleanse wound with wound cleanser. Apply Santyl to wound bed. Then lightly pack with Hydrofera Blue and apply Supers absorbent Dressing daily and as needed every day shift with a start date of [DATE]. <BR/>Order was changed to Cleanse wound with wound cleanser. Apply Silver Alginate to wound bed and cover with a super absorbent dressing daily and as needed, with a start date of [DATE]. There were no orders for the Pressure ulcer to the Resident's right heel. There were no orders for [DATE] for wound care to the resident's sacrum.<BR/>Record review of Resident #174's TAR for [DATE] reflected no documentation of wound care to the residents' sacral wound. <BR/>Record review of Resident #174's TAR for February 2024, reflected no documentation of wound care from [DATE] through [DATE], [DATE] through [DATE], and [DATE] for the Resident sacral wound. Further review revealed there was no documentation for wound care to the resident right heel from [DATE] through [DATE]. <BR/>Record review of Hospice GG's admission assessment dated [DATE] reflected Resident #174 had an unstageable 4x4 cm to her coccyx with bone exposed and bleeding. In addition, she had a Stage 1 pressure injury to her right heel that was red, mushy with a black center. Will follow up for wound care orders.<BR/>Record review of Hospice GG's assessment dated [DATE] reflected, Wound #1 Sacral is a [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #45) of two residents reviewed for incontinence care. <BR/>The facility failed to ensure RN D provided appropriate perineal care for Resident # 45 after an incontinent episode when she failed to clean the resident's scrotum, and penis. <BR/>This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. <BR/>Findings included:<BR/>Record review of resident #45's Comprehensive MDS assessment, dated 01/02/24, reflected a [AGE] year-old male with an admission date of 08/29/22 with diagnoses included injury of cervical spinal cord (permanent complete or partial loss of sensory function), muscle weakness, lack of coordination, and need for assistance with personal care. Resident #45 had a BIMS score of 15 which indicated Resident #45's cognition was intact. Resident#45 required moderate assistance of one-person physical assistance with toileting hygiene, and personal hygiene. Resident #45 had limited range of motion to right lower and upper extremities. The resident was frequently incontinent of urine bowel. <BR/>Review of Resident #45's care plan, initiated on 02/03/22, reflected .[Resident #45] has mixed bladder incontinence and is at risk for skin breakdown .Interventions .clean peri-area with each incontinence episode .<BR/>In an observation and interview with Resident #45 on 03/10/24 at 10:02 AM revealed the resident in bed, he stated he needed to be changed. <BR/>In an observation and interview on 03/10/24 at 10:15 AM revealed RN D entered Resident #45's room to provide incontinences care and change the resident's clothes. RN D washed her hands and put on gloves and unfasted the brief, she took a peri-wipe and wiped down each side of the resident's groin and across his pubic area but failed to clean his penis or scrotum. RN D rolled the resident over on his side revealing he was wet. Resident #45's skin was intact. RN D removed the wet brief and with the same soiled gloves she placed a clean brief under the resident. RN D removed her gloves and put on clean gloves without performing hand hygiene. RN D cleaned the resident's buttocks with a peri-wipe from front to back. RN D removed her gloves and put on clean gloves without performing hand hygiene. RN D rolled the resident back onto his back and fastened the brief and changed his clothes. RN D removed her gloves, and she washed her hands. <BR/>In an interview on 03/10/24 at 10:25 AM, RN D stated she supposed to clean the penis area from tip to base and then clean the peri-area and scrotum area. RN D stated she failed to do that. RN D stated she should change her gloves and perform hand hygiene when she went from dirty to clean. RN D stated failing to provide proper care exposed the resident to infections and risk of skin breakdown. <BR/>In an interview on 03/12/24 at 09:19 AM, the DON stated when providing incontinent care staff were to clean the peri area including penis and scrotum for male residents then moving toward the buttocks. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene.<BR/>In an interview on 03/14/24 at 02:15 PM, the Corp. Nurse stated they did not do skills check on peri care for nurses. <BR/>Record review of the facility's policy titled, Perineal Care, dated 10/01/21, reflected, .Wash and dry hands thoroughly .Put on gloves . For male resident .Use wipes .awash perineal area starting with urethra and working outward .Retract foreskin of the uncircumcised male . Cleanse urethral area using circular motion .Continue to wash the perineal area including the penis, scrotum, and inner thighs .Reposition the foreskin of uncircumcised male Instruct or assist the resident to turn on his side .Use wipes on the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks Remove gloves Wash and dry hands

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 12 (Residents #4, #23, #35, #36, #41, #52 and five residents in confidential group interview) of 12 residents reviewed for staffing concerns. <BR/>1. The facility failed to ensure there were sufficient staff to ensure Resident #35 and #23 received 8 AM medications on time on 03/10/24.<BR/>2. The facility failed to ensure there was sufficient staff available to provide timely incontinent care for Resident #4 on 03/10/24.<BR/>3. The facility failed to ensure residents received showers on their shower days due to staffing issues. <BR/>4. The facility failed to ensure sufficient staff to meet resident needs in February and March 2024. <BR/>These failures placed residents at risk of not getting needed care and services, a decrease in quality of care and quality of life and/or injury. <BR/>Findings included: <BR/>Observation of Medication Pass on 03/10/24 at 9:50 AM with MA F revealed 12 of Resident #35's 8 AM medications were administered to Resident #35 late. <BR/>Record Review of Resident #35's MAR for March 2024 reflected 8 AM medications for the following:<BR/>1. Amiodarone 200 mg 1 tab<BR/>2. Cetirizine 10 mg 1 tab<BR/>3. Stool Softener 100 mg 1 tab<BR/>4. Divalproex DR 500 mg 1 tab<BR/>5. Eliquis 5 mg 1 tab<BR/>6. Ferrous Sulfate 325 mg 1 tab<BR/>7. Vit B-12 1000 mcg 1 tab<BR/>8. D3-50 1 tab<BR/>9. MVT 1 tab<BR/>10. Hydrochlorothiazide 12.5 mg 1 tab<BR/>11. Lamotrigine 25 mg 1 tab <BR/>12. Metoprolol 25 mg 2 tab <BR/>Observation of Medication Pass on 03/10/24 at 10:00 AM with MA F revealed she administered 8:00 AM medications to Resident #23 late. <BR/>1. Atorvastatin 40 mg 1 tab<BR/>2. Stool Softener 100 mg 1 tab<BR/>3. Divalproex DR 500 mg 2 tabs<BR/>4. Benztropine 1 mg 1 tab<BR/>5. Hydrochlorothiazide 25 mg 1 tab<BR/>6. Coreq 12.5 mg 1 tab<BR/>7. Fluphenazine 5 mg 2 tabs<BR/>8. Levetiracetam 1000 mg 1 tab<BR/>9. Metformin 500 mg 1 tab<BR/>10. Venlafaxine ER 75 mg 1 tab<BR/>11. Losartan 25 mg 1 tab<BR/>12. Sertraline 50 mg 1 tab<BR/>13. Sertraline 50 mg 1/2 tab <BR/>Record Review of Resident #23's MAR for March 2024 revealed the above medications were scheduled for 8:00 a.m. <BR/>Interview on 03/10/24 at 11:00 AM with Resident #52 revealed he had not had a shower in 2 weeks. He stated his shower days were on Tuesdays, Thursdays, and Saturdays. He stated he asked the CNAs about getting a shower, but CNAs told him they were short staffed. <BR/>Interviews on 03/12/24 at 1:07 PM with CNA P revealed she had been off since 03/01/24 and showered Resident # 52 on 02/29/24. She stated Resident #52 was happy to see her because he told her he had not been showered since she last worked on the hall due to staffing. She stated Resident #52 told her he was ripe and needed a shower. She stated she showered Resident #52 after breakfast this morning. <BR/>Observation and Interview on 03/11/24 at 9:55 AM with Resident #36 revealed his hair was greasy. He stated he did not get showers but once a week for showers due to short staff. He stated they were short staffed and he was lucky if he gets a shower once a week. He stated the last time he was showered was on 03/07/24.<BR/>Observation and Interview on 03/11/24 at 10:00 AM with Resident # 41 revealed his hair and beard appeared greasy. He stated he got a shower last Thursday only because he asked for it on the night shift. He stated he only got showers once a week if lucky. He stated they were too short of staff and not able to get showered like he wanted. He stated this had been going on since he admitted to the facility about 2 months. <BR/>Interview on 03/10/24 at 10:30 AM with MA F revealed she was late on the medications because she was passing for 3 halls instead of the usual 2 halls. She stated they were short a nurse today and had been short for the past 2 weeks. She states there was no way she could get all 3 halls done with the current schedule of medication pass times. <BR/>Interview on 03/10/24 at 12:00 PM with MA A revealed she was usually the MA Monday through Friday. She stated she came in today to help out since the 2 scheduled CNAs called in. She stated one of the CNAs scheduled today was going to be her last day. She stated it was just her as the CNA on the 4 halls with the nurse helping out with care. She stated the facility does not use staffing agency and they had been told they were not going to use a staffing agency. She stated she was not sure why. <BR/>Confidential Group Interview with 5 of 5 residents on 03/11/24 at 11:00 AM revealed two of five residents only received showers once a week due to staffing issues and would like to be showered three times a week. <BR/>Interviews on 03/10/24 at 10:24 AM and 1:30 PM with LVN/Tx R revealed she was also the staffing coordinator for the facility. She stated she was working as a Med Aide today on hall 500 and 600 since they did not have a MA to come in. She stated she was working the floor as a CNA, Med Aide or Staff nurse when they could not get anyone to come in instead of the treatment nurse. She stated she will be working night shift as a charge nurse for the next 2 nights because they have no one else to work. She stated it had been like this since January 2024. She stated the last few weeks have been harder during the week and the weekends for short staffing. She stated they usually had 3 CNAs on the weekend but this weekend down one due to CNA transitioning to Monday through Friday and another CNA called in today. She said normally staffing was better during the week, but the last few weeks has been bad during the week also. She came in at 9 a.m. to cover the 6-2 p.m. shift but thinks she will be doing the 2-10 p.m. shift as well because the other med aide had been out. <BR/>Interview on 03/10/24 at 1:31 PM with CNA W revealed she was assigned to the locked unit but had to come and out assist with feeding on the other hall since there was only one other CNA in the building today. She had another staff member take her place on the locked out while she assisted resident with feeding. <BR/>Interview on 03/10/24 at 1:45 PM and 3:10 PM with RN G stated she was working a 16-hour shift today. She stated her usual schedule was M-F 2-10 p.m. She stated she was covering hall 200, 300 and part of 100 today since they did not have another weekend nurse to cover today. She stated the facility had been very short handed for several weeks. <BR/>Observation on 3/10/24 at 3:15 PM with MA A revealed she entered Resident #4's room to provide incontinent care and change her gown, which had food on it from breakfast. Interview with MA A stated this was the first time she had been in to do peri care on the resident since coming on duty at 6 a.m. <BR/>Interview on 3/10/24 at 3:25 PM with MA A revealed she had not had time to check Resident #4 before now, since she had been the only aide for 4 halls. She stated the ADON had come in after survey team had arrived at facility and was helping on the floor. She stated she was not sure if she or someone else had changed Resident #4 any other time today. <BR/>Interview on 3/10/24 at 3:32 PM with RN H revealed she was the weekend RN supervisor. She stated she had not provided any incontinences care on any of the residents. She stated they had been very short handed both in nurses and CNAs since December 2023. She stated they usually had 3 nurses and 4 CNAs in the building with one of the nurses and one of the CNAs on the locked unit. She stated she had wondered why the facility was not using agency until they got some of these positions filled. She stated the lack of staff had been a real concern for her. <BR/>Interview on 03/10/24 at 3:45 PM with RN D revealed they were doing their best to get patient care done since they were so shorthanded. She stated when they were fully staffed there would be one nurse and one aide on the locked unit and 2 nurses for the other 4 halls. She stated it had been only 2 nurses for the whole building for several months and they had really been short on aides. <BR/>Interview on 3/10/24 03:55 PM with the ADON revealed she got to facility between 9:30 AM to 10:00 AM today. She stated they had been very short staffed, and she had worked the floor numerous times in the last week. She stated she thinks she had put in 80 hours in the last week. <BR/>Interview on 03/11/24 at 5:30 PM with RN G revealed staffing issues were affecting residents getting showers because the facility did not have enough staff to ensure all residents were getting showers on their shower days. Last week Residents #41 mentioned to her about not getting showered but unable to be showered due to short staff. She was aware Resident #41 had to ask the night shift to shower him so he could get showered. She stated she was aware of Resident #36 missing showers due to short staff. <BR/>Interview on 03/12/24 at 10:28 AM with the DON revealed she was not aware of resident showers not being done due to staffing issues. She stated they were shorthanded especially on the weekends. <BR/>Interviews on 03/13/24 at 11:05 AM and 11:57 AM with LVN J revealed the facility had certain days of the week the residents got their showers depending on which side of the hall they are on. She stated since they have been short staffed and try their best to ensure residents get showers but were impacted by staffing issues. She stated it was difficult to ensure all residents received their showers and were inconsistent in getting showers due to low staffing issues. She stated since about [DATE] there had only been 2 nurses on shift and split 500 hall residents. <BR/>Interview on 03/12/24 at 2:51 PM with CNA KK revealed she had worked at facility for just over a month and the facility did not have enough staff which was a problem. She stated today was the most staff she had ever seen since she started working at facility. She stated they were lucky if they had 2 CNAs on shift and it was typical for nurse, ADON and LVN/Tx R to assist on the floor due to staffing issues. <BR/>Interview on 03/12/24 at 3:18 PM with CNA N revealed she had worked at facility for 6 months. She stated staffing was an issue and she has had to work the floors with 13 incontinent residents and divide 100 hall which made it difficult to be responsive to residents.<BR/>Interview on 03/13/24 at 11:35 AM with CNA C revealed they had been even more short staffed since CNA P had been out the last week and half ago. She stated she was the previous staffing coordinator until January 2024. She stated she was told by Administrator the facility did not use agency but did not know why. She stated the ADON and LVN Tx R would assist on the floor when short staffed but DON would not assist when short staffed. She stated the facility had more prn staff before when she was staffing coordinator but did not know what happened to them. She stated facility staff had left for various reasons. She stated staffing had gotten a lot worse in the last 2 months. She stated the facility was usually able to have 2 MAs on each shift along with 2 nurses, but CNAs were shorthanded. <BR/>Interview on 03/13/24 at 1:55 PM with the Administrator revealed she was aware of weekends having staffing issues. She stated she will be looking at rehiring staff who have left and see about having them return if not terminated due to abuse/neglect allegations. She stated she did have routine facility staff she could call to help on shifts. She stated they have hired new staff who come to orientation but then no show. She was aware they needed more staff. She stated some of the current staff were willing to work overtime to cover shifts. She stated their budget was the following for 6 am to 2 pm shift for 6 CNAs, 2 MAs, 3 nurses; 2 pm to 10 pm shift 5 CNAs, 2 MAs and 3 nurses. She stated if not able to have 3rd nurse would try to get a 3rd MA. She stated the night shift was covered with no staffing issues but she had issues with the other 2 shifts. <BR/>Interview on 03/14/24 at 9:40 AM with the Administrator revealed she was aware facility had staffing issues on weekends. She stated she was not aware the staffing issues were impacting the residents receiving care. She stated she will start using agency until she can get sufficient staff. She stated she had staff schedule for 4 CNAs on 6 am to 2 pm and 4 CNAs on 2 pm to 10 pm not including the 2 Mas and 2 nurses. She stated the last time facility used agency for staffing was in October 2022. She stated she did not review the timesheets for staff to look into staff patterns. She stated she was responsible to ensure staffing needs were met but the staff were not notifying her on the weekends when short staffed.<BR/>Interview on 03/14/24 at 11:15 AM with the Regional VP of Operations revealed he just started working for the corporation on 02/23/24 and had visited the facility last Tuesday on 03/05/24. He stated the Administrator told him having issues with staffing but was able to get current facility staff to cover the shifts they were shorthanded on. He stated the corporation had an agreement with staffing agency they could use if needed to help with staffing issues. He was not aware of any issues with staffing to the point of residents not getting care they need. He stated facility budget for staffing was not an issue. <BR/>Interview on 03/14/24 at 1:50 PM with CNA M revealed she had worked double weekends 6 a - 10 pm up until this past weekend because she was transitioning to Monday through Friday shift. She stated when she worked double weekends they would usually have 2 CNAs and 2 nurses along with 2 med aide. She stated on Saturdays it was difficult to get showers done since so short staffed. <BR/>Interview on 03/14/24 at 1:58 PM with RN E revealed the last 4 to 6 weeks they had been short staffed more. She stated only 2 nurses on the 6 am to 2 pm and 2 pm to 10 pm shifts. She stated she had talked to the DON about inadequate staffing for nursing and a note was put up saying nurses would split 500 hall (secure unit). She stated they had 2 nurses who worked at the facility who were on secure unit but not working currently. She stated the DON told her they were working on hiring more nurses. She stated they were supposed to have 4 CNAs but most frequently only have 1 to 2 CNAs on shift instead of 4. She stated usually they have 2 Medication Aides on each shift. She stated ADON told her they do not use agency but did not know why. <BR/>Review of facility's staff timesheets for February 2024 to March 2024 dated 03/13/24 reflected the following direct care staff:<BR/>-on 03/02/24 6am shift revealed 3 CNAs, 2 MAs, 2 nurses including ADON, 2 pm shift revealed 2 CNAs, 2 med aides, 2 nurses<BR/>-on 03/03/24 2 pm shift revealed 3 CNAs, 1 MA, 3 nurses including ADON<BR/>-on 03/05/24 6 am shift revealed 3 CNAs, 2 nurses with ADON 9 AM and Medication Aide coming in at 11:27 AM<BR/>-on 03/09/24 6 am shift revealed 3 CNAs, 1 MA, 1 Nurse and weekend RN supervisor with ADON arriving at 10:00 AM, 2 pm shift 3 nurses, 2 Medication Aides, ADON and weekend RN supervisor as only nurses. <BR/>-on 03/10/24 6 am shift revealed 1 CNA, 2 MA, 2 nurses and Weekend RN Supervisor with ADON coming in at 10:00 AM<BR/>-on 03/10/24 2 pm shift revealed 2 CNAs until 4 pm down to 1 CNA, 2 MAs, ADON, 1 nurse and Weekend RN supervisor.<BR/>-There were no shifts with 6 CNAs on 6a to 2 pm. <BR/>Review of facility's PBJ staffing run on 03/05/24 reflected low weekend staff triggered for 3rd quarter of 2023 and 1 star staffing rating for all quarters in the last year.<BR/>Review of the facility's policy Staffing revised October 2017 reflected Facility provided sufficient numbers of staff with the skills and competency necessary to provide care and service for all residents in accordance with resident care plans and the facility assessment .2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care .5. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of four residents (Residents #14 and Resident # 5) reviewed for pharmacy services in that-<BR/>1. RN G failed to follow the manufacturer's instructions to prime the Lispro Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #14. <BR/>2. RN D failed to follow the manufacturer's instructions to prime the Novolog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #5. <BR/>These failures placed residents at risk of not receiving full dosage of medication. <BR/>Findings included: <BR/>1. Review of Resident #14's Face sheet dated 03/14/24 reflected an [AGE] year-old female admitted to the facility on [DATE]. Active diagnoses included diabetes mellitus. <BR/>Record review of Resident #14's Physicians order summary report with a start date of 05/25/23, reflected, .Insulin Lispro 100 units/ml .Inject per sliding scale .subcutaneously (under the skin) before meals and at bedtime for diabetes . <BR/>An observation on 03/10/24 at 11:10 AM of the medication pass revealed RN G checked Resident #14's Fingerstick blood sugar and obtained a reading of 169. RN G returned to the medication cart, looked at the MAR and determined resident would need insulin according to sliding scale which indicated 151-200 give 4 units. RN G opened the medication cart and retrieved Resident #14's Lispro Flex Pen. RN G placed a needle on the insulin pen and dialed 4 units without priming the pen first. RN G then administered the Insulin to Resident #14. <BR/>Interview with RN G on 03/10/24 at 11:20 AM she stated she was unaware the insulin pen had to be primed. She stated it made sense because you might not be giving the full amount of insulin if the pen was not primed. She stated she had never been told she needed to [NAME] the insulin pen and had not checked the manufacture guidelines. <BR/>2. Record review of Resident #5's, Face sheet, dated 03/14/24 reflected a [AGE] year-old female with an admission date of 01/05/10. Resident #5 had a diagnosis which included Type 2 diabetes and dementia. <BR/>Review of the Physician Order Summary dated 03/18/24 revealed .NovoLog FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 121-150=2 units; 151-200=4 units; 201-250 = 6 units; 251-300 = 8 units; 301-350= 10 units If above 350 give 12 units and call MD, subcutaneously before meals and at bedtime .<BR/>An observation 03/10/24 at11:25 AM revealed RN D at the medication cart preparing to perform Resident #5's finger stick blood sugar. RN D performed hand hygiene and donned gloves and obtained Resident #5's blood sugar with a reading of 149. RN D checked the computer to determine the amount of insulin per sliding scale indicated 121-150 give 2 units. RN D dialed in the amount of insulin required (2 units) without priming the pen and administered the insulin. <BR/>In an interview with RN D on 03/10/24 at 11:35 AM, she stated she was not aware the insulin pen had to prime before dialing in the amount of insulin required. She stated she had not reviewed the manufacturer's instructions. She stated by not removing the air the resident could receive a less amount of insulin and wound not receive the full dose of medication. <BR/>In an interview with the DON on 03/11/24 at 01:10 PM she stated she was also unaware the insulin pen had to be primed. She stated she came from a hospital setting and they did not use insulin pens in that setting. She stated the Insulin pen needed to be primed first to ensure they removed the air and ensured the resident received the required amount of Insulin. She stated failing to follow procedures could result in residents not receiving the full amount of medication ordered. She stated their policy referred them to the manufacturers guidelines. <BR/>Review of the Facility's procedure, Injectable medication administration, dated August 2020, reflected, .Pen Devices: Dial the does as instructed by the Pen manufacture <BR/>Review of manufacture instructions for Lispro obtained from https://www.lillyinsulinlispro.com/ searched on 03/18/24 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. o prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps .<BR/>Review of manufacturer instructions for Novolog obtained from https://www.novomedlink.com/ searched on 03/18/24 reflected, .Giving the air shot before each injection .Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units .Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. A drop of Insulin should appear at the needle tip, if not .repeat the process .make sure the dose selector is set at 0. Turn the dose selector to number of units you need to inject .<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 6 residents (Resident #35, Resident #23, Resident #5, Resident #51, Resident #15, and Resident #45) of 8 observed for infection control. <BR/>The facility failed to ensure:<BR/>1. MA F sanitized the blood pressure cuff between uses on Resident #35 and Resident # 23 and performed hand hygiene after performing blood pressure checks. <BR/>2. RN D prevented cross contamination of Resident #5's insulin and the medication cart when she dropped the insulin pen cap onto the floor, removed her gloves after administering Resident #5's insulin and leaving Resident #5's room and opening the medication cart, retuning Resident #5's box containing the resident's glucometer and insulin pen. <BR/>3. RN G prevented cross contamination of Resident #51's wound care supplies when she failed to set up a clean field in the residents' room and failed to perform hand hygiene during wound care. <BR/>4. LVN J prevented cross contamination of Resident #15's wound care supplies when she failed to set up a clean field in the residents' room and performed hand hygiene during wound care. CNA M performed hand hygiene during incontinence care for Resident #15.<BR/>5. RN D performed hand hygiene during incontinence care for Resident #45.<BR/>Theses failure could place residents at risk for infection and cross contamination. <BR/>Findings include:<BR/>1. Record review of Resident #35's Face sheet, dated 03/14/24, reflected a [AGE] year-old male with an admission date of 11/29/23. Resident #35 had diagnoses which included diverticulitis (inflammation of the digestive tract), gastro-esophageal reflux (condition where stomach content moves up into the esophagus, and hypertension (high blood pressure).<BR/>Record review of Resident #23's Face sheet, dated 03/14/24, reflected a [AGE] year-old male with an admission date of 07/19/23. Resident #23 had diagnoses which included diabetes and hypertension (high blood pressure).<BR/>During a medication pass observation on 03/10/24 at 09:50 AM revealed MA F at the medication cart in the front lobby. MA F performed hand hygiene and retrieved a wrist blood pressure cuff and placed the cuff on Resident #35's wrist to obtain his blood pressure. MA F placed the wrist cuff on top of the medication cart without cleaning the cuff and without performing hand hygiene and proceeded to pull the resident's morning medication. After completing Resident #35's medication pass she pushed the medication cart to the dining room for her next medication pass.<BR/>Observation on 03/10/24 at 10:00 AM revealed MA F in the dining room with the medication cart. MA F performed hand hygiene and picked up the uncleaned wrist blood pressure cuff and obtained Resident # 23's blood pressure. MA F placed the wrist cuff on top of the medication cart without cleaning the cuff and without performing hand hygiene and proceeded to pull the resident's morning medication. After completing Resident #23's medication pass she pushed the medication cart to the dining room for her next medication pass.<BR/>In an interview with MA F on 03/10/24 at 10:30 AM, she stated she was supposed to sanitize the blood pressure cuff after each resident, and she failed to do that. She stated she was also required to perform hand hygiene after contact with a resident. She stated failure to sanitize the blood pressure cuff and perform hand hygiene placed residents at risk for the spread of germs. <BR/>In an Interview with the DON on 03/11/24 at 01:10 PM, she stated blood pressure cuffs had to be cleaned between resident-to-resident use and staff were to perform hand hygiene after taking a resident's blood pressure to prevent the spread of germs. She stated they did not have a policy on cleaning of resident equipment. She stated they follow CDC guidelines for the required cleaning procedure. <BR/>Record review of the CDC guideline obtained on 03/18/24 from https://www.cdc.gov/infectioncontrol/guidelines/disinfection, reflected, Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient .).<BR/>2. Record review of Resident #5's, Face sheet, dated 03/14/24 reflected a [AGE] year-old female with an admission date of 01/05/10. Resident #5 had diagnoses which included Type 2 diabetes and dementia. <BR/>An observation and interview on 03/10/24 at 11:25 AM revealed RN D at the medication cart preparing to perform Resident #5's finger stick blood sugar. RN D removed the glucometer from the Resident's box which contained a glucometer, lancets, bottle of test strips and an insulin pen. RN D stated they keep the resident's box containing her supplies on the medication cart instead of her room since she was on the secured unit. RN D performed hand hygiene and donned gloves and obtained Resident #5's blood sugar. RN D then placed the glucometer back in the box and removed her gloves and sanitized her hands. RN D checked the computer to determine the amount of insulin required, put on gloves, and assisted the resident into her room to administer the insulin. RN D removed the cap off the insulin pen and dropped it onto the floor. RN D dialed in the amount of insulin required without priming the pen and administered the insulin. RN D then picked up the cap from the floor and placed it back onto the insulin pen and left the room wearing her gloves. RN D placed the insulin pen back into the box containing the resident's glucometer and test strips and then placed the uncleaned box back into the medication cart, still wearing the gloves worn to administer the resident's insulin. <BR/>In an Interview with RN D on 03/10/24 at 11:35 AM she stated she should have removed her gloves and sanitized her hands before opining the cart to place the pen back in the box of supplies. She stated by not cleaning the cap of the insulin pen she had cross contaminated the pen as well as the supplies in the resident's box. She stated by doing this it created a risk of infections and the spread of germs to other residents. <BR/>3. Record review of Resident #51's, Face sheet dated 03/14/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #51 had a diagnosis which included hemiplegia affecting right dominant side (paralysis) and muscle weakness. <BR/>In an observation and interview of wound care on Resident #51 by RN G on 03/10/24 at 03:00 PM, revealed her at the treatment cart. RN G placed gauze, a pair of scissors, and a Xeroform dressing (mesh gauze occlusive dressing used for low drainage wounds) and a dry dressing in a plastic sack. RN G entered the resident's room and placed the sack of supplies onto the bed and then washed her hands and put on gloves. RN G pulled back the covers and revealed the dressing on Resident #51's left lower leg which had a date of 03/08/24. RN G stated she had changed the dressing on Friday 03/08/24 and it appeared no one had changed it on 03/09/24. RN G removed the old dressing slowly since it had dried and was stuck to the wound bed of the venous ulcer located on the front of the residents left lower leg. RN G reached into the plastic sack and retrieved a vial of normal saline and wet the old dressing to help facilitate removal. Once the dressing was removed the wound bed had some slough present with minimal drainage. RN G stated the wound looked a little better. RN G then removed her gloves and put on clean gloves without performing hand hygiene and again reached into the plastic bag of supplies and pulled out more vials of normal saline and gauze and cleaned the wound bed. RN G stated she needed more gauze. She removed her gloves, washed her hands, and left the room and retrieved more gauze. RN G returned to the room with gauze, put on gloves and then reached into the sack and pulled out the package containing a border dressing and opened the package and placed the opened package on the uncleaned bedside table. She then patted the wound bed dry with the gauze, removed her gloves and put on new gloves without performing hand hygiene and reached back into the sack of supplies and retrieved the Xeroform dressing and a pair of scissors. She opened the package of Xeroform and cut it to size for the wound bed and covered the wound with the Xeroform dressing and covered it with the border dressing, RN G then dated the dressing with a date of 03/10/24. RN G then removed her gloves and washed her hands. <BR/>In an interview with RN G 03/10/24 at 03:10 PM she stated she was supposed to sanitize her hands after each glove change and stated she had failed to do that. She stated she used the plastic sack as her clean field for the supplies, but then realized how this was not acceptable since the first time she reached back into the sack she had cross contaminated the other supplies. She stated failing to perform hand hygiene and set up a clean filed for her supplies created a risk of infection for the resident. <BR/>4. Record review of Resident #15's, Face sheet dated 03/14/24, reflected a [AGE] year-old-female with an admission date of 09/26/23. Resident #15 had diagnoses which included multiple sclerosis (disease in which the immune system eats away at protective coverings of nerves) and pressure ulcers. <BR/>In an observation and interview with LVN J on 03/11/24 at 09:10 AM revealed her at the treatment cart preparing supplies for wound care for Resident #15. LVN J stated the orders were: <BR/>1. Sacrum wound- Wound cleanser (contains normal saline and antimicrobial agents), apply collagen (protein used to make connective tissue) and calcium alginate (made from seaweed, absorbent dressing) and cover with dry dressing.<BR/>2. Left Lateral Malleolus (outside ankle)- wound cleanser, Santyl (enzyme used to break up and remove dead skin and tissue) and Calcium alginate and cover with dry dressing.<BR/>3. Left medial Malleolus (inside ankle) Wound cleanser, Santyl and calcium alginate and cover with dry dressing. <BR/>4. Right medal Malleolus (inside ankle) Wound cleanser, Santyl, calcium alginate and cover with dry dressing and cover with dry dressing.<BR/>5. Left heel- skin prep.<BR/>6. Left Ischial wound- Clean with Dakin's solution(a strong topical antiseptic used to clean infected wounds), apply Santyl and calcium alginate and cover with dry dressing. <BR/>7. Right gluteal fold- clean with Normal Saline, Apply Santyl, pack with kerlix moistened with Dakin's solution and cover <BR/>Observed CNA M and LVN J entered Resident #15's room to provide the residents wound care on 03/11/24 at 09:15 AM. Both staff washed their hands. LVN J cleaned the bedside table with a germicidal wipe and then placed the wound care supplies, plus a bottle of Dakin's solution and her computer on the table without placing the supplies on a barrier. CNA M put on gloves and uncovered the resident and found the resident with no brief lying on a cloth moisture resistant pad. CNA M rolled the resident on her right side revealing she had a bowel movement, which had contaminated the sacral wound dressing. CNA M provided incontinence care and changed her gloves but did not perform hand hygiene after she changed her gloves. LVN J noted the resident had 4 dressing on her right foot and stated she only had orders for her right Lateral ankle. She stated she was not sure what was going on with the resident's right foot. LVN J removed the dressing on the left outer ankle revealing a wound about the size of a golf ball with slough (yellowish white material in the wound bed consisting of dead cells) present, she stated this wound looked a little smaller since she saw it last week. LVN J cleaned the wound with normal saline, since she stated she was out of wound cleanser. LVN J removed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the wound bed and covered with a dressing. LVN J changed her gloves without performing hand hygiene and removed the dressing from the resident's left interior ankle revealing a wound about the diameter of a double D battery. The wound had slough present. LVN J cleaned the wound with normal saline, changed gloves, with no hand hygiene, and applied Santyl and Calcium alginate and covered with a dressing. LVN J then applied skin prep to the resident's left heel, which had a scab approximately the diameter of a triple A battery. LVN J changed her gloves- no hand hygiene and proceeded to remove all dressing on the outside the right ankle and revealed a wound approximately the diameter of a golf ball on the outer ankle with slough present and serous (yellow) drainage. Observed on the outer middle part of her foot a wound approximately the size of blue jean button. LVN J stated it appeared it had calcium alginate, but stated there was no order for a treatment of this wound. LVN J cleaned both wounds with normal saline, changed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the ankle and calcium alginate to the wound on her right mid foot and covered both with a dressing. LVN J changed her gloves without performing hand hygiene and proceeded to the wound on the resident's right gluteal fold. LVN J removed the dressing and revealed a wound with heavy greenish gray drainage and strong odor. Wound was approximately the diameter of a soup can and appeared to be to the bone. LVN J cleaned with normal saline, changed her gloves without performing hand hygiene and re-gloved and applied Santyl and packed with kerlix moistened with Dakin's solution and covered with a dry dressing. LVN J removed her gloves without performing hand hygiene and re-gloved and proceeded to the wound on the resident's sacrum. CNA M completed incontinence care, removing the remainder of the fecal matter after LVN J removed the soiled dressing. The sacral wound was crescent shaped and approximately the width of a tennis ball with slough present. LVN J cleaned with normal saline and applied collagen and calcium alginate and covered with a dressing. LVN J changed her gloves without performing hand hygiene and proceeded to the wound on the residents left Ischial - Wound is approximately the diameter of a drink coaster with the top part of wound having some granulation (red and moist) present. The bottom of the wound had slough and necrotic tissue present with heavy drainage and an odor. LVN J cleaned with Daikin's solution, applied Santyl to the necrotic portion of the wound and calcium alginate to the remainder of the wound bed and covered with a dressing. LVN J changed her gloves and re-gloved without performing hand hygiene and provided catheter care and both she and CNA M placed a clean brief on the resident and dressed her for the day. Resident #15 was transferred with a mechanical lift to her wheelchair. Resident #15 again stated she had asked for a Roho (air filled pressure relief cushion) cushion. Both staff removed their gloves and performed hand hygiene. <BR/>In an observation and interview with LVN J on 03/11/24 at 10:15 AM revealed she returned to the treatment cart with a full package of gauze and the bottle of Dakins solution. She stated she was throwing the gauze away since it had been in the room and was now considered contaminated. She stated she should have not carried the full bottle of Dakins. She stated she was supposed to perform hand hygiene between glove changes and stated she had failed to do that. She stated she should have placed a barrier down for her wound care supplies, but stated she was concentrating on the orders for the numerous wounds the resident had and forgot. She stated failing to perform hand hygiene after glove changes could spread infection from one site to another. <BR/>In an interview with CNA M on 03/11/24 at 10:25 AM, she stated she was supposed to perform hand hygiene between gloves changes during care. She stated she had failed to do that which could increase the risk of infection to the resident. <BR/>In an interview with the DON on 03/13/24 at 08:50 AM, she stated wound care supplies were supposed to be on a clean field and only carry in the supplies needed. She stated staff were to change their gloves and perform hand hygiene when going from dirty to clean. She stated failing to keep supplies form contamination and failing to perform hand hygiene after glove changes placed residents at risk of infection and cross contamination. <BR/>5. Record review of Resident #45's Comprehensive MDS assessment, dated 01/02/24, reflected a [AGE] year-old male with an admission date of 08/29/22 with diagnoses included injury of cervical spinal cord (permanent complete or partial loss of sensory function), muscle weakness, lack of coordination, and need for assistance with personal care. Resident #45 had a BIMS of 15 which indicated Resident #45's cognition was intact. Resident#45 required moderate assistance of one-person physical assistance with toileting hygiene, and personal hygiene. Resident #45 had limited range of motion to right lower and upper extremities. The resident was frequently incontinent of urine bowel. <BR/>Review of Resident #45's care plan, initiated on 02/03/22, reflected .[Resident #45] has mixed bladder incontinence and is at risk for skin breakdown .Interventions .clean peri-area with each incontinence episode .<BR/>In an observation and interview with Resident #45 on 03/10/24 at 10:02 AM revealed the resident in bed, he stated he needed to be changed. <BR/>In an observation and interview on 03/10/24 at 10:15 AM revealed RN D entered Resident #45's room to provide incontinences care and change the resident's clothes. RN D washed her hands and put on gloves and unfasted the brief. She took a peri-wipe and wiped down each side of the resident's groin and across his pubic area but failed to clean his penis or scrotum. RN D rolled the resident over on his side revealing he was wet. Resident #45's skin was intact. RN D removed the wet brief and with the same soiled gloves she placed a clean brief under the resident. RN D removed her gloves and put on clean gloves without performing hand hygiene. RN D cleaned the resident's buttocks with a peri-wipe from front to back. RN D removed her gloves and put on clean gloves without performing hand hygiene. RN D rolled the resident back onto his back and fastened the brief and changed his clothes. RN D removed her gloves, and she washed her hands. <BR/>In an interview on 03/10/24 at 10:25 AM, RN D stated she was supposed to clean the penis area from tip to base and then clean the peri-area and scrotum area. RN D stated she failed to do that. RN D stated she should change her gloves and perform hand hygiene when she went from dirty to clean. RN D stated failing to provide proper care exposed the resident to infections and risk of skin breakdown. <BR/>In an interview on 03/10/24 at 09:19 AM, the DON stated when providing incontinent care staff were to clean the peri area including penis and scrotum for male residents then moving toward the buttocks. She stated by not providing accurate incontinent care placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated staff were to change their gloves and perform hand hygiene when going from dirty to clean. She stated failing to perform hand hygiene after glove changes placed residents at risk of infection and [NAME] contamination. <BR/>Review of the facility policy revised Dated 8/4/2021, titled Hand Hygiene reflected, . You should always perform hand hygiene: . Before applying and after removing personal protective equipment ( . gloves, gown, mask .) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. <BR/>The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. Resident #1 had history of confusion, exit seeking behavior and wandering behavior. On 12/20/24, Resident #1 eloped out of the facility and the facility was not aware the resident eloped. Resident #1 was walking the streets about 3 blocks away from the facility in a residential area. <BR/>The noncompliance was identified as PNC. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began.<BR/>These failures could place residents at risk of potential accidents, injuries, harm or death. <BR/>Findings include:<BR/>Review of Resident #1's face sheet undated reflected Resident #1 was admitted to the facility on [DATE] from another skilled nursing facility with diagnoses of Muscle Wasting and Atrophy (significant shortening of the muscle fibers and loss of overall muscle mass), Syncope and Collapse (fainting), Dementia (loss of cognitive functioning that interferes with daily life and activities), Depression, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Glaucoma (eye disease that can cause vison loss and blindness and blindness), Hypertension, Osteoarthritis (chronic degenerative joint disease), Generalized Muscle Disease, Unsteadiness on feet, lack of coordination and cognitive communication deficit. Resident #1 was not her own responsible party. <BR/>Review of Resident #1's admission MDS dated [DATE] reflected Resident #1 had a BIMS of 7 indicating she was severely cognitively impaired. Resident #1 had wandering behavior daily. Resident #1 was independent with ambulation with no assistive devices. Resident #1 required supervision with ADLs except she required partial/moderate assistance with bathing. <BR/>Review of Resident #1's Admitting paperwork from previous facility discharge summary reflected: [Resident #1] has cognitive impairments and requires redirection for orientation, care and safety. [RP] would like to secure placement in a long-term care facility that can assist with redirection for wandering/exit seeking and a secure unit as needed. <BR/>Review of Resident #1's baseline care plan dated 12/06/24 reflected Resident #1 was an elopement risk. Resident #1 was cognitively impaired due to forgetfulness and dementia.<BR/>Review of Resident #1's Comprehensive Care Plan dated 12/20/24 reflected the following:<BR/>-dated 12/20/24 Resident #1 had impaired cognitive function or impaired thought processes related to impaired decision making abilities, is not always understand or able to understand verbal and non-verbal expression related to dementia. <BR/>-revised 12/31/24 Resident #1 is an elopement risk/wanderer and is at risk for possible injury [related to] impaired safety awareness and diagnosis of dementia 12/20/24 Resident had elopement event. Interventions included Distract resident from wandering ., Provide structured activities ., secure unit placement for increased monitoring.<BR/>-revised 02/06/25 Resident #1 resides on the facility security unit [due to] wander/elopement risks related to history of attempts to leave facility unattended, impaired safety awareness, resident wanders aimlessly. Interventions included Identify pattern of wandering: Is wandering purposeful, aimless or escapist? .Intervene as appropriate.<BR/>Review of Resident #1's Incident Report dated 12/20/24 reflected elopement incident for Resident #1. It reflected received phone call that resident was at a nearby house. Resident of the home was able to retrieve this resident's cell phone and call resident's[RP]. [RP] picked resident up and returned resident to facility. Resident states 'the girls and I went to a dance and got lost. Head to toe assessment performed, with no injuries noted. Resident on one-on-one monitoring until moved to secure unit on this day .Admin initiated self-report. Medical Director informed. Resident #1 was oriented to person only. Resident #1 had predisposing physiological factor s of confused and impaired memory. <BR/>Review of Resident #1's 24 Hour report dated 12/20/24 reflected Resident #1 elopement 12/20/24. One to one monitoring until moved to unit moved to 509B. <BR/>Observation and Interview on 03/12/25 at 10:28 AM revealed Resident #1 was sitting on her bed in her room on the secure unit. Resident #1 was confused and could not recall the incident. She stated she felt safe at the facility. <BR/>Review of Resident #1's progress note for December 2024 reflected the following:<BR/>Dated 12/05/24 12:45 PM by RN A resident admitted to facility ambulatory has dx of dementia and wondering alzheimers .very pleasant oriented to room .will continue to monitor and assess will update [medical doctor] family and admin prn status changes.<BR/>Dated 12/06/24 12:40 PM by LVN B Resident exit seeking and attempting to exit out of 200 hall exit door. Resident redirected to eat lunch.<BR/>Dated 12/06/24 1:55 PM by LVN B Resident continuing to attempt to exit seek. Resident pushing on exit doors. Staff attempting to redirect resident. Resident confused. [Alert and Oriented] x1. DON notified.<BR/>Review of Incident/Accident Reports December 2024 to March 2025 reflected no other elopement incidents for any other residents in the facility.<BR/>Interview on 03/12/24 at 1:54 PM with LVN C revealed Resident #1 eloped on 12/20/24 but he was not working when the incident occurred. He stated Resident #1 was confused, had wandering behavior and would ask about leaving the facility. He stated he had been in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. He was knowledgeable about his role as a charge nurse for a missing resident. He stated Resident #1 was placed on the secure unit after the elopement incident.<BR/>Interview on 03/12/24 at 3:22 PM with LVN B revealed Resident #1 had expressed desire to go home constantly, would say her family member was coming to pick her up, and asked LVN B what door do I exit from. She stated she would redirect Resident #1 when she expressed wanting to leave and go home. She stated on the morning of 12/20/24 before the incident Resident #1 was confused and did not understand why she was at facility. She stated Resident #1 required redirection and distraction from wanting to leave. She stated on 12/06/24 Resident #1 did have 2 occurrences of exit seeking on pushing on hall 200 doors and she documented it in the nurse's note. She stated she redirected Resident #1 when she attempted to exit seek and distracted her. She stated she was not aware of Resident #1's history if she was an elopement risk upon admission. She stated on 12/06/24 she was not Resident #1's charge nurse and could not recall who she notified about the exit seeking behavior for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident. She was unaware of any elopement incidents since Resident #1's elopement on 12/20/24.<BR/>Follow-up Interview on 03/13/25 at 10:15 AM with LVN B revealed on 12/20/24 Resident #1 was last seen at the facility's Christmas party at 1:45 PM or 2 PM. She stated 2:00 PM is shift change so she was not working when Resident #1 returned to the facility after the elopement. She stated she documented Resident #1's exit seeking behavior on 12/06/24 in a nurse's note since she was not Resident #1's charge nurse. <BR/>Interview on 03/12/24 at 3:40 PM with MDS Coordinator revealed Resident #1 admitted from another skilled nursing facility. She stated Resident #1 did have wandering behavior and the baseline care plan reflected she was at risk for elopement. She could not find an elopement assessment upon admission for Resident #1. She stated she was not working the day of Resident #1's elopement. She stated the charge nurse who admits a resident was responsible to ensure elopement assessment completed to determine resident's elopement risk level. She stated she was in-serviced after the incident in December 2024 on elopement policy and signs/symptoms of residents at risk for elopement.<BR/>Interview on 03/13/24 at 8:45 AM with RN A revealed Resident #1 was oriented to her self only but confused about the place. Resident #1 was ambulatory and wandered within the facility. She stated Resident #1 would go to the door but was not aware of her attempting to exit prior to the elopement. She stated Resident #1 was a risk for elopement due to confusion and wandering behavior. She stated she was the admitting nurse for Resident #1 and she could not recall why elopement assessment was not done at admission. She stated she could not recall reviewing Resident #1's discharge paperwork from the previous facility. She was not aware Resident #1 was an elopement risk. She stated she was not aware Resident #1's baseline care plan showed Resident #1 as an elopement risk. She stated the DON was the charge nurse at time of elopement incident for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. She stated after being in-serviced she was aware all residents upon admission should have elopement assessment completed to determine elopement risk. <BR/>Interview on 03/13/25 at 9:25 AM with CNA D revealed Resident #1 was confused and would misplace her phone asking for assistance from facility staff to find it. She stated Resident #1 had occasional exit seeking behavior of going towards the exit doors. She stated Resident #1 constantly wandered within the facility and would ask to go to go with Resident #1's RP. She stated nurses were aware of Resident #1's wandering, confusion and exit seeking behavior. She stated Resident #1 was placed on the secure unit after the elopement incident. <BR/>Interview on 03/13/25 at 9:32 AM with Med Aide E revealed she did could not recall Resident #1 prior to being on the secure unit and did not recall elopement incident for Resident #1 in December 2024. She stated Resident #1 was currently on the secure unit for resident safety. She stated she had been in-serviced on elopement policy and signs/symptoms of residents at risk for elopement.<BR/>Interview on 03/13/25 at 9:55 AM with Resident #1's RP revealed at the previous facility she exhibited behavior of wandering and would go to the exit doors to look out. She stated Resident #1 was confused and had dementia. She stated Resident #1 had not eloped at previous facility but they had Resident #1 moved to this facility for the resident safety and risk for elopement. She stated she had not had a care plan meeting with the facility. She stated nursing had not reached out to her prior to this incident of any exit seeking behavior for Resident #1. She stated she did not meet with facility staff to review the baseline care plan and facility had not discussed with her secure unit until after this elopement incident. She stated on 12/20/24 when she was shopping at a local store she received a phone call from a stranger using Resident#1's phone informing Resident #1 was walking the streets in a residential area. She stated she responded by telling the stranger the resident could not be there she was a resident at the facility. She stated she immediately left to go get Resident #1. She attempted to call the facility and was not able to get through but called a friend who called the facility to inform them Resident #1 was found walking the streets. She stated when she got to Resident #1 it was about like 10 minutes from when she first received the phone call. She stated she found her about 3 blocks away from the facility in a black sweatshirt with pants, socks and shoes on. Resident #1 told her she was dancing with her friends and got lost. She stated Resident #1 was cold and shivering with a blanket covering her provided by the bystander. She stated the bystander told her Resident #1 had flagged them down on the street saying she knew them and was walking the streets in residential area. She stated the facility had informed her later she must have gone out the door after the Christmas party when other visitors were exiting. She stated she took Resident #1 back to the facility in her car and nurse assessed her. She stated Resident #1 was not injured and was mad when Resident #1's RP left. She stated Resident #1 was placed on the secure unit after the elopement incident. <BR/>Interview on 03/13/25 at 10:29 AM with CNA F revealed she saw Resident #1 at the facility's Christmas party eating but she had to leave about 2 pm to transport another resident to an appointment. She stated Resident #1 did have exit seeking behavior and would express her desire to leave the facility especially after her family would visit. She stated she had been in-serviced after Resident #1's elopement on elopement policy, signs/symptoms of residents at risk for elopement, abuse/neglect.<BR/>Interview on 03/13/25 at 10:48 AM with Activity Director revealed on 12/20/24 facility had a Christmas party in the dining room including facility staff, residents and visitors from 1:30 PM to 2:00 PM. She stated she saw Resident #1 at the Christmas party but she did not recall seeing her after that. She stated she was not at the facility when Resident #1 returned to facility after elopement incident later that day. She stated Resident #1 was ambulatory on her own, had some confusion and looked like a visitor. She stated she was not aware of Resident #1 exit seeking behavior. She stated there was like 60 people at the Christmas party and maybe she had followed visitors out the door after the party. <BR/>Interview on 03/13/25 at 10:35 AM with CNA K revealed she was knowledgeable on elopement policy, signs of residents with elopement risk, abuse/neglect and would immediately report to Charge Nurse, Administrator and DON if a resident was found missing. She had been recently in-serviced on elopement protocol and abuse/neglect policy. <BR/>Interviews on 03/12/25 at 1:21 PM and 03/13/25 at 11:45 AM with CNA G revealed she had been recently in-serviced on elopement policy and signs of residents with elopement risk. She was aware she needed to notify Charge Nurse, Administrator and DON when resident is found missing. She was knowledgeable of types of abuse/neglect and had been in-serviced on abuse/neglect recently. <BR/>Interview on 03/13/25 at 11:28 AM with ADON revealed she was working today as a charge nurse and works the floor as needed as the charge nurse. She stated she was in-serviced on elopement protocol including signs of residents at risk for elopement and the nurse's role when resident is found missing. She stated she had been in-serviced on nurse responsibility to complete elopement assessment upon admission and as needed when resident exhibits exit seeking behavior. She stated when Resident #1 eloped she was at risk of injury.<BR/>Interviews on 03/13/25 at 12:10 PM with LVN L revealed she worked 2 pm to 10 pm shift on 12/20/24 but was not the charge nurse for Resident #1. She stated she was unaware of resident elopement risk and had not witnessed any exit seeking behavior from Resident #1. She stated Resident #1 was ambulatory on her own and did look like a visitor. She stated Resident #1 had confusion. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident.<BR/>Interview on 03/13/25 at 1:13 PM with DON revealed she was unable to provide any witness statements of Resident #1's elopement. She stated she was the charge nurse for Resident #1 on 2 pm to 10 pm shift on 12/20/24. She received a phone call from a friend to Resident #1's RP who also worked for the facility that Resident #1's RP had received a phone call from a stranger that Resident #1 was found at a neighboring house. The DON looked at incident report and stated she had received the phone call at 3:45 PM on 12/20/24 because this is when she initiated the incident report for Resident #1. She stated Resident #1's RP brought Resident #1 back to the facility and Resident #1 was confused saying she went dancing with her friends. She stated she assessed Resident #1 head to toe with no injury noted. She could not recall the specific vitals but stated Resident #1's vitals were within normal limits. She stated facility initiated 1:1 for resident safety when she returned and after consent placed her on the secure unit for exit seeking behavior and elopement incident. She stated when interviewing staff after the elopement Resident #1 was last seen by staff at Christmas party on 12/20/24. She stated Resident #1 did wander within the facility but she was not aware of any exit seeking behavior. She stated when she reviewed Resident #1's progress notes she found the note on 12/06/24 stating Resident #1 had exit seeking behavior and stated she was not made aware of it. She stated she completed the baseline care plan for Resident #1 and stated she put down Resident #1 was an elopement risk based on previous stay at skilled nursing facility. She stated she did not review the baseline care plan with Resident #1's RP and did not look to see if elopement assessment had been completed upon admission. She stated she completed Resident #1's elopement assessment after the incident on 12/20/24 indicating she was high elopement risk due to elopement. She could not recall discussing secure unit placement with Resident #1's RP until after she had eloped on 12/20/24. She stated nursing had been in-serviced on completing elopement assessments upon admission and as needed when residents exhibit exit-seeking behavior. She stated if she had been made aware of Resident #1's exit seeking behavior on 12/06/25 she stated an elopement assessment would have been completed to determine elopement risk and to discuss with team about secure unit placement for safety. She stated the potential risk of elopement was serious injury or accident for Resident #1. She stated Resident #1 had intermittent cognition especially after Resident #1's RP visited and did not understand why she was placed at facility. <BR/>Interview on 03/13/25 at 1:55 PM with Administrator revealed Resident #1's Previous Facility expressed she would go to the exit door asking about a car. He was not aware of Resident #1 having exit seeking behavior until after elopement incident in December 2024. He stated facility investigation revealed Resident #1 was last seen at the Christmas party on 12/20/24 and may have exited behind visitors or other people at the end of the party. He stated Resident #1 did elope and was immediately placed on 1:1 with staff until placed on secure unit for elopement and resident safety. He stated there have been no other elopements. He stated if he was aware of the exit seeking behavior prior to incident they could have assessed her with elopement assessed and review to determine if she required more supervision. He stated the potential risk to Resident #1 could be injury and serious harm. He stated the facility completed an elopement drill with facility staff to ensure staff were knowledgeable of facility policy on elopement. <BR/>Review of staff In-services reflected:<BR/>12/20/24 and 12/26/24 staff in-serviced on elopement education including elopement drill<BR/>12/26/24 nurses in-serviced on completing all admission assessments by DON included RN A, LVN B, LVN C, ADON, MDS Coordinator and other nurses.<BR/>12/20/24 and 12/28/24 staff in-serviced on abuse/neglect<BR/>Review of facility's policy Elopement dated 11/01/19 reflected To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing .6. When the patient/resident is located, the nurse completes a head-to-toe assessment. The social service designee assesses the patient/resident for emotional distress. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Examples of criteria that put a resident at higher risk of elopement .Cognitive impairment (example: those who dementia, Alzheimer's, brain injury) Exit-seeking behaviors (example: confused resident that thinks he/she needs to go pick their kids up from the school) New admission wanting desperately to leave .History of elopement at other communities<BR/>Review of facility's policy Elopement Risk assessment dated [DATE] reflected facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. PROCEDURE 1. All patients/residents are assessed on admission by a licensed nurse for elopement risk utilizing the elopement risk assessment form. 2. All patients/residents are re-assessed for elopement potential by the licensed nurse/social service designee quarterly throughout a patient's/resident's stay and with a significant change .4. The licensed nurse or social service designee completes the elopement risk assessment form and presents to the interdisciplinary team for further intervention.6. The physician and the patient/resident or the patient's/resident's representative are notified of the patient's/resident's risk for elopement and the interventions that are recommended for prevention of elopement and patient/resident safety. 7. The patient's/resident's legal representative should be contacted, if possible, to obtain all pertinent information in relation to elopement risk .10. A licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjust as needed. 11. A baseline plan of care should be completed on admission and any elopement risks should be identified. <BR/>The DON and Administrator were notified and provided the IJ template on 03/13/25 at 6:05 PM of PNC IJ for F689. The DON was provided the IJ template for PNC F689 on 03/13/25 at 6:05 PM. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident has a right to a safe, clean, comfortable and homelike environment for 9 (Residents #1, #5, #20, #21, #39, #41, #59, #67, #69) of 24 residents reviewed for safe and sanitary environment.<BR/>1. The facility failed to ensure Resident #20, #21, #41 and #59 had bed sheets in good condition without holes in them.<BR/>2. The facility failed to ensure Resident #39's curtain was without food stains. <BR/>3. The facility failed to ensure sheet rock behind toilet was in good condition not exposing pipes in Resident #69's bathroom. <BR/>4. The facility failed to ensure Resident #67's room had a curtain over the window. The facility failed to ensure Resident #67's bathroom had a toilet paper holder, a mirror, and sheet rock in bathroom wall did not expose pipes.<BR/>5. The facility failed to ensure residents in secure unit (500 hall) were comfortable with room temperature.<BR/>These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.<BR/>Findings include: <BR/>1. Record Review of Resident #21's admission MDS assessment dated [DATE] reflected Resident #21 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of closed fracture of left femur with routine healing, heart failure and hypertension. Resident #21 required substantial/maximal assistance with most ADLs except partial/moderate assistance with mobility. Resident #21 had a BIMS of 15 indicating she was cognitively intact. <BR/>Observation on 03/10/24 at 9:53 AM revealed Resident #21 was lying in bed with about 4 dime sized holes in her white fitted sheet above her head to the left of her pillow, about 3 dime sized holes in her fitted sheet to the left of her arm and a large tear on bottom corner about 4 inches length by 2 inches height exposing resident's mattress. <BR/>Interview on 03/10/24 at 9:54 AM with Resident # 21 revealed her bed sheets had holes in them and staff changed her sheets yesterday. She stated she noticed the holes in her bed sheets.<BR/>Interview on 03/10/24 at 11:20 AM with ADON revealed Resident #21's fitted sheet should not have holes in it but she stated it was difficult for the facility staff to find fitted sheets that are right size to cover the mattress and without holes in it especially on the corners of the bedding. She stated the staff should not be putting bed linen with holes on it on resident's beds. <BR/>Record review of Resident #41's quarterly MDS assessment dated [DATE] reflected Resident #41 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diabetes, coronary artery disease, dementia, generalized muscle weakness and lack of coordination. Resident #41 required partial/moderate assistance with showering. Resident #41 had a BIMS of 14 indicating he was cognitively intact. <BR/>Observation and Interview on 03/11/24 at 9:56 AM with Resident #41 revealed he was lying in bed with bed sheets with five small dime sized holes on top of bed sheet near his head. He stated he had noticed holes in the sheets since admitting to the facility.<BR/>Record Review of Resident #59's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of early onset Alzheimer's disease, depression, generalized anxiety disorder, and hypertension. Resident #58 had a BIMS score of 0 indicating she was severely cognitively impaired.<BR/>Observation on 03/11/24 at 9:54 AM of Resident #59's room revealed 5 small holes on the fitted bed sheet at the foot of the bed.<BR/>Record Review of Resident #20's quarterly MDS assessment dated [DATE] reflected Resident #20 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of bipolar disorder (mood disorder with extreme mood swings), recurrent depressive disorder, encephalopathy (brain dysfunction), nontraumatic subdural hemorrhage (bleeding in the layer of tissue around the brain), arthritis (disorder causing joint pain and stiffness). Resident #20 had a BIMS score of 6 indicating he was severely cognitively impaired. <BR/>Observation on 03/11/24 at 10:00 AM revealed Resident #20's fitted sheet had 8 small holes in her sheets at the head of the bed and 5 small holes at the foot of the bed. <BR/>Interview with CNA B on 03/11/24 at 10:05 AM revealed that she was aware of the holes on Resident #5, #20, and #59's sheets. CNA B stated the facility has been in need of linens and facility had not gotten new bed sheets. CNA B stated that she had no choice but to use the sheets with holes and that it was better than having no sheets for residents. CNA B stated that risk to resident for not having clean and comfortable environment was an infection risk if not cleaned and reduced psychosocial outcomes.<BR/>Observation of the linen closet and interview on 03/14/24 at 12:04 PM, with Housekeeping and Laundry Supervisor revealed 4 fitted sheets with holes. She removed them from the closet. The Housekeeping and Laundry Supervisor revealed her expectation of facility staff was to remove and discard any stained linen or linen having holes. She stated stained linen and linen with holes should not go to the floor. She stated the risk would be resident dignity and residents have the right to have clean and intact linen.<BR/>2. Record review of Resident # 39's Comprehensive MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of malignant melanoma, dementia (loss of cognitive functioning), depression, and anxiety disorder. Resident #39 had a BIMS score of 4 indicating she was severely cognitively impaired.<BR/>Observation and interview on 03/10/24 at 10:10 AM revealed Resident #39's curtain in between the door and her bed had dark brown and black splatters. Resident #39 revealed she had not noticed curtain because it was not facing her side of the bed. <BR/>Interview on 03/10/24 at 10:11 AM with CNA W revealed she saw Resident #39's curtain yesterday and forgot to take it down and believed it was food smears from another resident that wanders into rooms. CNA W stated that housekeeping was responsible for looking at curtains when they check resident rooms. CNA W stated not having clean curtains in resident rooms would put residents at risk of infections or negatively impact their mood.<BR/>3. Review of Resident #69's quarterly MDS assessment dated [DATE] reflected Resident #69 was an [AGE] year old male admitted to the facility on [DATE] with diagnose of frontotemporal neurocognitive disorder (result of damage to neurons in the frontal and temporal lobes of the brain), atherosclerosis heart disease(the buildup of plaque in and on the artery walls of the heart), peripheral vascular disease (systematic disorder that involves narrowing of vessels situated away from the heart or the brain), diabetes, stroke, dementia and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). Resident #69 had a BIMS of 11 indicating he was moderately cognitively impaired. <BR/>Observation on 03/10/24 at 10:14 AM revealed in Resident # 69 and Resident #30's bathroom had a square of sheeting rock sitting to the right of the toilet next to wall and a hole size of the sheet rock square (12 in x 12 in) behind the toilet seat exposing pipes in the wall.<BR/>Interview on 3/10/24 at 10:15 AM with Resident # 69 revealed the hole in bathroom wall behind toilet had been there since he was admitted to the facility. He stated Maintenance Director was aware of it.<BR/>Interview on 03/11/24 at 5:45 PM with Maintenance Director revealed in Resident #69's bathroom wall sheet rock was off due to past issues with plumbing but he had not replaced the sheet rock yet exposing plumbing pipes behind toilet. He stated he did not know exactly how long the sheet rock had been off. He stated he did not document it in the Maintenance log and had difficulty getting facility staff to document maintenance requests in the maintenance log so he could keep track of them. <BR/>4 . Record review of Resident #67's quarterly MDS dated [DATE] reflected Resident #67 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of metabolic encephalopathy (brain dysfunction due to disease or toxins in body), dementia (loss of cognition), hypotension (low blood pressure). Resident #67 had a BIMS score of 11 indicating she was moderately cognitively impaired. <BR/>Observation on 03/10/24 at 11:00 AM revealed Resident #67's window had a privacy curtain for her side of the bed pinned to window with a thumbtack with no curtain. Observation of Resident #67 bathroom revealed no toilet paper towel holder on wall and toilet paper sat on top of back of toilet. Observation of Resident #67's bathroom revealed a large hole about 2 feet by 2 feet across underneath sink and at top right corner of bathroom wall above sink exposing plumbing. Resident #67's bathroom had no mirror. <BR/>Interview on 03/10/24 at 11:01 AM with Resident #67 revealed that she wanted to go home and did not feel like her room was home-like.<BR/>Interview with CNA B on 03/11/24 at 10:05 AM revealed she did not know about Resident #67's window curtain and would look into it. CNA B stated that risk to resident for not having clean and comfortable environment was an infection risk if not cleaned and reduced psychosocial outcomes.<BR/>Interview on 03/11/2024 at 1:50 PM with Maintenance Director regarding Resident #67's bathroom revealed there had been a leak and the holes in the drywall were to identify the leak and repair it. Maintenance Supervisor was unable to say how long ago the holes were made or when he was going to repair the holes. Maintenance Supervisor was not aware Resident #67's privacy curtain was pinned to window.<BR/>5. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of anoxic brain injury (brain deprived of oxygen), altered mental status, anemia (low iron), hypothyroidism (decreased production of thyroid hormone), and congestive heart failure. Resident #1 had a BIMS score of 14 indicating she was cognitively intact. <BR/>Observation and interview on 03/10/24 at 2:49 PM of Resident #1's room revealed Resident #1 in bed wearing a long sleeve shirt and sweatshirt, covered with 2 blankets, and a blanket over her head. Observation of Resident #1's room revealed it to be cold and the air conditioner was running with cold air coming from vent above Resident #59's bed. <BR/>Interview on 03/10/24 at 2:50 PM with Resident #1 revealed she was not sure why her room was so cold and it seemed like the air conditioning was always on even now. <BR/>Interview on 03/10/24 at 2:55 PM with RN D revealed she was aware Resident #1's room was cold and stated they keep the door open to try to help the cold air escape. RN D stated she was not sure why Resident #1's room was so cold. <BR/>Observation and Interview on 03/11/24 at 2:18 PM revealed Resident #1 lying in bed with two blankets and head covered with blanket stated she was cold and cold all the time. Observation of Maintenance Director using a digital thermometer revealed Resident #1's vent room temperature was 55 degrees Fahrenheit and wall was 63 degrees Fahrenheit.<BR/>Record review of Resident #5's quarterly MDS assessment dated [DATE] reflected Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of traumatic subarachnoid hemorrhage (burst blood vessel in the brain), need for assistance with personal care, mild intellectual disabilities, bipolar type schizoaffective disorder (mood disorder with periods of intense feelings), diabetes. Resident #5 had a BIMS score of 9 indicating she was moderately cognitively impaired.<BR/>Observation and interview on 03/11/24 at 9:49 AM revealed Resident #5 lying in bed on her left side wearing a long sleeve shirt, covered with 3 blankets and wearing a bow on the top of her hair. Interview with Resident #5 revealed she was a poor historian and was not sure how long she had been at facility. <BR/>Observation on 03/11/24 at 2:21 PM of Resident #5's room revealed Resident #5 lying in bed covered with two blankets wearing a long sleeve sweater. Interview with Resident #5 revealed she was cold and she did not like feeling cold. <BR/>Observation of Resident #5's room revealed air conditioner is on and blowing cold air from vent, which was shut, temperature at vent measured 52 degrees Fahrenheit and 63 degrees Fahrenheit on wall. <BR/>Observation on 03/11/24 at 10:00 AM revealed Resident #20 sitting in her wheelchair in her room in front of her bed wearing long sleeve shirt and pants with non-slip socks. <BR/>Record review of Resident # 47's Quarterly MDS dated [DATE] revealed Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke), dementia (loss of cognitive functioning), and lack of coordination. She had a BIMS score of 99 indicated she was not interviewable and was severely impaired in cognitive skills for decision making. <BR/>Observations on 03/11/24 at 2:16 PM revealed Maintenance Director used a digital thermometer to measure Resident #47's room revealed air conditioner blowing cold air from vent with temperature from vent measuring 60 degrees Fahrenheit and 65 degrees Fahrenheit at wall. <BR/>Observation on 03/11/24 at 2:22 PM of Resident #39's room revealed air conditioner was on and blowing cold air from vent. Observation of Maintenance Director using a digital thermometer revealed room temperature at vent measured 60 degrees Fahrenheit and 66 degrees Fahrenheit on wall. <BR/>Observation on 03/11/24 at 2:23 PM of Resident #20's room revealed air conditioner is on and blowing cold air from vent. Observation of Maintenance Director using a digital thermometer revealed room temperature at vent measured 52 degrees Fahrenheit and 62 degrees Fahrenheit on wall.<BR/>Interview on 03/12/24 at 2:25 PM with Maintenance Director revealed temperature of resident rooms should be 71 degrees Fahrenheit at a minimum. He stated the risk to residents if the temperature was under 71 degrees Fahrenheit would be discomfort. Maintenance Director stated the staff were responsible for ensuring the temperature was not below a comfortable level for residents. He stated the facility used to have locked boxes on the thermostats, but they were broken off not being replaced.<BR/>Interview on 03/14/24 at 9:40 AM with Administrator revealed she had in-serviced facility staff including to put maintenance repairs in maintenance log at nurses' station. She stated it was difficult on the Maintenance Director to keep up with needed maintenance requests if not documented in the log. <BR/>Review of facility's maintenance log from January to March 2024 did not reflect repairs needed in Resident #69's bathroom sheet rock. <BR/>Review of facility's In-service dated 12/28/23 to all facility staff included maintenance log location and maintenance Director telephone number.<BR/>Review of facility's policy Quality of Life - Homelike Environment last revised May 2017 reflected Residents are provided with a safe, clean, comfortable and homelike environment .1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment .e. clean bed and bath linens that are in good condition .h. comfortable and safe temperatures (71 F - 81 F) .<BR/>Review of facility's policy Maintenance Service last revised December 2009 reflected Maintenance service shall be provided to all areas of the building, grounds and equipment. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 (Resident #1) of 5 resident reviewed for care plan revisions.<BR/> The facility failed to update Resident #1's care plan to reflect interventions of suicidal ideations.<BR/>This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, printed on 04/17/23, revealed a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses of sequelae of cerebral infarction, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side (paralysis of one side of the body), hyperlipidemia, anxiety disorder, nonpsychotic mental disorder, and depression. <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #1 had a resident mood interview severity score of 3, indicating minimal depression. Resident #1's potential indicator for psychosis was marked as delusions. Resident #1 required supervision with ADLs of bed mobility, transfers, dressing, eating, toilet use and personal hygiene.<BR/>Record review of Resident #1's electronic medical record tab entitle progress note, dated 04/05/23 at 6:23 a.m., indicated Resident #1 made small cuts to the right side of her neck, with scissors while stating she would kill herself if she could not leave the facility. The progress noted the scissors were confiscated, the resident was sent to a local hospital for psychological evaluation and suicide ideations. <BR/>Record review of Resident #1's care plan, revised on 04/21/22, revealed Resident #1 had depression. Interventions were Monitor/document/report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Arrange for psych consult, follow up as indicated, and Administer medications as ordered. Monitor/document for side effects and effectiveness. The care plan did not address suicidal ideations and self-harm. <BR/>Record review of Resident #1 's physician's order, dated 04/13/23, indicated Sertraline HCI Tablet 100 mg, give 1.25 tablet by mouth one time a day for depression. <BR/>Record review of Resident #1 's physician's order, dated 04/12/23, indicated Buspirone HCI oral Tablet 15 mg, give 3 tablets by mouth two times a day for anxiety.<BR/>In an interview on 04/14/23 at 12:38 p.m., Resident #1 stated she attempted to kill herself with scissors about two weeks ago. She stated an aide was able to get the scissors from her before she hurt herself. Resident #1 stated she suffered from depression because of her childhood experiences. She stated at the time of the suicide incident, she no longer wanted to stay in the facility, and she was having a hard time mentally. Resident #1 stated she had suicidal thoughts before but that was her first time trying to harm herself in the facility. Resident #1 stated she received was seen by a psychiatrist in the facility, but she felt the did not know what she needed. Resident #1 stated she no longer had thoughts of harming herself and would speak to a staff member if she did in the future. <BR/>In an interview on 04/17/23 at 2:33 p.m., LVN D stated she worked in the facility as the wound care and treatment nurse for two years. LVN D stated herself and DCO were responsible for resident's care plans and were to update care plans as needed. LVN D stated she was aware of the 04/05/23 incident involving Resident #1. LVN D stated Resident #1 had an extreme frequency of behaviors that varied nature. LVN D stated all of Resident #1's had been care planned and had interventions in place. LVN D stated she unsure if Resident #1's suicide ideations were care planned, but it should have been updated to include the incident and interventions. <BR/>In an interview on 04/17/23 at 3:17 p.m. the DCO stated at the beginning of the night shift on 04/04/23 Resident #1 began having behaviors and later began stating she wanted to harm herself. The DCO stated the resident was placed on 1-on-1 supervision and was taken to her room at roughly 6:00 a.m. on 04/05/23. Shortly after wheeling the resident to her room, Resident #1 grabbed scissors and attempted to cut her throat. The DCO stated staff were able to stop Resident #1, but she did have a few areas of broken skin on the right side of her neck. She stated Resident #1 was taken to the nurse's station for supervision and was transferred to the hospital for behavioral services. The DCO stated herself, the treatment nurse and assistant director of clinical operations were responsible for care plans. She stated when LVN D asked her if the incident was care planned, she saw that it was not and added the incident, interventions, and action plan to Resident #1's care plan at that time. The DCO stated the incident should have been added to the care plan and believed because the resident was out of the facility for about a week, it was not added. The DCO stated not including suicide ideations in a resident's care plan could leave nursing staff who were new to the resident not knowing of all behaviors of the resident.<BR/>In an interview on 04/12/23 at 3:44 p.m., the EDO stated she was aware of the incident involving Resident #1 on 04/05/23. The EDO stated she was unaware the incident was not added to Resident #1's care plan but should have been. The EDO stated the DCO and MDS nurse were responsible for updating residents care plans and not having behaviors care planned could allow residents to harm themselves or others. The EDO stated she would in-service the DCO and MDS nurse to ensure this error did not occur again. <BR/>The facility's policy, Comprehensive Care plan, 01/20/21, read in part:<BR/> Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident withing forty-within (48) hours of admission. The interdisciplinary Team will continue to develop the plan in conjunction with the .MDS .completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The care plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from resident's representatives, external partners .Hospice, Therapy, Clinician and not as all inclusive

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs and preferences for three (Residents #26, #4 and #5) of nine residents reviewed for call lights. <BR/>1. Facility failed to ensure Resident #26's call button was within reach of Resident #26 while she was lying in bed.<BR/>2. Facility failed to ensure Resident #4's call button was within reach of Resident #4 while she was lying in bed. <BR/>3. Facility failed to ensure Resident #5's call button was within reach of Resident #5 while she was lying in bed.<BR/>These failures could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity.<BR/>Findings included:<BR/>1. Review of Resident #26's Annual MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinsons disease, stroke, diabetes, seizures and chronic obstructive pulmonary disease. Resident #26 had a BIMS of 8 indicating she was moderately cognitively impaired. She required extensive assistance with ADLs of bed mobility, dressing, toileting, hygiene with one to two person assistance .<BR/>Observations on 02/07/23 at 11:21 AM and 11:25 AM revealed Resident # 26 was lying in bed with the call button not within reach. The call button was located about 3 feet away from Resident #26's bed on a pile of stuff.<BR/>Interview on 02/07/23 at 11:21 AM with Resident #26 revealed her call button was not within reach and she used it when it was in reach to get assistance from staff. She stated she would fall out of the bed trying to reach for the call button and had fallen before in her room. <BR/>Interview on 02/07/23 at 11:26 AM with the ADON revealed Resident #26's call button should have been within reach and she would talk to the aides about ensuring call lights were within reach of residents. She stated Resident #26 did use the call button to ask for assistance. <BR/>2. Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of heart failure, hypertension, Alzheimer's disease, Parkinson's disease, schizophrenia and chronic obstructive pulmonary disease. Resident #4 had a BIMS of 11 indicating she was moderately cognitively impaired. She required extensive assistance with most ADLs except limited assistance with transfers. <BR/>Review of Resident #4's Comprehensive Care Plan last revised 01/24/23 reflected Resident #4 was at an increased risk for falls as evidenced by a history of falls, cognitive impairment, physical impairment, unsteady gait, generalized weakness. Interventions included to Anticipate needs, provide prompt assistance and Ensure call light in in reach and answer promptly.<BR/>Observation and interview on 02/07/23 at 11:34 AM revealed Resident # 4 was lying in bed with the call button about 3 feet away from her. Resident #4 stated her call light was not working for the last 2 days and was not within reach for her to use. <BR/>Interview on 02/07/23 at 11:37 AM with the Director of Plant Operations revealed he had to replaced the bulb (light in the hallway) since it was not lighting up when Resident #4 pressed her call button. At 11:43 AM the Director of Plant Operations stated he was not aware of residents in room [ROOM NUMBER]'s call light not working and was unaware the bulb went out until when he just looked at it. He stated he checked the resident call lights monthly.<BR/>3. Review of Resident #5's significant change MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of kidney failure, hypertension, arthritis, stroke and hemiplegia/hemiparesis on right side (weakness on side which caused paralysis). She had a BIMS of 9 indicating she was moderately cognitively impaired. She required extensive assistance with ADLs except eating was supervision and toileting was total dependence. <BR/>Observation and interview on 02/07/23 at 11:38 AM revealed Resident #5 was lying in bed with the call button not within reach. The call button was about 4 feet away from her bed, hanging down vertically from the wall. Resident #5 stated she would use the call button if it was within reach of her while in her bed .<BR/>Interview on 02/07/23 at 11:39 AM with the ADON revealed the call buttons should be within reach of the residents while in bed so they could use it to ask for assistance. She stated not having a call button within reach can place residents at risk for falls and a delay in getting assistance from staff when needed. She stated Resident #4 and #5's call buttons were not within reach of the residents and both residents used their call buttons. She told the CNAs on her hall to check and ensure call buttons are within reach of residents. She stated she was not aware of Resident room [ROOM NUMBER]'s light bulb in the hallway not working to alert staff in the hallway 600 about the call light being on.<BR/>Interview on 02/07/23 at 2:40 PM with the Administrator revealed call buttons should be within reach of residents and working properly. She stated the staff had been in-serviced recently on call lights. <BR/>Interview on 02/08/23 at 11:00 AM with LVN C revealed they had a recent in-service about ensuring call buttons are within reach of residents when in their room. <BR/>Interview on 02/08/23 at 11:42 AM with the Director of Plant Operations revealed he did not have a log he kept checking resident call buttons to ensure they were working. He stated he checked call buttons monthly to ensure they were working and checked different resident rooms on different hallways. <BR/>Interview on 02/09/23 at 10:45 AM with the Administrator revealed the Director of Plant Operations stated he would start a log documenting checking residents' call buttons to ensure they are in working order. She stated focused care partners. which are department heads assigned to resident rooms. would start checking their assigned residents' call buttons to ensure they were working and within reach of residents when they do their resident rounds. <BR/>Review of facility's policy Quality of Life/Accommodation of Needs revised August 2009 reflected the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being .1. The resident's individual needs and preferences shall be accommodated to the extent possible .<BR/>Review of facility's policy Nurse Call effective 08/08/2022 reflected All facilities must ensure that nurse call cords are installed and functioning properly in all patient rooms. The nurse call cords must be easily accessible to patients and located within reach from the patient's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Residents #71) of one resident reviewed for feeding tubes.<BR/>The ADON failed to check placement of Resident #71's G-Tube by checking for gastric residual prior to administering the resident's medications. <BR/>This failure could affect residents by placing them at risk of obstruction of the G-tube, nausea, vomiting and potential for aspiration and discomfort. <BR/>Findings included:<BR/>Record review of Resident #71's quarterly MDS assessment, dated 12/21/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. The resident was unable to complete the brief interview for mental status and was coded as severely cognitively impaired by staff assessment. Diagnoses included dysphagia (swallowing difficulties), cerebrovascular accident (stroke) neurogenic bladder (lack of bladder control due to brain or nerve problem), and malnutrition. Resident #71 received 51% or more of total calories through tube feeding (G-tube - tube inserted through the abdomen that delivers nutrition directly to the stomach.).<BR/>Resident #71's Care Plan implemented on 07/26/22 did not address the residents G-tube status or interventions to prevent complications related to the G-Tube. <BR/>Record review of Resident #71's Physicians Order Summary Report dated 02/08/23 reflected, .Check placement and residual (quantity remaining) prior to administering feeding or medication. Notify MD and hold administration if residual &gt;200 ml. Reassess hourly until residual &lt; 200 ml. or change in orders obtained every shift . with a start date of 07/11/22. <BR/>Record review of Resident #71's MAR for February 2023 reflected, . Check placement and residual prior to administering feeding or medication. Notify MD and hold administration if residual &gt;200 ml. Reassess hourly until residual &lt; 200 ml. or change in orders obtained every shift . with a start date of 07/11/22. <BR/>An observation on 02/07/23 at 01:25 p.m. revealed the ADON at the medication cart pulling the following medications for G-tube administration for Resident #71: <BR/>Hydrocodone-Acetaminophen 7.5 mg-325mg 1 tablet (narcotic)<BR/>Hydroxyzine HCL 10mg tab 1 tablet (antihistamine to control itching) <BR/>The ADON performed hand hygiene and put on gloves and placed each of the tablets into a plastic sleeve and crushed them and placed each of the medications into an individual plastic cup. The ADON gathered the pill cups and 1 plastic water cup and entered the resident's room and filled the cup with tap water. The ADON poured approximately 10 to 15 ccs of water into each pill cup. The continuous feeding pump was off. The ADON retrieved a 60-cc piston syringe (syringe used for measuring) and drew back to approximately 30 cc of air, disconnected the G-tube line, and placed the syringe onto the end of the g-tube and pushed approximately 15 cc of air into the resident's stomach and listened with her stethoscope. The ADON then removed the plunger from the piston syringe and flushed the G-tube with approximately 30cc of water and began administering each of the medication, flushing with approximately 10 ccs of water between each medication without checking for residual. The ADON flushed the G-tube with approximately 30 cc after the last medication and re-started the continuous enteral feeding at 55 cc per hour. <BR/>In an interview with the ADON on 02/07/22 at 01:35 p.m. she stated the steps for checking placement were air auscultation (act of listening) with 15-20 cc of air and then check residual. She stated she forgot to check for residual. When asked the risk of not checking for residual she stated the resident could be too full and adding more fluid could cause aspiration. <BR/>In an interview with the DON on 02/08/23 at 09:20 a.m. she stated the standard of care had changed and they no longer checked placement of the G-Tube with air auscultation. She stated the staff must check placement by checking for residual. She stated failure to do so placed the resident at risk, stating they could be over full which in turn would cause discomfort and possible aspiration pneumonia. <BR/>Review of the facility's policy, Enteral Tube Medication Administration, dated September 2018, reflected, .The physician's orders must specify the route of administration of any medication via feeding tube .Prepare medications for administration .With gloves on, check for proper tube placement in accordance with facility policy .Check gastric content for residual feeding. Return residual volumes to the stomach

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one (Dietary Manager) of three dietary staff reviewed for qualifications. <BR/>The facility failed to employ a qualified Dietary Manager.<BR/>This failure could place the residents at risk of not being provided a nutritional well-balanced diet and not have their dietary needs identified and addressed.<BR/>Findings included:<BR/>Review of the Dietary Manager's employee file revealed a hire date of 12/30/21 and she had food handlers' training certificate dated 08/04/22 with expiration date of 08/04/24. She did not have certified dietary manager certificate or ServeSafe Manager certification in her file. The Dietary Manager did not have an associate degree or higher in food service management or in hospitality. The Dietary Manager's job description was not in the employee's file. <BR/>Interview on 02/07/23 at 10:13 AM revealed the Dietary Manager stated she started working at the facility as the Dietary Manager since August 2022.<BR/>Interview on 02/09/23 at 12:50 and 1:18 PM with the Dietary Manager revealed she was in the process of completing modules in an online course for the Dietary Manager Certification which she started the online course in October 2022 and had 13 months to complete getting certified. She stated the Consultant Dietitian visited the facility twice a month. She stated she was not aware she had to complete ServeSafe Manager training and did not know anything about this training. <BR/>Interview on 02/09/23 at 1:12 PM with the Administrator revealed she thought the Dietary Manager's job description was in her file and signed by the Dietary Manager. She stated the Consultant Dietitian was overseeing the Dietary Manger while she worked on her dietary manager certificate. She stated she was not aware the Dietary Manager needed to complete ServeSafe Manager training prior to working in the kitchen. She stated she was not aware if the Dietary Manager had taken the ServeSafe Manager training. She stated the consultant dietitian came to facility twice a month and was not full time at the facility. <BR/>Interview on 02/09/23 at 1:52 PM with Consultant Dietitian revealed the Dietary Manager did have a food handlers license and was not aware the Dietary Manger had to complete the ServeSafe Manager training prior to working in the kitchen. She stated she was available for the Dietary Manager to consult with her and came to facility twice a month. She stated she had provided the Dietary Manger a food manager booklet and the Dietary Manager was working on her online course work to get her certification as a dietary manager. She stated she did go over kitchen sanitation issues with the Dietary Manager and the Administrator when she visited twice a month. <BR/>Review of facility's job description for the Director of Food and Nutrition Services revised March 2022 reflected one of the primary purposes of the job was directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility. Under qualifications it reflected ServeSafe Manager Certification required to be presented during orientation/before working in the kitchen if not CDM (Certified Dietary Manager) and holds a current and valid Food Service Manager/Dietary Manager Certificate or CDM Certification or CDM Exam eligibility .If verifiable proof of CDM Credential or CDM Exam eligibility is not provided, applicant will be required to enroll in an ANFP approved CDM course within 30 days of hire and complete all course work and testing within 12 months of hire.<BR/>Review of the facility's policy Food and Nutrition Services Staff revised October 2017 reflected The food Services Department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department .

Based on observations, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure refrigerator item in walk -in refrigerator was labeled, dated and sealed.<BR/>2. The facility failed to ensure black refrigerator unit with freezer on top and drink cooler freezer had thermometers. The facility failed to document temperatures. The facility failed to ensure cleanliness of drink cooler freezer.<BR/>3. The facility failed to ensure the Dietary Manager and Food Service Manager E washed their hands when touching PPE and changing gloves during lunch preparation on 02/08/23.<BR/>4. The facility failed to ensure hamburger patties' food temperature was taken after cooked and before served to residents for lunch on 02/08/23.<BR/>5. The facility failed to ensure the low temperature dish machine was meeting the temperature of 120 degrees Fahrenheit for wash and rinse cycle.<BR/>6. The facility failed to ensure trays and bowls were allowed to air dry before use at lunch on 02/08/23. Dietary Aide G failed to ensure plates air dried before stacking plates on top of one another on 02/08/23. <BR/>These failures could place residents at risk for food-borne illness and food contamination.<BR/>Findings included:<BR/>1. Observation on 02/07/23 at 9:52 AM revealed the walk-in refrigerator had fries in a plastic bag unsealed, open about 2 inches and not dated when opened.<BR/>Interview on 02/07/23 at 9:54 AM with Dietary Aide F revealed the fries should be dated and sealed properly.<BR/>Interview on 02/07/23 at 10:13 AM with the Dietary Manager revealed refrigerated food items should be dated when opened, labeled and sealed properly .<BR/>2. Observation on 02/07/23 at 9:56 AM revealed the drink freezer had numerous food stains and debris on the bottom along with a wrapper stuck to bottom of freezer. There was a box of individual vanilla ice cream containers. There was no thermometer in the drink freezer.<BR/>Interview on 02/07/23 at 9:57 AM with Dietary Aide F revealed she did not know the ice cream was in the drink cooler freezer and did not know where the thermometer was.<BR/>Interview at 02/07/23 at 9:58 AM with Food Service Manager I revealed he thought they did not use the drink freezer and was unaware that the ice cream containers were in the freezer. He stated he did not know where thermometer was for the drink freezer.<BR/>Observations on 02/07/23 at 9:50 AM revealed the black refrigerator unit with freezer on top which contained bread in refrigerator and freezer had no temperature log or thermometer in it. Dietary Aide F could not find a thermometer in the black refrigerator.<BR/>Observation and interview on 02/07/23 at 9:59 AM revealed the Dietary Manager was unable to find a thermometer in the black refrigerator unit with freezer on top. <BR/>Interviews on 02/07/23 at 10:04 AM and 10:13 AM with the Dietary Manager revealed the black refrigerator/freezer in the dining room started to be used about a month ago so they could keep bread in it. She stated she would put a thermometer in the black freezer and refrigerator so they could know the temperatures. She stated they did not have a log for the temperatures of the refrigerator/freezer. She stated she was not aware of the drink freezer being used and did not know anyone had stored the ice cream in there. She stated the drink freezer should have a thermometer and be kept clean when in use. She stated when there was no thermometer in refrigerator or freezer they were unable to know whether cold foods were being kept within appropriate temperatures.<BR/>Review of facility's policy Food Receiving and Storage revised October 2017 reflected Food shall be received and stored in a manner that complies with safe food handling practices .Food Services, or other designated staff, will maintain clean food storage areas at all times .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date) .12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.<BR/>Review of facility's policy Refrigerators and Freezers revised December 2014 reflected facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .1. Acceptable temperature ranges are 35 F to 40 F for refrigerators and less than 0 for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.3. Monthly tracking sheets will include time, temperature, initial, and 'action taken.' 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening .7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and individual items removed from cases for storage .10. Refrigeration and freezers will be kept clean, free of debris .<BR/>Review of facility's policy Food Preparation and Service revised October 2017 reflected Thermometers will be placed in hot and cold storage areas and checked for accuracy in accordance with accepted public health standards.<BR/>3. Observation on 02/08/23 at 11:40 AM revealed Food Service Manager E touched her surgical mask with her gloved hands and then started plating food for residents with her gloved hands touching inward of the residents plates. She did not change her gloves or wash her hands. At 11:47 AM she touched her face shield with her gloved hands. She did not change her gloves or wash her hands. She continued to plate food for the residents with her gloved hands touching the inward part of the residents plates.<BR/>Observation on 02/08/23 at 11:52 AM revealed the Dietary Manger touched her face goggles with her gloved hands to adjust them on her face. She did not change her gloves or wash her hands. She continued to place plate covers over the residents plates and condiments on meal trays.<BR/>Interview on 02/08/23 at 12:35 PM with Food Service Manager E revealed she did touch her surgical mask, did not change her gloves and failed to wash her hands like she should have. <BR/>Interview on 02/08/23 at 12:37 PM with Dietary Manager revealed she and Food Service Manager E should have changed their gloves and washed their hands after touching their PPE. The Dietary Manager stated when they contaminated their gloves, they needed to change their gloves and wash their hands prior to putting on new gloves. <BR/>Review of the facility's policy Food Preparation and Service revised October 2017 reflected Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness.<BR/>Review of The US Public Health Service Food Code, dated 2017, retrieved 02/16/23, reflected the following regarding hand hygiene, 2-301.14 When to Wash Food employees shall clean their hands and exposed portions of their arms as specified under &sect; 2-301.12 immediately before engaging in food preparation including working with exposed Food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; . (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat foods; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the Hands.<BR/>4. Observation on 02/08/23 at 12:15 PM revealed frozen hamburger patties were cooking in water over the stove top. At 12:24 PM the hamburger patties' temperature were not checked prior to being placed on meal trays for residents and placed on hall trays. At 12:32 PM there were additional frozen hamburger patties cooked in water on the stove top and hamburger patties temperature was not checked. At 12:37 PM the cooked hamburger patties went out on lunch meals trays to three residents for hall trays for 300 hall and on a lunch test tray. <BR/>Observation on 02/08/23 at 12:41 PM the facility staff were passing out resident meal trays on the 300 hall. At 12:48 PM last hall meal tray for the 300 hall was served to a resident. Observation at 12:50 PM of the lunch test tray included one cooked hamburger patty in a bun . The patty was temped at 136.3 degrees F and the hamburger patty was barely warm. <BR/>Interview on 02/08/23 at 1:05 PM with the Dietary Manager revealed the hamburger patties were usually temped prior to being served to ensure the temperature was appropriate and maintained until resident meal trays were passed out. She stated they should have checked the food temperature of the hamburgers prior to serving them to ensure the hamburger patties were at the appropriate temperature of at least 160 degrees Fahrenheit .<BR/>5. Observation and interview on 02/08/23 at 3:16 PM revealed the dish machine temperature was 100 degrees Fahrenheit for wash and rinse. A 2nd observation at 3:18 PM revealed 100 degrees wash and 102 degrees Fahrenheit rinse. Interview with Dietary Aide G revealed in the morning dish machine's wash and rinse temperature was checked. He stated he did not know what the minimum temperature was for the wash and rinse since he was new and did not check the dish machine temperature.<BR/>Observation and Interview on 02/08/23 at 3:23 PM revealed the Dietary Manager checked the dish machine temperatures and it was only 101 degrees Fahrenheit for wash cycle. She stated it is supposed to be 120 degrees Fahrenheit minimum for wash and rinse for the facility's low temperature dish machine. She stated she would talk with the Dir of Plant Operations to have him look at it. She stated she told Dietary Aide G to stop using the dish machine until they got it working. She stated earlier today the dish machine was 120 degrees Fahrenheit or above for wash and rinse when it was checked.<BR/>Interview on 02/08/23 at 3:40 PM with the Administrator revealed she was informed about the dish machine temperature being too low and they would have the dish machine representative come out to look at it if the Dir of Plant Operations was unable to get it working properly, he was looking at it now. She stated they would start using Styrofoam containers if they were not able to get the dish machine working until it is fixed. <BR/>Interview on 02/09/23 at 9:10 AM with the Dir of Plant Operations revealed the dish machine was still not meeting 120 degrees Fahrenheit minimum for wash and rinse. He stated he looked at the booster for dish machine but it did not help the temperatures. He stated he was waiting for the representative from the dish machine company to look at it today.<BR/>Review of dish machine's installation and operation manual dated 12/05/07 from http://manuals.jacksonmsc.com/ecolab%20manuals/ES-2000%20&%20ES-4000%20Rev%20O.pdf reflected under section 1 the dish machine required a minimum temperature of wash and rinse of 120 degrees Fahrenheit. <BR/>6. Observations on 02/08/23 at 11:54 AM revealed resident meal lunch trays had water droplets on them and were used for resident meal trays for lunch. Bowls were stored in different directions in a plastic container with water droplets inside the bowls. Food Service Manager E used bowls from the container for food for the residents' lunch.<BR/>Interview on 02/08/23 at 12:36 PM with the Dietary Manager revealed they did not have the space in the kitchen to allow for dishware like trays, plates and bowls to air dry prior to use. She stated they had very limited counter space. <BR/>Observation on 02/08/23 at 3:15 PM revealed Dietary Aide G took plates from dish rack which just came out of the dish machine. Dietary Aide G started stacking them on top of other plates. He did not allow them to air dry.<BR/>Interview on 02/09/23 at 1:52 PM with Consultant Dietitian revealed dietary staff should change gloves and wash their hands when they touch anything that could contaminate them before putting on new gloves. She stated the refrigerator and freezers should have a thermometer in them to ensure temperatures were maintained. She stated the dish machine should have been working to meet the appropriate temperature requirements. She stated the hamburger patties' food temperature should have been checked prior to be served to ensure hamburger patties' food temperature met serving temperature.

Based on observations, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice and the residents' goals and preferences for three (Residents #47, #48 and #230) of five residents reviewed for oxygen therapy. <BR/>1. The facility failed to ensure there was a process in place to ensure there was an adequate amount of portable oxygen in the facility to meet the needs and preferences of residents who were on oxygen therapy. The administration did not maintain a reserve of portable oxygen tanks for residents to use as needed. <BR/>2. The Administration did not contact the Oxygen Vendor timely to ensure a delivery of portable oxygen tanks would be received before running out of portable oxygen tanks. <BR/>3. The facility did not have a designated staff assigned to monitor the supply of portable oxygen tanks and therefore was not aware that the facility was running low on supply of portable oxygen tanks. <BR/>These failures placed residents on continuous oxygen therapy at risk for compromised safety, comfort, and medical care.<BR/>Findings included:<BR/>Interview on 2/7/2023 at 10:00 AM with Resident #48 revealed he did not have a portable oxygen tank and he needed it when he left his room. Resident stated he usually went out on smoke breaks and whatever else he wanted to do outside of his room with his portable oxygen. He stated he must hurry back to his room to hook back to his oxygen concentrator. He stated that he had no access to a portable oxygen tank for a few days. He stated he made the facility aware that his portable oxygen tank was empty . Resident #48 stated he had not been provided with a portable oxygen tank. <BR/>Record review of Resident #48 revealed he had an admitting diagnosis of acute embolism and thrombosis of deep veins of left lower extremity (obstruction of artery/vein by a blood clot), atherosclerotic heart disease of native coronary artery (thickening of the heart artery) with unspecified angina pectororis (chest pain), chronic obstructive pulmonary disease, and chronic diastolic congestive heart failure (the heart main pumping chamber becomes stiff and unable to fill properly). Resident had orders to be on continuous oxygen between 2-5 Liters.<BR/>Observation on 2/7/2023 at 11:45AM with Resident #230 revealed she had an oxygen concentrator in the dining room under the table. Resident was alert but unable to answer why she was brought to the dining room with her whole oxygen concentrator instead of a portable oxygen tank. Resident #230 did not appear to be in distress or having issues breathing at the time.<BR/>Record Review of Resident #230 revealed she had an admitting diagnosis of traumatic subarachnoid hemorrhage (brain bleed) with loss of consciousness of unspecified duration, Chronic Obstructive Pulmonary Disease, Malignant Neoplasm of Main Bronchus (cancer of the lung). She had physician orders to be on 2 liters of continuous oxygen. <BR/>Interview on 2/7/2023 at 11:45 AM with LVN D revealed the facility had been without portable oxygen tanks for at least a couple of days. She stated the facility ran out of portable oxygen tanks over the weekend. LVN D stated she reported it to LVN C, who was the Charge Nurse on duty at the time. LVN D stated the solution to not having available portable oxygen tanks was to bring the oxygen concentrator along with the resident if they want to come out of their rooms. She stated that in case of a power outage, she would have to plug the resident's concentrator into a red outlet plug. She stated that she was unsure what she would do if the facility had to evacuate and there were no portable oxygen tanks available for her oxygen dependent resident.<BR/>Interview with CNA H on 2/7/2023 at 12:05PM revealed Resident #230 was the only person on the unit that required continuous oxygen. She stated she had to bring her oxygen concentrator to the dining room because there were no available portable oxygen tanks. She stated she has made her Charge Nurse aware that there were no portable oxygen tanks available.<BR/>Interview with DON on 2/7/2023 at 12:27 PM revealed she did not know that there were no portable oxygen tanks in the building. The DON and surveyor went to the portable oxygen storage closet and the DON discovered that there were approximately 15 empty portable oxygen tanks in the closet. She stated that she called the supplier, and they would be out today to fill them. She stated that she did not believe that the building was without oxygen for the weekend. The DON stated she gave out a portable oxygen tank on Monday (02/06/2023). She stated that she will follow up with supplier to get the estimate time of arrival on the vendor coming to refill the portable oxygen tanks. She stated that she called the oxygen vendor company as needed . The DON stated the facility does not have a routine schedule of service. She stated that if they were to have a power outage while there were no portable oxygen tanks in the building, they would plug the oxygen concentrator into the red outlet plug. When asked what if they needed to evacuate the building with no portable oxygen tanks in the building, she stated that she would have to call emergency services for assistance. She stated that the facility currently has five residents who were on continuous oxygen.<BR/>Observation on 2/7/2023 at 12:30 PM revealed there was a posted sign on the portable oxygen tank storage closet that listed the oxygen vendor. Observation revealed two telephone numbers with one number for emergencies . If you start the getting low call and tell them. Try to make it before 8am or as early as possible!! It is everyone's responsibility to make sure we don't run out of oxygen!<BR/>Interview on 2/8/23 at 10:30 AM with Resident #47 revealed she needed oxygen and a nurse was called into assist the resident with putting on the oxygen. Resident #47 stated that she received oxygen as needed but the portable oxygen tanks were not available over weekend. Resident #47 stated that she did not have any major difficulty breathing over the weekend but felt like the oxygen would have helped. <BR/>Interview with LVN C on 2/8/2023 at 11:50 AM revealed she noticed that the portable oxygen supply was low and that they only had one tank left over the weekend. She stated that she called Oxygen Vendor on Saturday 2/4/23 using the local number to request them to come out and service. She stated she was not able to reach anyone. She did not use the emergency number listed on the signage provided by Oxygen Vendor. She stated that MDS Coordinator A was the on-call RN, and she was made aware that the facility was running low on portable oxygen tanks. <BR/>Interview with MDS Coordinator A on 2/8/2023 1:00 PM revealed she was made aware that the facility was running low on portable oxygen tanks on Saturday 2/4/23 when she came into the facility. She stated that she was aware that there were four portable oxygen tanks in the building. She stated that the facility had two residents who go through portable oxygen tanks quicker than most residents and that was why they are so low. She stated that she called the Oxygen Vendor's local number but was unable to get through to anyone. She stated that she was still new and learning and was not aware of an emergency number for Oxygen Vendor. <BR/>Interview with Oxygen Representative A on 2/8/23 at 1:30 PM revealed there was no one in the office on the weekends and the facility should have been provided with an emergency contact number if they needed assistance on the weekend. He stated that the facility was set up on portable oxygen tank delivery on an as needed basis and did not have a routine service schedule.<BR/>Interview with Oxygen Representative B on 2/9/23 at 11:20AM stated that he did not receive a phone call over the weekend. He stated that if the facility called the local number, that is the number to the store, and no one was available from Friday 2pm until Monday morning around 8am. Oxygen Vendor B stated that he provided the facility with his personal cell for emergencies and that's the number that should have been utilized over the weekend. He stated that he delivered six oxygen tanks as an emergency service on Tuesday evening (2/7/23). He stated the remaining portable oxygen tanks were delivered on Wednesday morning (2/8/23). He stated that currently the facility was not set up on a routine schedule. He stated that this was partially due to an outstanding balance they had prior to Tuesday. He stated that he would be willing to set the facility up on a more routine service. <BR/>Interview with Administrator on 2/9/23 at 12:15PM, revealed that going forward, her expectation will be that the floor nurses were to let the MDS Coordinator A or DON know when they are running low on portable oxygen tanks. She stated that the facility will have an appointed person, their supply manager, to oversee staying on top of the portable oxygen tanks. She stated that she will check daily the number of available portable oxygen tanks the facility had on hand and would order as necessary. Administrator stated that staff will be in-serviced on new procedures effective immediately. She also stated that she will set up an arrangement where Oxygen Vendor will come out regularly. Admin stated that she was not aware of an outstanding balance with Oxygen Vendor that could prevent them from possible service. She stated that billing was done through corporate. <BR/>Record Review on 2/9/2023 at 11:00 AM revealed that the facility does have a valid contract with Oxygen Vendor dated 4/7/22 and was valid for three years. <BR/>Record Review on 2/9/2023 at 11:10 AM revealed that In-Service was started with employees on 2/8/2023 on procedures for notifying the appropriate person when portable oxygen tanks were running low.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Residents #71 and Resident #62) of eighteen residents reviewed for comprehensive care plans.<BR/>1. Resident #71's care plan failed to address interventions to prevent complications related to his indwelling urinary catheter and his G-tube.<BR/>2. Resident # 62's care plan failed to address his hospice election and failed to identify services that were provided by the hospice. <BR/>These failures placed residents at risk of not receiving individualized care and services to meet their needs and interventions to prevent complications related to each individuals identified concerns. <BR/>Findings included:<BR/>1. Record review of Resident #71's quarterly MDS assessment, dated 12/21/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. The resident was unable to complete the brief interview for mental status and was coded as severely cognitively impaired by staff assessment. The resident had a foley catheter and was always incontinent of bowel. His diagnoses included dysphagia (swallowing difficulties), cerebrovascular accident (stroke), neurogenic bladder (lack of bladder control due to brain or nerve problem), and malnutrition. Resident #71 received 51% or more of total calories through tube feeding (G-tube - tube inserted through the abdomen that delivers nutrition directly to the stomach).<BR/>Record review of Resident #71's Care Plan implemented on 07/26/22 revealed it did not address the residents G-tube status or interventions to prevent complications related to the G-Tube and there was no mention of the resident's foley catheter or interventions to prevent complications with the use of a foley catheter. <BR/>Record review of Resident #71's Physician's Order Summary Report dated 02/08/23 reflected, .Check placement and residual (quantity remaining) prior to administering feeding or medication. Notify MD and hold administration if residual &gt;200 ml. Reassess hourly until residual &lt; 200 ml. or change in orders obtained every shift .with a start date of 07/11/22 . Check Foley catheter placement, ensure Foley is secured via Velcro strap to reduce friction/pulling every shift .with a start date of 08/01/22 <BR/>Record review of Resident #71's MAR for February 2023 reflected, . Check placement and residual prior to administering feeding or medication. Notify MD and hold administration if residual &gt;200 ml. Reassess hourly until residual &lt; 200 ml. or change in orders obtained every shift .Check foley catheter placement, ensure Foley is secured via Velcro strap to reduce friction/pulling. Every shift . <BR/>An observation on 02/07/23 at 01:25 p.m. revealed Resident #71 had a G-tube with continuous enteral feedings and had a foley catheter. <BR/>In an interview with the DON on 02/08/23 at 2:55 p.m. revealed any resident with a G-tube or foley catheter should have those areas care planned with interventions to prevent complications. <BR/>2. Record review of Resident #62's Quarterly MDS assessment, dated 01/11/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. He had a BIMS of 15 which indicated he was cognitively intact. His diagnoses included viral hepatis (infection that causes liver damage) and alcoholic cirrhosis of liver with ascites (late-stage liver disease). The MDS indicated the resident was receiving hospice care in the facility. <BR/>Record review of Resident #62's Care Plan dated 01/24/23 reflected no mention indicating the resident was receiving hospice services, or what services hospice was providing. <BR/>In an interview with Resident #62 on 02/07/23 at 9:00 a.m. he stated he had asked the facility to make him an appointment with the only liver doctor in town. He stated he was wanting to know how bad his liver disease had progressed. <BR/>In an Interview with LVN C on 02/08/23 at 10:25 a.m. she stated Resident #62 had requested to see the liver doctor, but stated he was on hospice. She stated he was asked if he was wanting to seek aggressive treatment, since his hospice diagnosis was cirrhosis of the liver related to alcoholism. She stated he stated he was not seeking aggressive treatment. She stated they could make him an appointment if that is what he wanted to do.<BR/>In an interview with the DON on 02/08/23 at 3:00 p.m. she stated any resident on hospice was supposed to be care planned to identify what services the facility provided and what services the hospice agency provided. She stated the MDS Coordinator was responsible for creating the comprehensive care plan. She stated the care plan had to include all the resident's identified problems and interventions to prevent complications. She stated they had been without a full time MDS Coordinator until recently and were still trying to get care plans caught up. <BR/>In an interview with MDS Coordinator B on 02/08/23 at 3:20 p.m. she stated she was responsible for creating the comprehensive care plan in conjunction with the interdisciplinary team. She stated any resident with a foley catheter, G-tube and hospice needed to be care planned for interventions to prevent complications. She stated the care plan was supposed to represent the needs of the resident while in the facility. She stated she had been part time since middle of the summer 2022 and was trying to get the care plans caught up with the limited amount of time she had. <BR/>The facility's policy, Comprehensive Care plan, revised January 2021, reflected, Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident withing forty-within (48) hours of admission. The interdisciplinary Team will continue to develop the plan in conjunction with the .MDS .completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The care plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from resident's representatives, external partners .Hospice, Therapy, Clinician and not as all inclusive

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs and preferences for three (Residents #26, #4 and #5) of nine residents reviewed for call lights. <BR/>1. Facility failed to ensure Resident #26's call button was within reach of Resident #26 while she was lying in bed.<BR/>2. Facility failed to ensure Resident #4's call button was within reach of Resident #4 while she was lying in bed. <BR/>3. Facility failed to ensure Resident #5's call button was within reach of Resident #5 while she was lying in bed.<BR/>These failures could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity.<BR/>Findings included:<BR/>1. Review of Resident #26's Annual MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinsons disease, stroke, diabetes, seizures and chronic obstructive pulmonary disease. Resident #26 had a BIMS of 8 indicating she was moderately cognitively impaired. She required extensive assistance with ADLs of bed mobility, dressing, toileting, hygiene with one to two person assistance .<BR/>Observations on 02/07/23 at 11:21 AM and 11:25 AM revealed Resident # 26 was lying in bed with the call button not within reach. The call button was located about 3 feet away from Resident #26's bed on a pile of stuff.<BR/>Interview on 02/07/23 at 11:21 AM with Resident #26 revealed her call button was not within reach and she used it when it was in reach to get assistance from staff. She stated she would fall out of the bed trying to reach for the call button and had fallen before in her room. <BR/>Interview on 02/07/23 at 11:26 AM with the ADON revealed Resident #26's call button should have been within reach and she would talk to the aides about ensuring call lights were within reach of residents. She stated Resident #26 did use the call button to ask for assistance. <BR/>2. Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of heart failure, hypertension, Alzheimer's disease, Parkinson's disease, schizophrenia and chronic obstructive pulmonary disease. Resident #4 had a BIMS of 11 indicating she was moderately cognitively impaired. She required extensive assistance with most ADLs except limited assistance with transfers. <BR/>Review of Resident #4's Comprehensive Care Plan last revised 01/24/23 reflected Resident #4 was at an increased risk for falls as evidenced by a history of falls, cognitive impairment, physical impairment, unsteady gait, generalized weakness. Interventions included to Anticipate needs, provide prompt assistance and Ensure call light in in reach and answer promptly.<BR/>Observation and interview on 02/07/23 at 11:34 AM revealed Resident # 4 was lying in bed with the call button about 3 feet away from her. Resident #4 stated her call light was not working for the last 2 days and was not within reach for her to use. <BR/>Interview on 02/07/23 at 11:37 AM with the Director of Plant Operations revealed he had to replaced the bulb (light in the hallway) since it was not lighting up when Resident #4 pressed her call button. At 11:43 AM the Director of Plant Operations stated he was not aware of residents in room [ROOM NUMBER]'s call light not working and was unaware the bulb went out until when he just looked at it. He stated he checked the resident call lights monthly.<BR/>3. Review of Resident #5's significant change MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of kidney failure, hypertension, arthritis, stroke and hemiplegia/hemiparesis on right side (weakness on side which caused paralysis). She had a BIMS of 9 indicating she was moderately cognitively impaired. She required extensive assistance with ADLs except eating was supervision and toileting was total dependence. <BR/>Observation and interview on 02/07/23 at 11:38 AM revealed Resident #5 was lying in bed with the call button not within reach. The call button was about 4 feet away from her bed, hanging down vertically from the wall. Resident #5 stated she would use the call button if it was within reach of her while in her bed .<BR/>Interview on 02/07/23 at 11:39 AM with the ADON revealed the call buttons should be within reach of the residents while in bed so they could use it to ask for assistance. She stated not having a call button within reach can place residents at risk for falls and a delay in getting assistance from staff when needed. She stated Resident #4 and #5's call buttons were not within reach of the residents and both residents used their call buttons. She told the CNAs on her hall to check and ensure call buttons are within reach of residents. She stated she was not aware of Resident room [ROOM NUMBER]'s light bulb in the hallway not working to alert staff in the hallway 600 about the call light being on.<BR/>Interview on 02/07/23 at 2:40 PM with the Administrator revealed call buttons should be within reach of residents and working properly. She stated the staff had been in-serviced recently on call lights. <BR/>Interview on 02/08/23 at 11:00 AM with LVN C revealed they had a recent in-service about ensuring call buttons are within reach of residents when in their room. <BR/>Interview on 02/08/23 at 11:42 AM with the Director of Plant Operations revealed he did not have a log he kept checking resident call buttons to ensure they were working. He stated he checked call buttons monthly to ensure they were working and checked different resident rooms on different hallways. <BR/>Interview on 02/09/23 at 10:45 AM with the Administrator revealed the Director of Plant Operations stated he would start a log documenting checking residents' call buttons to ensure they are in working order. She stated focused care partners. which are department heads assigned to resident rooms. would start checking their assigned residents' call buttons to ensure they were working and within reach of residents when they do their resident rounds. <BR/>Review of facility's policy Quality of Life/Accommodation of Needs revised August 2009 reflected the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being .1. The resident's individual needs and preferences shall be accommodated to the extent possible .<BR/>Review of facility's policy Nurse Call effective 08/08/2022 reflected All facilities must ensure that nurse call cords are installed and functioning properly in all patient rooms. The nurse call cords must be easily accessible to patients and located within reach from the patient's bed.

Based on observation, interview, and record review, the facility failed to safeguard medical record information against loss and unauthorized use for one (Resident #1) of five reviewed for medical information.<BR/>The facility failed to ensure MA A secured Resident #1's information on medication cards and stickers on her medication cart for hall 600. <BR/>This failure could affect the residents, placing them at risk of resident-identifiable information being accessed by the public. <BR/>Findings included: <BR/>Observation on 02/17/23 at 8:40 AM revealed two empty cards of medications on top of the medication cart for Hall 600. Each card contained Resident #1's information including name, room number, medication type and administration instructions. Observation at 9:45 AM revealed the same two empty cards of medications on top of the medication cart for Hall 600. MA A was away from the cart and went to Hall 100 leaving the information unprotected for approximately one hour. There were residents and unauthorized personnel in the hallway at that time. <BR/>Interview on 02/17/23 at 9:45 AM with the Administrator revealed she expected all the staff to keep the resident's information always secured. The Administrator stated that MA A should not leave resident information out in the open for anyone to see. She stated if a visitor accessed the information, it could be used inappropriately. <BR/>Interview on 02/17/23 at 9:48 AM with the ADON confirmed MA A should have secured Resident #1's information in her medication cart before walking away. The ADON confirmed MA A was supposed to lock the empty medication cards and stickers in the medication cart away from public view when she walked away from it. The ADON stated that not securing resident information was risking the resident's confidentiality. <BR/>Interview on 02/17/23 at 10:31 AM with MA A confirmed she was supposed to lock the empty medication cards and stickers in the medication cart, away from public view, when she walked away from it. MA A stated she was aware that she should not have left the resident information out in the open and it was a violation of the resident's privacy. She stated that anyone who was walking in the hallways could have obtained the residents information. MA A stated that she just forgot to put the information away. <BR/>The DON was not available for interview on 02/17/23.<BR/>Review of the facility's policy titled Confidentiality of Information and Personal Privacy, dated October 2017, revealed Policy statement: Our facility will protect and safeguard resident confidentiality and person privacy. 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: b. medical treatment. 4. Access to resident personal and medical records will be limited to authorized staff and business associates .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) to avoid duplicative testing and effort for one (Resident #9) of 2 residents reviewed for PASARR. <BR/>The facility failed to refer Resident #12 to the state authority for potential mental illness trigger by submitting a corrected PASARR evaluation after the addition of a mental health diagnosis. <BR/>This failure could affect the residents who had a documented psychiatric diagnosis by placing them at risk for not receiving needed treatment and services.<BR/>Findings included:<BR/>A review of Resident #12's Face Sheet dated 5/9/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #12 had on onset of schizoaffective disorder on 11/27/24. <BR/>Review of Resident #12's MDS annual assessment dated [DATE] indicated the resident was considered by the State Level 2 PASARR process to have serious mental illness to include Schizophrenia (a chronic mental illness characterized by significant disruptions in though, perception, emotion, and behavior). Her other active diagnoses were Depression (a mood disorder characterized by persistent feelings of deadness, loss of interest and difficulty functioning in daily life) and Psychotic Disorder (a mental disorder characterized by a disconnection from reality). <BR/>Review of Resident #12's PASARR Level 1 Screening, dated 3/12/24, revealed no mental illness. <BR/>Review of Resident #12's medical records revealed no PASARR Level II screening or no Mental Illness Resident Review Form.<BR/>Interview with the Regional MDS Coordinator on 5/8/25 at 11:57pm revealed that Resident #12 completed the first PASSAR on 3/12/24 and it was negative for mental illness. Then her PCP added schizoaffective disorder with an onset of 11/27/24. She stated the resident should have had a Level II screening or a Mental Illness Resident Review filed with the LIDDA but did not. She was unsure of why it was not completed. She stated the MDS coordinators were supposed to check for new orders on the 24-hour reports and send the appropriate referrals if necessary. She noted the order for Schizoaffective diagnosis was uploaded, but communication failed somehow. The risk to the resident for not being properly referred for PASARR would be the resident missed out on services they possibly qualified for that could help with their symptoms. <BR/>Review of the facility's policy PASARR revised 11/15/23 reflected . The purpose of this policy is to ensure PASARRs are being obtained and completed timely and accurately .6. Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASARR status.

Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two (Residents #4 and #5) of 10 residents reviewed for resident call system in that: <BR/>The facility failed to ensure Resident # 4 and Resident # 5 call light outside the resident door was working properly. Resident # 4 and Resident # 5 resided in the same room.<BR/>This failure could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity.<BR/>Findings included:<BR/>Observation and interview on 02/07/23 at 11:34 AM with Resident # 4 revealed she was lying in her bed. She stated her call light had not been working for the last 2 days and was not within reach for her to use. Observation at 11:35 AM revealed the call light outside resident room did not light up when the call button was pushed by Resident #4.<BR/>Observation and interview on 02/07/23 at 11:38 AM revealed Resident #5 was lying in bed in resident room. Resident #5 stated she did use the call button to get assistance from staff . <BR/>Interview on 02/07/23 at 11:37 AM with Dir of Plant Operations revealed he had to replace the bulb (light in hallway) since it was not lighting up when Resident #4 pressed her call button. At 11:43 AM Dir of Plant Operations stated he was not aware of Resident # 4 call light not working and unaware of bulb that went out until when he just looked at it. He stated he checked the resident call lights monthly.<BR/>Interview on 02/07/23 at 11:39 AM with ADON revealed not having a call light working properly can place residents at risk for falls and a delay in getting assistance from staff when needed. She was not aware of Resident # 4's and Resident #5's call light not working. The ADON was not aware the light bulb in the hallway was not working to alert staff in hallway 600 about the call light being on.<BR/>Interview on 02/07/23 at 2:40 PM with Administrator revealed call buttons should be within reach of residents and working properly. She stated the staff had been in-serviced recently on call lights. <BR/>Interview on 02/08/23 at 11:00 AM with LVN C revealed they had a recent in-service about ensuring call buttons are within reach of residents when in room. <BR/>Interview on 02/08/23 at 11:42 AM with Dir of Plant Operations revealed he did not have a log he kept checking resident call buttons to ensure they were working. He stated he checked resident call buttons monthly to ensure working and checked different resident rooms on different hallways. <BR/>Interview on 02/09/23 at 10:45 AM with Administrator revealed the Dir of Plant Operations will start a log documenting checking resident's call buttons to ensure they are in working order. She stated focused care partners which are department heads assigned to resident rooms will start checking their assigned residents' call buttons to ensure working and within reach of residents when they do their resident rounds. <BR/>Review of facility's policy Nurse Call effective 08/08/2022 reflected All facilities must ensure that nurse call cords are installed and functioning properly in all patient rooms. The nurse call cords must be easily accessible to patients and located within reach from the patient's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 4 (Residents #7, #13, #49 and #325) of 12 residents reviewed for resident abuse.<BR/>1. The facility failed to ensure Resident #325 was free from physical abuse by CNA O on [DATE]<BR/>2. The facility failed to ensure Resident #49 was free from physical abuse by CNA O on [DATE].<BR/>3. The facility failed to ensure Resident #7 was free from physical abuse by CNA O.<BR/>4. The facility failed to ensure Resident #13 was free from physical abuse by RN G on [DATE].<BR/>These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 6:10 PM. While the IJ was removed on [DATE] at 7:00 PM, the facility remained out of compliance at actual harm with a scope identified as pattern.<BR/>These failures placed residents at risk for serious injuries, abuse, and serious harm.<BR/>Findings included:<BR/>1. Record Review of Resident #325's Baseline Care Plan completed by ADON revealed resident admitted on [DATE] for end-of-life care and was on hospice services with Hospice KK and required extensive assistance with ADLs, and was not able to communicate easily with staff and not understood by staff. <BR/>Record review of Hospice KK medical records for Resident #325 revealed a document titled Visit Report dated [DATE] which stated resident required maximum to total assistance, total assistance with ADLS, and was a two (2) person transfer. <BR/>Record review of Resident #325's nurse's progress note dated [DATE] completed by ADON revealed resident expired on [DATE]. <BR/>Review of grievance log for [DATE] revealed grievance dated [DATE] regarding CNA O being rough regarding Resident #325. There were blank spaces for categories of resolved, followed up with resident, or reported to state, or if follow up was needed.<BR/>Record review of document titled Witness Interview dated [DATE] at 8:30 AM by Resident #325's family member and signed by the DON revealed complaint alleging on the morning of [DATE] [CNA O] was very rough in the way he got her up from the wheel chair and threw her into the bed.<BR/>Record review revealed grievance complaint form dated [DATE] provided by Administrator on [DATE] for Resident #325 by family member and signed by the Administrator revealed there was an established pattern with complaints of staff members while providing care and CNA O was suspended pending investigation. <BR/>Record review of Resident #325 nurse progress note dated [DATE] at 4:00 PM by RN G revealed Upon entering the room at 1600 the resident was noted to have her right leg caught in the blinds and her leg was bleeding and there was blood on the blinds and the wall. The resident was noted to be restless and agitated . called [Hospice K] asking for a nurse to come see her and that I needed the comfort kit sent here faster than it seemed to be coming. Resident was cleaned and repositioned. The bed was positioned away from the wall. The blinds were taken down due to being torn and having blood on them. One of the [family member of Resident #325] arrived around 1630 and then shortly after that the Hospice nurse arrived. Resident was given a one-timedose of Lorazepam 0.5mg PO and a short time after that began calming down.<BR/>Interview on [DATE] at 3:24 PM with RN G revealed she contacted the DON on [DATE] after family member of Resident #325 complained about not receiving the care kits timely for Resident #325 and that CNA O was rough with his transfer of resident and tossed her into the bed. RN G stated she called the DON and was told CNA O tossing resident into the bed was a reportable incident and to contact the Administrator. RN G stated she then called the Administrator on [DATE] and the family spoke with the Administrator over the phone and then was told by the Administrator because the family did not use the word abuse it was not reportable incident to the state and CNA O continued to work and CNA O continued to work despite this allegation. RN G stated she assessed the cut on Resident #325 leg but did not complete a head-to-toe assessment.<BR/>Interview on [DATE] at 11:59 AM with Resident #325's family member revealed she observed on the morning of [DATE] CNA O picked up Resident #325 from her wheelchair by himself and transferred resident into the bed. Family member stated she would describe the transfer as resident was plopped or tossed into the bed and the resident cried out. Family member stated she asked CNA O if he needed help before transferring resident and he said no. Family member stated she reported incident along with other concerns about care on the evening of [DATE] to RN G and then spoke with the Administrator. Family member stated Resident #325 was heavy and should have been a two person transfer which was why it appeared that resident was tossed into bed, and there was a lack of staff to assist. Family member stated she also arranged a meeting the following morning on [DATE] with the DON to go over her concerns further. Family member stated during her meeting with the DON and was told that they would look into the incident and did not recall filling out a witness statement or a grievance. Family member stated Resident #325 expired the following day and she had not been contacted by facility with an update. <BR/>Interview on [DATE] at 2:57 PM with DON revealed Resident #325 was admitted to facility for end of life care and expired on [DATE]. DON stated Resident #325 required a significant amount of care and needed assistance to be turned. DON stated on the evening of [DATE] RN G called to report family of Resident #325 stated CNA O roughly picked up and tossed Resident #325 into the bed. DON stated she told RN G that the abuse allegation was reportable and instructed RN G to call the Administrator immediately. DON stated she came to the facility around 8:00 PM and asked Administrator what needed to be done for the investigation. DON stated Administrator told her everything had been done except for the in-services on abuse and neglect. DON stated Administrator printed the abuse and neglect policy and DON went to every CNA and clinical staff member and reviewed the policy with them and had them sign the in-service sheet. DON stated she met with the family member on [DATE], wrote a witness statement, and the Administrator refused to take the statement during the morning meeting in-service on abuse and neglect. Administrator told DON she did not want the statement because she did not think it was abuse, she was already investigating the allegation of abuse by CNA O to Resident #49, and CNA O was already suspended. DON stated Administrator expressed irritation at having to come back to facility the evening on [DATE]. DON stated she took the witness statement back to her office. DON stated the Corporate Nurse DD was onsite on [DATE] and saw the witness statement on her desk and instructed DON to give it to Administrator. DON stated she told Corporate Nurse DD that Administrator refused to take the statement and Corporate Nurse DD suggested she file a grievance for the family of Resident #325 because the Administrator was the abuse coordinator and would have to report and investigate the incident. DON stated she gave the information to SSD who wrote the grievance and put it back on DON's desk. DON stated Corporate Nurse DD gave grievance to Administrator. DON stated she was not aware the allegations regarding CNA O and Resident #325 were not reported to HHSC. DON stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse. <BR/>Interview on [DATE] at 3:42 PM with Administrator revealed she had concerns regarding CNA O handling of Resident #325 during transfer on [DATE] and spoke to family member on [DATE] over the phone but because family member did not use the words abuse she thought it was more of a training issue she did not believe CNA O would intentionally abuse any resident so she did not report the allegation with Resident #325. Administrator stated there were no witness statements for Resident #325. Administrator stated she did not suspend CNA O until a second similar allegation later in the evening on [DATE] about a rough transfer was made by Hospice RN stated she and RN G regarding Resident #49. Administrator commonly would receive conflicting reports from staff regarding different issues and took this report more seriously because Hospice RN was a neutral party. Administrator stated sometimes what may look like abuse was just a transfer and that sometimes staff had to just pick up a resident and it may appear to be rough. <BR/>Interview on [DATE] at 9:48 AM with MDS Coordinator revealed she was present during the morning meeting on [DATE]. MDS Coordinator stated the Administrator was leading the meeting and reviewing the abuse and neglect policy with the department heads including the DON. MDS Coordinator stated that all allegations of abuse are to be reported to the Administrator who was the abuse coordinator. MDS Coordinator stated when Administrator read aloud examples of neglect the DON interjected and stated- see that was what I am talking about, it was abuse. MDS Coordinator stated Administrator became upset and stated it was not abuse, and ADON had observed CNA O provide care to residents and there were no concerns. MDS Coordinator stated Administrator stated she already recorded all the witness statements and did not want the witness statement from DON. MDS Coordinator stated Administrator and DON began to argue and MDS Coordinator and staff quickly left the room. MDS Coordinator stated she did not know which residents Administrator and DON were talking about. <BR/>Interview on [DATE] at 2:56 PM with DON revealed she did not provide a thorough physical assessment for Resident #325 or Resident #49 and thought they had been done by the charge nurse and it should be documented in the resident's chart such as the progress notes. DON stated that RN G would have done an assessment and she did not follow up with RN G. DON stated she had asked Administrator the evening of [DATE] after the incident if the assessments had been done and what she could help with and Administrator stated only the in-services were left. <BR/>Interview on [DATE] at 4:25 PM with Administrator revealed she did not report the family complaint about CNA O's treatment of Resident #325 because she did not think it was abuse at the time and did not think CNA O would intentionally abuse a resident. Administrator stated CNA O admitted to inappropriately transferring residents.<BR/>Interview on [DATE] at 5:15 PM with Director of Therapy with Director of Therapy revealed Resident #325 was at facility for end of life care and would have concern with a CNA transferring Resident #325 by scooping resident out of bed by themselves and into shower chair because it could result in a resident being dropped or injured. Director of Therapy stated residents who required extensive assistance meant the person required a resident to be transferred with 2 people assisting and with gait belt at a minimum, possibly Hoyer lift. <BR/>Interview on [DATE] at 11:02 AM with ADON revealed she worked the day of [DATE] until 6:00 PM. ADON stated Resident #325 had admitted to facility on [DATE] for hospice services, was on oxygen and was restless. ADON stated on [DATE] around 3:30 PM, she was in her office and heard RN G call for help and immediately went to assist RN G who was in Resident #325's room. ADON stated she observed RN G in Resident #325 room and Resident #325 was in bed next against the window and Resident #325 appeared confused of her surroundings, restless, agitated, and was flailing her arms around and kicking her legs. ADON stated she did not see any visible injuries on Resident #325 ADON stated she and RN G did not perform a head-to-toe assessment because the resident was restless and they stayed with resident to ensure safety while they waited for hospice services to arrive. ADON stated RN G asked CNA O to assist with moving the bed from the window to against a wall. ADON stated that family members of Resident #325 arrived before hospice services and were talking with RN G about their concerns and ADON left the room to give them privacy. ADON stated she was not aware that an allegation was made against CNA O until the following day at the morning meeting on [DATE]. ADON stated during the morning meeting the Administrator was reviewing the abuse and neglect policy and stated that there was an allegation of abuse of Resident #49 and Resident #325 by CNA O and that Administrator had done an investigation and felt that no abuse occurred. ADON stated DON interjected and said that she believed there was abuse. ADON stated Administrator replied that DON was showing favoritism to the nurse that reported the abuse, RN G. ADON stated DON stated it was the same favoritism the Administrator showed the Maintenance Director and began to leave the meeting and the Administrator told DON not to get in her feelings and that she had done this investigation and talked to family members of the residents and she did not feel like it was abuse. ADON stated she spoke with the Administrator after the meeting and the Administrator told her that she did not believe abuse occurred and that if RN G witnessed abuse then why did she not intervene. ADON stated she was responsible for assessing competencies quarterly of MA's and CNA's and assessed for peri-care, hand washing, and use of Personal Protective Equipment (PPE). ADON stated she had only assessed CNA O for hand washing and PPE use because CNA O used to work full time then switched to only a couple days a week as needed and she had not gotten to him to assess the peri-care. ADON stated she was aware that Administrator spoke with CNA O in the past about not communicating with residents when providing care by not introducing himself and letting them know what care he was going to provide. <BR/>2. Record Review of Resident #49's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] and diagnoses of dementia (loss of cognition), bi-polar disorder (mood disorder with periods of intense feelings), major depressive disorder (a mood disorder causing persistent feeling of sadness and loss of interest), and pseudobulbar affect (episodes of uncontrollable and inappropriate laughing or crying), unspecified pain, and a BIMS score of 0 (severely impaired cognition). Review revealed Resident #49 was dependent on assistance for ADL care including showers and transfers.<BR/>Record review of medical record for Resident #49 revealed document titled Physical Therapy PT Evaluation and Plan of Treatment dated [DATE] revealed resident experienced mood swings, visual and auditory hallucinations, had a history of agitation, aggressive behavior and was combative. Record review of physical therapy evaluation or Resident #49 revealed resident was known for grabbing hold of individuals nearby and hit and kicked. Record review of physical therapy evaluation revealed Resident #49 habitually coiled legs into extreme flexion at hip and knees which led to recurrent tightness and contractures and was non-weight bearing on her legs which caused additional challenges with assisted transfers. Review of physical therapy evaluation revealed Resident #49 did not ambulate on her own and used a geri chair. <BR/>Record review of witness statement by Hospice RN, dated [DATE] at 8:05 PM, and signed by Administrator revealed Resident #49 had vomited multiple times on [DATE] and Hospice RN asked CNA O to shower resident. Hospice RN stated CNA O entered the room and did not say anything to Resident #49 before he rolled resident over and picked her up and roughly sat her in the chair. Hospice RN stated that Resident #49 was startled and was not covered all the way when transported through the hallway. Hospice RN stated she did not think he was abusive, but it was overly rough and aggressive. <BR/>Record review of witness statement by RN G, dated [DATE] at 8:22 PM, and signed by Administrator revealed RN G witnessed CNA O roughly handled the shower chair as he transported Resident #49 out of shower room and she did not see his hands on physically on Resident #49 at any time.<BR/>Record review of Resident #49 revealed nurse's progress notes dated [DATE] at 10:51 PM by RN G that resident had frequent vomiting and Hospice nurse gave Resident #49 new order for Zofran. <BR/>Review of nurse's progress notes from [DATE] through [DATE] revealed no mention of incident with CNA O and no physical assessment.<BR/>Record review of hospice medical records for Resident #49 revealed visit note report dated [DATE] by Hospice RN that CNA O was aggressive when providing care for Resident #49 and she had redness around her collarbone and incident was reported to Administrator and Hospice Director. <BR/>Observation on [DATE] at 3:22 PM of Resident #49 revealed she was laying in geri chair wearing a long sleeve shirt, pants, with hair that appeared clean, with her legs curled up and arms in contracture, she was non-interviewable.<BR/>Interview on [DATE] at 3:24 PM with RN G revealed on the evening of [DATE] she was at the nurses station when she observed Hospice RN appeared upset. RN G stated Hospice RN told her CNA O picked up resident out of bed roughly and put Resident #49 into the shower chair. RN G was unable to explain why she did not intervene. RN G stated she felt startled when the shower door opened and CNA O jerked Resident #49 out of shower room and placed her at the nurses station. RN G stated she had training on Abuse, Neglect, and Exploitation during onboarding and in-services and was not sure if what she witnessed was abuse. RN G stated she called DON and Administrator and was told to have CNA O leave pending investigation.<BR/>Interview on [DATE] at 6:54 PM with Hospice RN revealed she visually assessed Resident #49 shoulders and demeanor when she was seated in the geri chair at the nurses station after the incident and observed some redness on resident's shoulders. Hospice RN stated she did not complete any additional assessment other than the assessment for pain, nausea and vomiting, and a visual observation of resident. <BR/>Interview on [DATE] at 3:19 PM with CNA N revealed Resident #49 required a two person transfer or hoyer lift with two people assisting because she was very strong and swings her limbs around and kicks during transfers. CNA N stated CNA O was a male and was stronger than the female CNA's and they would call CNA O when they needed assistance with heavy residents.<BR/>Interview on [DATE] at 2:57 PM with DON revealed Resident #49 required at least two (2) staff and a Hoyer lift to be transferred.<BR/>Interview on [DATE] at 5:17 PM with Director of Therapy revealed Resident #49 was in PT therapy for contraction management and for balance training and had a tendency to grab things like ears, arms, anything within reaching distance and kicked. Director of Therapy stated Resident #49 was totally dependent with care and was a two (2) person assist or hoyer lift. Director of Therapy stated concern with a CNA who lifted Resident #49 by himself by scooping resident out of bed into shower chair would be CNA could have dropped or injured resident. <BR/>Interview on [DATE] at 9:04 AM with Hospice LL Director revealed she received a phone call from Hospice RN on [DATE] regarding a concern with possible physical abuse of Resident #49 by CNA O and Hospice RN had reported incident to Administrator and RN G, the charge nurse, and CNA O had been removed from facility. Hospice LL Director stated that abuse should be reported to HHSC within 2 hours and did not report it herself because she was told the facility had reported incident. Hospice LL Director stated she received a phone call on [DATE] from Administrator who asked her how often hospice staff receive training on abuse and neglect. Hospice LL Director stated Administrator told her she did not feel that what CNA O did was abuse and that if a hospice nurse was present and believed they witnessed abuse then they should be the one to report the incident. Hospice LL Director stated Administrator told her that sometimes a transfer could look abusive if the observer was not trained to recognize abuse and sometimes staff just needed to pick up residents. Hospice LL Director stated Administrator sounded annoyed to have to conduct an investigation and told her CNA O had been suspended and the incident was self-reported. Hospice LL Director stated she documented her phone call with Administrator and submitted a report of abuse to state following her phone call with Administrator. Hospice LL Director stated that showers for Resident #49 would require two staff members because of Resident #49's functional status. Hospice LL Director stated risk to resident if not properly transferred or are showered with one staff member when they require two staff would be resident could be dropped, injured, or develop a skin tear due to friction or shearing. <BR/>Interview on [DATE] at 9:49 AM with MDS Coordinator revealed Resident #49 required two people to transfer including a hoyer lift because resident has involuntary movements of her arms and legs and grabs on to anything within reach, kicks, and hits. MDS Coordinator stated the risk to residents when improperly transferred were injury from being dropped or pull on improperly. <BR/>Interview on [DATE] at 3:33 PM with SSD revealed she was not in-serviced on the facility's abuse and neglect policy before she provided an in-service to staff on abuse and neglect on [DATE] and used the previous Abuse and Neglect policy dated 2020 by mistake instead of the most current policy dated [DATE].<BR/>Interview on [DATE] at 11:49 AM with CNA P revealed Resident #49 required two people and a Hoyer lift to transfer because she is a fall risk and commonly grabs anything within reach when being transferred. CNA P stated the risk to residents by not properly transferring would be injury from being dropped. <BR/>Interview on [DATE] at 6:05 PM with MA Z revealed she had worked at facility since 2019 and typically worked on Hall 200 and 300. MA Z stated Resident #49 was a two (2) person assist and was not aware of her surroundings and would swing her limbs around, hit, and bite the elbows of staff during transfers. MA Z stated hospice usually gave Resident #49 showers with two (2) people assisting and she would always hear Resident #49 yelling during showers. MA Z stated she liked CNA O because he was strong and assisted with transfers of residents and could not recall ever seeing CNA O use a gait belt. MA Z stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse.<BR/>3. Record review of Resident #48 Discharge MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to facility on [DATE] with diagnoses of chronic pulmonary disease (chronic lung disease obstructing airflow), Parkinson's disease (a chronic and progressive movement disorder), hypotension (low blood pressure), major depressive disorder (mood disorder with persistent feeling of sadness and loss of interest), was hospitalized on [DATE] and had a BIMS score of 14 (cognitively intact). <BR/>Record review of resident safe surveys performed by SSD on [DATE] revealed Resident #48 reported she witnessed CNA O rip Resident #7's pants off roughly from her hip to her ankles and Resident # 7 was screaming.<BR/>Observation of Resident #48 on [DATE] at 11:27 AM revealed resident was lying in bed asleep and wearing hospital gown. Surveyor attempted to interview resident #48 but was unable to due to illness. <BR/>Interview on [DATE] at 3:24 PM with RN G revealed when she left work on [DATE], Resident #48 was smoking outside and talking with someone else about witnessing a CNA O treating Resident #7 roughly. RN G stated she asked Resident #48 about the incident. RN G stated that Resident #48 said she was in the hallway and able to see in Resident #7's room because the door and privacy curtain were not closed and she saw CNA O put Resident #7 in her bed and rip the pants off of Resident #7 when providing care. RN G stated she asked Resident #48 if she reported this incident and Resident #48 stated she told the social worker the previous day, [DATE]. RN G stated she called and let DON know of the conversation and was told it was being investigated. <BR/>Interview on [DATE] at 5:05 PM with SSD revealed she conducted a safe survey on [DATE], in regard to Resident #49's allegation of abuse by CNA O, and Resident #48 reported she witnessed CNA O rip off the pants of Resident #7 while providing ADL care. SSD stated Resident #48's room was across the hall from Resident #7. SSD stated during safe surveys, Resident #44, who was the roommate of Resident #7, indicated a concern regarding treatment of Resident #7 by CNA O but Resident #44 declined to give further information. SSD stated she did not follow up with Resident #44. SSD stated she attempted to interview Resident #7 but resident was non-interviewable. SSD stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse.<BR/>4. Record Review of Resident #7 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of late onset Alzheimer's disease (loss of cognitive function), generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear or unease), spondylolysis (crack or break in the bone of the spine), a BIMS score of 5 (severely impaired cognition). <BR/>Record review of Resident #7 Care Plan dated [DATE] and revised [DATE] revealed resident required moderate assistance by one (1) staff to move between surfaces. <BR/>Observation and interview on [DATE] at 2:07 PM of Resident #7 revealed resident was sitting in an electric wheelchair with her hair brushed wearing a long sleeve shirt, pants, and shoes. Resident #7 was non-interviewable due to cognitive impairment and could not recall incident with CNA O. <BR/>Record review of medical record for Resident #7 revealed document titled Physical Therapy PT Evaluation and Plan of Treatment dated [DATE] revealed resident was confused regarding her surroundings, had difficulty communicating, was a fall risk, and required substantial to maximal assistance with ADL care. <BR/>Interview on [DATE] at 5:17 PM with Director of Therapy revealed Resident #7 required moderate assistance with transfers, a one person assist with staff using a gait belt at the minimum. Director of Therapy stated a CNA who lifted Resident #7 under her arms to transfer from wheelchair to bed without gait belt placed the resident at risk of being dropped and injury. Director of Therapy stated improper transfers such as picking up a resident from under their arms when transferring increased risk of resident injury, fracture, and multiplied the fall risk for resident.<BR/>Interview on [DATE] at 11:38 AM with LVN J revealed Resident #7 was care planned as a one person transfer assist which would mean always use a gait belt. LVN J stated she had seen Resident #7 be transferred from wheelchair to bed and usually the staff member would have Resident #7 put her hands on their shoulders and wrap around the resident and lift while wearing a gait belt. LVN J stated improper transfers of residents increased a resident risk of injury and harm. LVN J stated that if she observed abuse she would immediately inform the Administrator who is the abuse coordinator.<BR/>5. Record Review of Resident #44's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (loss of cognition), hypertension (high blood pressure), anxiety disorder (feelings of worry and fear or unease), depression (persistent feelings of sadness) and BIMS score of 10 (moderately impaired cognition).<BR/>Observation on [DATE] at 11:16 AM revealed Resident #44 was seated upright in wheelchair in 200 Hall wearing shirt, pants, and shoes and her hair was brushed. <BR/>Interview on [DATE] at 11:18 AM with Resident #44 revealed she was roommates with Resident #7 and about a week ago she was in her room lying in bed and Resident #7 was sitting in an electric wheelchair next to her bed when CNA O entered the room and said he was going to change Resident #7. Resident #44 stated CNA O picked up Resident #7 by lifting from underneath both armpits and placed her roughly in bed. She recalled Resident #7 told CNA O to stop as soon as CNA O began to lift Resident #7 up from the armpits and CNA O continued to transfer resident. Resident #44 stated he roughly and quickly jerked Resident #7's pants off to perform ADL care and recalled Resident #7 screamed and said stop several times and that he was being rough with her and she was going to tell. Resident #44 stated she felt upset when she witnessed this and told CNA O to leave Resident #7 alone and CNA O finished providing ADL care to resident. Resident #44 stated that she told SSD about the incident during a safe survey ([DATE]) and that she was told CNA O was no longer at the facility. Resident #44 stated she had no issues with CNA O and she currently felt safe at facility. <BR/>Interview on [DATE] at 3:44 PM with Administrator revealed she did not report or investigate allegation of abuse for Resident #7. Administrator stated she did not interview Resident #48 about their allegation from safe survey or the roommate of Resident #7 (Resident #44) because she thought it was more of a dignity issue than abuse allegation. Administrator stated she should have investigated the incidents by including the additional residents because it was a similar allegation to Resident #49. Administrator stated Resident #7 should have been assessed by either the charge nurse or DON and was not aware if an assessment had been completed.<BR/>Interview on [DATE] at 2:56 PM with DON revealed she was not aware of any abuse allegation for Resident #7 at the time of the safe survey and had only heard about it from other staff recently. DON stated she did not provide a physical assessment of Resident #7. DON stated she did not speak with Resident #44 about the incident. <BR/>Interview on [DATE] at 3:10 PM with LVN K revealed she began working at facility at the end of [DATE]. LVN K stated that she had observed CNA O transfer Resident #7 without a gait belt in the past. LVN K stated she observed CNA O put Resident #7's hands on his shoulders then he lifted resident and put her into bed. LVN K stated she could not recall if CNA O lifted Resident #7 from under her arms or if he bear hugged resident. <BR/>Interview on [DATE] at 3:20 PM with CNA N revealed she had observed CNA O transfer other residents and did not see CNA O use a gait belt. CNA N stated she observed CNA O pick up at least two (2) different residents, over the past two (2) months, who were two (2) person assists and were on the floor by bear hugging them and lifted residents into bed without a gait belt and without asking for assistance from herself and other staff. <BR/>Interview on [DATE] at 3:24 PM with RN G revealed she did not perform a thorough physical assessment for Resident #49 after allegation of abuse and she thought Hospice RN did an assessment. RN G stated she only assessed Resident #325 for the cut on her leg. <BR/>Interview on [DATE] at 2:57 PM with DON revealed [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allow the resident to obtain a copy of the medical records upon request and within 2 working days advance notice to the facility for 1 Resident (#227) of 24 sampled residents.<BR/>The facility failed to provide a copy of Resident #227's medical records upon request by the resident's representative.<BR/>The deficient practice could place residents at risk of contributing to a delay in the due legal process for residents and not having continuity of care.<BR/>Findings included:<BR/>Record Review of Resident #227's face sheet revealed resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's MDS dated [DATE] revealed a BIMS score of 6 (severely cognitively impaired).<BR/>Interview on 3/12/24 at 9:34 a.m. with Resident #227's POA, revealed the POA was unable to get any medical records and had requested them through email and in person on 1/31/24. <BR/>Interview on 3/13/24 at 12:48 p.m. was attempted with Corporate Medical Records. A voicemail was left but call was not returned.<BR/>Interview on 3/13/24 at 2:56 p.m. with Transporter/medical records stated the file regarding Resident #227 was held up at corporate because the POA requested the medical records be emailed. She stated they usually do not send the medical records by email due to HIPPA policy. Medical Records said she would have to get corporate to unlock the file so she could get access to the records. She will contact the POA of Resident #227 and see how they would like them sent to them.<BR/>Record Review of facility policy Medical Records dated 4/21/2021, indicated: Each resident has the right to access and or obtain copies of his or her personal and medical records upon request.<BR/>Procedure: a resident/responsible party may submit his/her request either orally or in writing for access to personal or medical information pertaining to him/her.