Navasota Nursing & Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice, and accounted for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #1) of 1 resident reviewed for trauma informed care.<BR/>The facility had Resident #1 in a shared room with Resident #2, when his care planning for Post-Traumatic Stress Disorder (PTSD) documented that having roommates triggers his PTSD. <BR/>This failure could place residents at increased risk for psychological distress due to re-traumatization.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet dated 07/17/2024 reflected a [AGE] year-old male initially admitted to the facility on [DATE] with the following diagnoses: chronic / acute post-traumatic stress disorder (mental health condition that can affect anyone who has experienced a traumatic event, such as military combat, sexual or physical assault, or a natural disaster - chronic suffers my experience symptoms such as flashbacks, nightmares, and severe anxiety that can interfere with daily life), dementia (loss of cognitive functioning -thinking, remembering, and reasoning), and major depressive disorder (persistent feeling of sadness and loss of interest that can interfere with daily life).<BR/>Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected that he had a BIMS Score of 11, indicating moderate cognitive impairment. The MDS reflected that Resident #1 did not exhibit any behavior indicating rejection of care. The MDS reflected that Resident #1 had an active diagnosis for post-traumatic stress disorder (PTSD). <BR/>Review of Resident #1's Comprehensive Care plan reflected the following focus area with revision on 09/14/2023, [Resident #1] has PTSD or other similar diagnosis related to military service Date Initiated: 11/06/2022. Resident #1's Interventions included: [Resident #1] needs his own room. Having roommate triggers his PTSD, Date Initiated: 11/06/2022; Identify situation/event/images that trigger recollections of the traumatic event and limit [Resident #1] exposure to these as much as possible, Date Initiated 11/06/2022.<BR/>Review of Resident #1's Psychological Services Supportive Care Progress Note, Service Date 7/10/2024, DX: F43.11 post-traumatic stress disorder acute; Summarize Progress and plan: (include significant developments since last session, session gains, additional recommendations, comments) Clinician {health professional who works one-on-one with patients, diagnosing or treating illness. A clinician might be a physician or nurse, a psychologist, or a speech-language pathologist} met with resident for weekly session. Resident was engaged with clinician and responded well to therapy. Clinician conducted supportive therapy to encourage patient to engage in meeting therapeutic goals. Resident expressed his frustration about being moved to yet another room. Resident stated that it would be better if he did not have to live with his current roommate.<BR/>Review of Resident #2's Face Sheet dated 07/17/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: cerebral palsy (abnormal brain development or damage to the developing brain that affects a person's ability to control their muscles), depressive episodes (person experiences a depressed mood (feeling sad, irritable, empty) that last most of the day, nearly every day, for at least two weeks), and anxiety disorder (persistent and excessive worry that interferes with daily activities).<BR/>Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected that he had a BIMS Score of 15 indicating cognition was intact. <BR/>Interview and observation on 07/11/2024 at 1:04 PM, revealed the resident identifier on the outside of room indicated it was occupied by Resident #1 and Resident #2. Resident #2 was out of the room and Resident #1 was lying in his bed awake. Resident #1 was greeted and quickly sat up in his bed, spun around to face the door, and requested to know what was needed. Resident #1 stated he did not want to speak and lied back down in bed. <BR/>In an interview on 07/11/2024 at 2:16 PM, LVN A stated care plans were utilized by staff to ensure the needs of the resident were met. LVN A stated she did not know whether Resident #1 had a diagnosis of PTSD, but stated if he does it should be care planned. LVN A stated that Resident #1 can be very moody. LVN A stated if Resident #1 was care planned to not have a roommate, then he should not have had anyone in his room. LVN A stated that Resident #1 and Resident #2 have been in the room together for over a month with no issues . <BR/>In an interview on 07/11/2024 at 2:34 PM, the MDS Coordinator stated she put together the residents' care plan with the assistance of the interdisciplinary team, which were signed off on by the DON. The MDS Coordinator stated care plans set measurable goals and were utilized for the overall care of the resident. The MDS Coordinator stated PTSD and triggers should be care planned and followed through with. The MDS Coordinator in review of the care plan stated Resident #1 did have a known trigger that he should be in a room by himself and currently had a roommate. The MDS Coordinator stated that the failure to follow his intervention could result in a physical altercation with the roommate or cause Resident #1 to be re-traumatized . <BR/>In an interview on 07/11/2024 at 2:53 PM, the SW stated she facilitates the care plan meetings and takes care of social work concerns if the resident has any. The SW stated she would be involved in the planning of residents with a diagnosis of PTSD and that it should be care planned. The SW stated she worked in coordination with psychological services to find out the root cause of PTSD to identify triggers. The SW stated failure to follow the plan of care for triggers could result in the resident experience flashbacks and possibly hurting themselves or others. The SW stated she was not aware that Resident #1 had a diagnosis of PTSD and had never seen any triggers or behaviors. The SW stated in review of the care plan for Resident #1 that he should not currently have a roommate and knew that he had been annoyed by having to switch rooms. <BR/>In an interview on 07/11/2024 at 3:10 PM, the DON stated care plans give a picture of the resident, their needs, and were to be utilized by staff to provide proper care for residents. The DON stated if a resident has an active diagnosis of PTSD, it should be care planned and should include triggers. The DON stated if a resident was triggered it could lead to bad consequences and re-traumatization. The DON stated Resident #1 and Resident #2 have been in room together for approximately one month . <BR/>In an interview on 07/11/2024 at 3:35 PM, Resident #2 was in a common area working with building blocks after having exited room . Resident #2 stated that he liked it in the facility but wanted to move back into his old room in a different hallway. Resident #2 stated that he has not had any problems with Resident #1 but wants to move out of the room because it was off the main hallway of the facility. <BR/>In an interview on 07/11/2024 at 4:34 PM, the Regional Compliance Nurse stated care plans direct care of the residents and that PTSD and triggers should be specifically care planned. The Regional Compliance Nurse stated that staff need to know what care to provide for the resident and to ensure they were not triggered, which could lead to adverse effects and re-traumatization. The Regional Compliance Nurse stated in review of Resident #1's care plan that no one should be in the room with him .<BR/>In an interview on 07/11/2024 at 5:05 PM, the Administrator stated care plans were based on what was triggered during MDS assessments and to address resident needs. The Administrator stated care plans were to be adjusted and modified to make the residents as happy and comfortable as possible. The Administrator stated that Resident #1's care plan should have been followed for his PTSD and known trigger until it was ruled out and then changed if it was no longer a concern. The Administrator stated that Resident #1 should not have had a roommate. <BR/>Review of progress and behavior notes for Resident #1 and Resident #2 from 2024 revealed no physical or verbal incidents between the two residents.<BR/>Review of the facility's provided resident roster dated 7/17/2024 revealed that Resident #1 was in room and Resident #2 was in room together.<BR/>Review of the facility's Trauma-Informed Care Policy dated 10/2022 revealed, I. Purpose: The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care by professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that my cause re-traumatization of the resident. IV. Assessment Facilities should use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preference. This would include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI) admission Assessment, the history and physical, the social history/assessment, and others. Triggers Facilities must identify triggers that may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts a recall of a previous traumatic the event, even if the stimulus itself is not traumatic or frightening. For many trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. While most [NAME] are highly individualized, some common [NAME] may include: Experiencing a lack of privacy or confinement in a crowded or small space; Exposure to loud noises, or bright/flashing lights' Certain sights, such as objects that are associated with those that used to abuse, and/or Sounds, smells, and even physical touch. Care Planning to Address Past Trauma: The facility should collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals (such as psychologists, mental health professionals) to develop and implement individualized interventions. In some cases, if a facility has more than one trauma survivor, social services might consider establishing a support group that is run by a qualified professional, or allowing a support group to meet in the facility. In situations where a trauma survivor is reluctant to share his or her history, facilities are still responsible to try to identify triggers that may re-traumatize the resident and develop care plan interventions that minimize or eliminate the effect of the trigger on the resident. Trigger-specific interventions should identify ways to decrease the resident's exposure to triggers that re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #21) of six residents reviewed for pressure ulcers.<BR/>The facility failed to ensure Resident #21 who was at risk for skin breakdown was turned every two hours and provided incontinent care. on 05/07/2024, Resident #21 was left in the same position in her Geri-chair (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl.) for 6 and a half hours from 8:00 AM till 2:30 PM. Once Resident #21 was placed in bed she was observed to have two DTIs (A pressure-related injury to subcutaneous tissues under intact skin.) to her coccyx that were previously unidentified by the facility. <BR/>An immediate Jeopardy (IJ) situation was identified on 05/07/2024 at 5:10 PM. While the IJ was removed on 05/09/2024 at 3:12 PM, the facility remained out of compliance at a scope of isolated with no further actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>These failures placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. <BR/>Findings Include:<BR/>Review of Resident #21's face sheet dated 05/07/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) and chronic lymphocytic leukemia (is a type of cancer in which the bone marrow makes too many lymphocytes (a type of white blood cell).<BR/>Review of Resident #21's quarterly MDS dated [DATE] reflected Resident #21 was assessed to have a BIMS assessment was not conducted indicating Resident #21 had severe cognitive impairment. Resident #21 was assessed to be dependent on staff for all areas of ADL care and was assessed to be incontinent of bowel and bladder.<BR/>Review of Resident #21's comprehensive care plan reflected:<BR/>-problem dated 09/26/2022 Resident #21 is incontinent of bowel and bladder. Interventions included .Check resident every two hours and assist with toileting as needed. Provide peri care after each incontinent episode and report any skin change to nurse immediately.<BR/>-problem dated 11/22/2023 and revised 04/19/2024 Resident #21 has actual impairment to skin integrity related to fragile skin, prone to easily bruising with pressure due to chronic lymphocytic leukemia. Interventions included .Keep skin clean and dry .reposition resident to prevent pressure for body parts . further review of Resident #21's care plan reflected no plan of care for pressure ulcers.<BR/>Review of Resident #21's consolidated physician orders dated 05/07/2024 no orders for pressure ulcer wound care. Further review reflected an order dated 09/27/2022 pad all boney prominences with pillows to prevent breakdown. <BR/>Review of Resident #21's weekly skin assessment dated [DATE] and locked on 05/06/2024 reflected no MASD or pressure ulcers were identified.<BR/>Observation and interview on 05/07/2024 at 8:00 AM, revealed Resident #21 in her Geri chair in her room. Resident #21 was not interviewable.<BR/>Observation on 05/07/2024 at 9:43 AM, revealed Resident #21 in her Geri chair in the same position in her room. <BR/>Observation on 05/07/2024 at 12:00 PM, revealed CNA E passing out meal trays on Resident #21's hall. CNA E arrived at Resident #21's room at 12:25 PM and started feeding Resident #21. CNA E did not reposition Resident #21.<BR/>Observation on 05/07/2024 at 12:45 PM, revealed Resident #21 up in her Geri chair in the same position. <BR/>Observation on 05/07/2024 at 1:45 PM, revealed Resident #21 up in her Geri chair in the same position.<BR/>In an interview on 05/07/2024 at 1:54 PM, CNA E stated she had not done incontinent care or repositioned Resident #21 since she got her up at around 8:00 AM. She stated she was fixing to go get help since she was on the hall by herself, and she needed help to put her to bed.<BR/>Observation on 05/07/2024 at 2:30 PM, revealed CNA E and CNA F in Resident #1's room to put her in bed via the Hoyer lift. Observation of Resident #21's brief revealed it was saturated with urine and had a strong odor. CNA E turned Resident #21 to her right side to reveal a DTI approximately 0.1cm x 0.1cm to her right ischial tuberosity surrounded by a blanchable area of redness approximately 3 cm long and a 0.2 cm x 0.2 cm DTI to her lower coccyx area.<BR/>In an interview on 05/07/2024 at 3:00 PM, the ADON state Resident #21 did not currently have skin breakdown so any areas on her would be new. After observing the areas to Resident #21's coccyx area she stated Resident #21 did have breakdown areas on her boney prominences.<BR/>In an interview on 05/07/2024 at 3:15 PM, the DON stated she looked at Resident #21 yesterday and her skin was clear. When asked if the area could have resulted from her being up in her chair for an extended period of time she stated, I did not know she was up all day.<BR/>In an interview on 05/07/2024 at 3:20 PM, Resident #21's Hospice Nurse stated Resident #21 was at risk for breakdown and her skin was very delicate. She stated Resident #21's coccyx area was clear on her last visit a few days ago.<BR/>Observation and interview on 05/08/2024 at 10:38 AM, revealed Resident #21 in room being prepped for wound care with the Wound care physician. Observation of Resident #21's coccyx area DTIs revealed both had declined and were darker in color from 05/07/2024. Resident #21's wound care physician stated both areas on Resident #21's coccyx were DTIs. He stated the areas could definitely be caused by not being turned and being on the same bony prominences for an extended period of time. <BR/>Review of Resident #21's Physician wound evaluation and management summary dated 05/08/2024 reflected Resident #21 was assessed to have an unstageable DTI to the distal sacrum measuring 0.1cm x 0.1cm and undetermined depth. Further review reflected an unstageable DTI to the sacrum measuring 0.3cm x 0.3cm and undetermined depth.<BR/>In an interview on 05/08/2024 at 2:13 PM, the DON stated she expected the CNAs to check on the residents every 2 hours and do position changes. She stated CNA E could have asked anyone to help her and she did not. The DON stated CNA E did not give her an explanation of why she did not change Resident #21. The DON stated she expected the nurses as well to make rounds every two hours to ensure the CNAs are doing their jobs and to make sure the residents are taken care of to prevent skin breakdown. <BR/>Review of the facility policy pressure injury prevention, assessment and treatment dated 08/12/2016 reflected 1.Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems . 4. Causes of Pressure Injuries: Unrelieved pressure over a bony prominence resulting in ischemia at the area of pressure. 1.Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. 2. Do the blanching test by pressing the finger into a reddened area, a normal blood supply to the reddened area is seen when the area blanches white and then turns pink again. If the area remains red, a pressure sore is impending due to impaired circulation, keep resident off the area for 24 hours and then repeat the test.<BR/>Review of the facility' policy Perineal care dated 04/27/2022 reflected An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible . Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. One form of early skin breakdown is maceration or the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes soggy texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations. Skin erosion is the loss of some or all of the epidermis (comparable to a deep chemical peel), leaving a slightly depressed area of skin. Because frequent washing with soap and water can dry the skin, the use of a perineal rinse may be indicated. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition .<BR/>The Administrator was notified on 05/07/2024 at 5:10 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided.<BR/>The following POR was accepted on 05/09/2024 at 11:40 AM:<BR/>Date: 5/7/2024 <BR/>On 5/6/2024 an annual survey was initiated at the facility.<BR/>5/7/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the<BR/>Regulatory Services has determined that the condition at the facility constitutes an<BR/>Immediate jeopardy to resident health and safety.<BR/>Plan of Removal for F686 <BR/>Approximately 48 residents who are incontinent and/or require assistance with turning and repositioning could be affected by this deficient practice. <BR/>Problem: Failure to prevent pressure injury <BR/>Root cause analysis was conducted. CNA E failed to change the resident's brief timely. CNA E failed to reposition the resident at minimum of every two hours while in the Geri chair. This caused pressure injuries. The Administrator, DON, and ADON will review the schedule daily to include weekends. This review will include that 2 staff members will be present at all times on station #1 to assist with ADLs. The call-in process is that they call the DON's cell phone when calling in. DON is responsible for initiating finding additional coverage. The DON will utilize the PRN call list, shift bonuses, staff from nearby sister facilities, or agency staffing if needed. <BR/>Interventions:<BR/>Weekly ulcer assessments for Residents #21 were completed to include measurements by DON, ADON, and Tx Nurse on 5/7/24. Two new pressure wounds were identified, measured, and treated according to physician orders. <BR/>The MD was notified on 5/7/24 of Resident #21 new pressure wounds by the Tx Nurse. Orders were received for treatment and implemented on 5/7/24.<BR/>Wound care treatments for Residents #21 were completed as ordered by the Tx Nurse on 5/7/24. <BR/>100% skin rounds were initiated 5/7/24 by DON, ADON, Treatment Nurse. No additional pressure wounds were identified. <BR/>Administrator, DON, ADON, and Tx Nurse were in-serviced 1:1 by the Regional Compliance Nurse on 5/7/24 on the following topics. Completed 5/7/24.<BR/>Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. <BR/>Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. <BR/>Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately.<BR/>CNA E was in-serviced 1:1 by the DON on 5/7/24 for the following topics. Completed on 5/7/24. <BR/>Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. <BR/>Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. <BR/>Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The hall is adequately staffed with 1 nurse, 1 med aide, and 2 CNAs. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. <BR/>In-services:<BR/>The following in-services were initiated by Regional Compliance Nurse, DON on 5/7/24 for all clinical staff. Any clinical staff not present or in-serviced on 5/7/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. <BR/>Pressure Injury Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. <BR/>Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours while in bed or chair could result in skin breakdown which is neglect. <BR/>Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. <BR/>The Administrator, DON, and ADON/designee will be responsible for ensuring that residents are checked for incontinence, brief changed, turned, and repositioned while in bed or Geri chair. Monitoring will occur during rounds daily for 10-15 randomly selected residents 7 days per week across all shifts including weekends. Monitoring will be documented on a form will continue for a minimum of 6 weeks. <BR/>The Medical Director was notified of the immediate jeopardy situation on 5/7/24 by the administrator. <BR/>An ADHOC QAPI meeting was held with the Administrator, DON, ADON, Tx Nurse and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 5/7/24.<BR/>The Survey Team monitored the POR on 05/08/2024 through 05/09/2024 as followed:<BR/>Review of the facility's weekly wound assessment for Resident #21 reflected it was complete and conducted by the wound care physician on 05/08/2024.<BR/>Review of Resident #21's nursing progress notes and weekly wound assessment dated [DATE] reflected Resident #21's physician was notified, and orders received for treatment and consult with wound care physician.<BR/>Observation on 05/08/2024 at 10:38 AM, revealed wound care treatment conducted by the ADON and wound care physician. <BR/>Review of the facility's skin round documentation initiated on 05/07/2024 reflected skin assessments conducted on all residents without new pressure ulcers being identified. <BR/>Review of the one-on-one in-services for the Administrator, DON, ADON and Treatment Nurse dated 05/08/2024 reflected it was conducted by the RNC and covered the following areas: Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing included requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately.<BR/>In an interview on 05/08/2024 at 9:29 AM, the DON stated she was in-serviced by the RNC regarding pressure ulcer prevention, ADL care and monitoring staff to ensure care is provided. <BR/>In an interview on 05/08/2024 at 9:45 AM the Administrator stated the RNC performed the one on one inservices for her and the DON and ADON. <BR/>Review the one-on-one in-service for CNA E dated 05/08/2024 reflected it was conducted and covered the following topics: Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The hall is adequately staffed with 1 nurse, 1 med aide, and 2 CNAs. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately.<BR/>Attempts to interview CNA E on 05/09/2024 were unsuccessful.<BR/>Review of the facility conducted in-services for Pressure Injury Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024.<BR/>Review of the facility conducted in-services for Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours while in bed or chair could result in skin breakdown which is neglect was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024.<BR/>Review of the facility conducted in-services for Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024.<BR/>In an interview on 05/09/2024 at 9:18 AM, CNA H stated she had been trained on rounds. She stated that the training covered doing rounds every two hours, changing the resident, and getting them off their bottoms. She stated residents on the secure unit were changed every hour to every hour and a half. She stated that when a resident had a change in skin condition that it should be reported to the nurse. She stated she was trained on pressure injury prevention. She stated the training covered making sure the resident was not on their bottom for an extended period and to keep them dry. She felt like the facility had enough staff and that the staff could do all their tasks and showers. <BR/>In an interview on 05/09/2024 at 9:23 AM, the ADON stated she had been trained on doing rounds. She stated that the training covered turning the resident and changing the resident. She stated residents were checked every two hours. She stated that when changing a resident staff were to reposition the resident to ensure the resident was not on the same side they had been on. The ADON stated she had been trained on change in skin condition. She stated that she would take care of the resident. She said she would assess the skin, so she could get measurements. She said she would then call the wound doctor and the family about the change in skin. She stated she would get an order in place. She stated that she had been trained on pressure injury prevention. She stated the training covered making sure that the resident is turned or repositioned every two hours. She stated when the resident was in a chair staff are supposed to repositioned in the chair. She stated that she felt the facility had enough staff. She stated everyone worked together and the staff were able to get everything done. She said she felt she had enough time to do all tasks and rounds.<BR/> In an interview on 05/09/2024 at 9:37 AM, CNA G stated he was trained on rounds. He stated the training covered making sure the rounds were done every two hours and repositioned when finished changed. He stated that if the resident had a change in skin condition, he would report it to the nurse. He stated he was trained on pressure injury prevention. He stated the pressure injury prevention training covered turning the resident every two hours, making sure the resident was of the injury and put a pillow under the resident and keeping them dry. He stated he did not think the facility had enough staff. He stated he was able to complete all tasks because the shift is 12 hours. He stated he will do a shower for 30 minutes and then check the residents. He stated that the nurses and CMAs were good about helping. <BR/>In an interview on 05/09/2024 at 9:12 AM CNA I stated she has been in-serviced this morning on turning every 2 hours, abuse, and neglect, not feeding 2 patients at one time, and reporting skin issues. I asked if you see a change in skin condition what do you do? She stated she tells her charge nurse immediately. When asked her if she felt there is enough staff working on the floor. She said yes. There is always 2 people on the locked unit. She stated if someone calls in sick, they bring someone else in. <BR/>In an interview on 05/09/2024 at 9:22 AM LVN C stated she had been in-serviced this morning on abuse and neglect, pressure injury, skin breakdown, turning residents every 2 hours, not to feed 2 patients at one time and reporting skin issues. I asked if you see a change in skin condition what do you do? She told me she does an assessment, reports to the DON, lets the doctor know, and then puts treatment into place. I asked her how often she checks on residents, and she told me every 2 hours and if resident is having diarrhea more often. I asked her if she felt there is enough staff. She said for the most part yes. There is a shortage everywhere. I asked her what happens when there is not enough staff on the floor. She said there are enough resources and people come help.<BR/>In an interview on 05/09/2024 at 9:32 AM, CNA J stated she had in serviced on rounds, checking residents every 2 hours, abuse, and neglect, and who to report skin breakdown to. I asked her how often she checks on her residents she said every 2 hours. I asked her if she felt there was enough staff on the floor. She said yes. I asked her what happens when there is not enough staff. She said she does her job and does what she needs to do. <BR/>In an interview on 05/09/2024 at 9:38 AM, CMA D stated she has been in serviced this morning on not feeding 2 people at once, completing rounds every 2 hours, abuse, and neglect. I asked her if she sees a change in skin condition what she does. She reported she goes to the charge nurse. I asked her who she reports skin changes to she said the charge nurse. I asked her how often rounds are she said every 2 hours. <BR/>In an interview on 05/09/2024 at 9:42 AM, LVN B stated she has been in-serviced this morning on abuse and neglect, skin breakdown, incontinent care, cleaning glucometers. I asked her how often they check on residents. She said every 2 hours. I asked her if she felt there was enough staff she said yes. That they always call people in if someone does not come in. <BR/>In an interview on 05/09/24 at 12:55 PM, LVN K worked 6P to 6 A on 5/8 to 5/9 She stated they were in serviced on a lot last night and she was half asleep and will try to remember<BR/>1. <BR/>Incontinent care<BR/>2. <BR/>Using barrier cream<BR/>3. <BR/>Foley catheter and using PPE when giving care to Foley Catheter<BR/>4. <BR/>Abuse and Neglect<BR/>5. <BR/>Reporting any new skin concerns<BR/>6. <BR/>Pressure Ulcers<BR/>She stated there was more, but she could not remember. <BR/>In an interview on 05/09/2024 at 12:49 PM, CNA O stated she was in serviced on abuse neglect the rounds and PPE for open wound and foley. Reposition the resident every two hours with the rounds. Was in serviced on pressure injury precautions put a pillow under the resident. The resident has heel protectors on to prevent pressure. Stated she thinks there is enough. No task not able to complete has not been short in over a month. Yes, stated she can do all her rounds and shower she is the only aid for two halls. <BR/>In an interview on 05/09/2024 at 12:58 PM, CNA P stated he had been in serviced on rounds, checking residents every 2 hours, abuse, and neglect. He said he checks on residents every 2 hours and felt there was enough staff on the floor. He said they will call and see if more people come in she stated there is not enough staff.<BR/>On 05/09/2024 at 3:12 PM, the Administrator was notified the IJ was removed on 05/09/2024 at 3:12 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to keep two (Resident #1, Resident #2) of sixteen residents free from accident hazards and supervision.<BR/>The facility failed to:<BR/>1. Ensure Resident #1, who had exit-seeking behaviors and resided in the secure unit, did not elope from the facility on 12-16-22. <BR/>2. Ensure Resident #2, who had exit-seeking behaviors and resided in the non-secure unit, did not elope from the facility on 09-14-22. <BR/>On 1-2-23 at 5:17 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 1-5-23 at 7:00 PM, the facility remained out of compliance at a scope of J isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>These failures placed residents at risk of abuse, harm, or hospitalization.<BR/>Findings Included:<BR/>Record review of Resident #1's undated admission record reflected, Resident #1 was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis ), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs ), and major depressive disorder (causes a persistent feeling of sadness and loss of interest and can interfere with your daily), recurrent, severe with psychotic symptoms (hallucinations, delusion, confused/disturbed thoughts).<BR/>Record review of Resident #1's MDS assessment, dated 12-21-2022, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. The MDS further reflected Resident #1 had a behavior of wandering that occurred daily during the look-back period of the assessment. Resident #1 did not require any assistive mobility devices. <BR/>Record review of Resident #1's care plan, initiated on 10-22-21, reflected Resident #1 is at risk for wandering. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system. Resident #1 had cognitive function/dementia or impaired thought processes Dementia.<BR/>Record review of Resident #1's Securecare Environment Screening Tool dated 7-18-22, reflected Resident #1 had a diagnosis of Alzheimer's disease, continued to exhibit exit seeking behavior and resident is continuously wandering and looking for an exit.<BR/>Record review of Resident #1's progress note, dated 7-23-22, reflected Resident #1 had pushed his way through the doors of the locked unit and took off running down the street. Law enforcement assistance had been required because Resident #1 was running down the road and Licensed Vocational Nurse D had to block traffic. 911 was called, resident [#1] was restrained after swinging at officers. Resident #1 had been transferred to local hospital. Resident #1 returned to the facility with a diagnosis of altered mental status with no new orders.<BR/>Record review of Resident #1's progress note, dated 7-24-22, reflected Resident #1 was increasingly agitated and commenting I'm going to the house. Resident #1 had set off the back door alarm 3 times. Staff attempted to redirect him and he charged at them with a closed fist. <BR/>Record review of Resident #1's progress note, dated 8-6-22, reflected Resident #1 had been observed due to increased agitation. Resident #1 had been walking from one door to the next, and walking away from the front door down to the hall.<BR/>Record review of Resident #1 progress note, dated 10-29-22, reflected Resident #1 tried to push the courtyard door open and stated I want to go home. Resident #1 was shaking the front doors to the secure unit and became combative with staff, and law enforcement was called. The law enforcement officer spoke to Resident #1 and Resident #1 was redirected to his room without complaints. <BR/>Record review of Resident #1 progress note, dated 12-16-22 reflected, Resident #1 had run and hit the exit doors in the secure unit which caused it to open. Resident #1 ran down the sidewalk and was followed by Certified Nurse Aide F. Resident #1 was in view of Certified Nurse Aide F at all times.<BR/>Record review of Texas Department of Aging and Disability Services Form 3613-A provided by the Administrator reflected the Investigation Findings to be confirmed. Staff were moving residents from the dining room to the day room following an activity. [Certified Nurse Aide F] was coming out of the dining room, she spotted resident [Resident #1] running down the hall toward the door. When he [Resident #1] reached the door he pushed hard on it until it released. [Certified Nurse Aide F] was running after him calling for help as she went. [Certified Nurse Aide E] was asked to help. He [Certified Nurse Aide E] told [Licensed Vocational Nurse B], what was going on and joined the pursuit. Resident [#1] was in eye sight at all times. Staff caught up with the resident [#1] (as he was running down the sidewalk), calmed him down and coaxed him into a care to return him to the facility. Resident [#1] had been taken out on a pass the day before. The form was signed by the Administrator and dated on 12-20-2022. <BR/>On 1-2-23 at 10:05 AM, an observation revealed, the nurse's station outside of the secure unit. Two locked clear doors led to the secure unit. Licensed Vocational Nurse A pressed the doorbell located on the left side of the wall and unlocked the doors to the secure unit. <BR/>On 1-2-23 at 10:07 AM, Resident #1 was observed in the secure unit at the end of the hall, trying to push the emergency doors open. Certified Nurse Aide C and Licensed Vocational Nurse A stood in front of the doors and redirected him away from the doors. Resident #1 was angry and agitated, and continued trying to push the doors open. Resident #1 continued to talk loudly and aggressively to staff as he walked away from the exit doors.<BR/>On 1-3-23 at 9:15 AM, an observation revealed the distance between the private driveway in front of the home where Resident #1 was found and the facility was .26 miles. <BR/>Record review of the posted speed limit on the busy street in front of the facility to be 30 miles per hour.<BR/>During an interview on 1-3-23 at 10:56 AM, Certified Nurse Aide E stated he had been trained in elopement procedures and had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide E stated the Maintenance Supervisor notified the nurse who in turn notified him that Resident #1 had eloped. Certified Nurse Aide E stated he ran down the sidewalk located next to a busy street and saw Resident #1 on the opposite side of the street running away from the facility. Certified Nurse Aide E stated he saw cars slowing down as Resident #1 continued to run down the street. Certified Nurse Aide E stated Resident #1 was found approximately 2 blocks away in a private driveway in front of a home. Certified Nurse Aide E stated the street located in front of the facility was very busy and there was traffic on the day Resident #1 eloped. Certified Nurse Aide E stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Certified Nurse Aide E stated Resident #1 has a history of trying to exit the facility and has witnessed him push and pull the front doors of the secure unit attempting to leave when he is mad or agitated. <BR/> During an interview on 1-3-23 at 9:04 AM, Licensed Vocational Nurse B stated she had been trained in elopement procedures and she had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Licensed Vocational Nurse B stated Resident #1 had a history of being upset after the family visited and attempted to leave the facility after those visits. Licensed Vocational Nurse B stated a family member visited Resident #1 the day before and he had been upset since then. Licensed Vocational Nurse B stated she had been told by Certified Nurse F that Resident #1 was running back and forth down the hallway of the secure unit when he hit the exit doors and they opened. Licensed Vocational Nurse B stated she and Certified Nurse Aide E ran out of the facility and saw Resident #1 running down the sideway next to a busy street. Licensed Vocational Nurse B stated Resident #1 ran fast and finally stopped near a fast food restaurant, a couple of blocks away. Licensed Vocational Nurse B stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Licensed Vocational Nurse B stated a head-to-toe assessment was done on Resident #1 and no injuries were noted, vitals were taken and all were normal. She stated he was also hydrated, and was assigned a one to one person for the next 72 hours. Licensed Vocational Nurse B stated on 12-30-22, Resident #1 was moved from his room located at the end of the hall to the first room at the beginning of the hall because the facility need his room for a new admission. <BR/>During an interview on 1-3-23 at 10:56 AM, Certified Nurse Aide E stated he had been trained in elopement procedures and had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide E stated the Maintenance Supervisor notified the nurse who in turn notified him that Resident #1 had eloped. Certified Nurse Aide E stated he ran down the sidewalk located next to a busy street and saw Resident #1 on the opposite side of the street running away from the facility. Certified Nurse Aide E stated he saw cars slowing down as Resident #1 continued to run down the street. Certified Nurse Aide E stated Resident #1 was found approximately 2 blocks away in a private driveway in front of a home. Certified Nurse Aide E stated the street located in front of the facility was very busy and there was traffic on the day Resident #1 eloped. Certified Nurse Aide E stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Certified Nurse Aide E stated Resident #1 has a history of trying to exit the facility and has witnessed him push and pull the front doors of the secure unit attempting to leave when he is mad or agitated.<BR/>During an interview on 1-3-23 at 3:38 PM, Certified Nurse Aide F stated she had been trained in elopement procedures and she had worked on the secure unit on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide F stated she was in the dining room in the secure unit when she heard the alarm door beeping and saw Resident #1 standing at the exit doors. Certified Nurse Aide F stated she knew she had 15 seconds before the door released and opened. Certified Nurse Aide F stated the door opened and Resident #1 ran out the door and it shut behind him. Certified Nurse Aide F stated when she opened the door, Resident #1 was running in a private driveway located next to the facility. Certified Nurse Aide F stated she could see Resident #1 as he ran away from the facility. Certified Nurse Aide F stated Resident #1 stopped at the grocery store near the facility.<BR/>During an interview on 1-3-23 at 10:36 AM, the Licensed Vocational Nurse I stated she had been trained in elopement procedures. Licensed Vocational Nurse I stated she was in orientation on 12-16-22 when Resident #1 eloped from the secure unit. Licensed Vocational Nurse I stated she got into her personal vehicle and traveled down the road and saw Resident #1 and other staff members across the street in the private driveway of a home. Licensed Vocational Nurse I stated she coaxed Resident #1 into her vehicle and transported him back to the facility. Licensed Vocational Nurse I stated the street had a normal flow of traffic. Licensed Vocational Nurse I stated she was stationed at the nurse's station outside of the secure unit and will do rounds every hour or as needed. <BR/>During an interview on 1-2-23 at 10:10 AM, Certified Nurse Aide D stated she had been trained on elopement procedures. Certified Nurse Aide D stated Resident #1 was agitated and attempted to push the doors open on 1-2-23. Certified Nurse Aide D stated she had redirected Resident #1 away from the door. Certified Nurse Aide D stated Resident #1 had exit seeking behaviors and had eloped from the facility in the past. Certified Nurse Aide D stated when Resident #1 is agitated, extra eyes were kept on him to prevent him from eloping. Certified Nurse Aide D stated Resident #1 had touched the exit door bar and waited for the staff to respond. Certified Nurse Aide D stated Resident #1 had acted up after past family visits. Resident #1 had been visited by family on 1-1-23 and that is what caused him to become angry and agitated. Certified Nurse Aide D stated Resident #1's room was located at the end of the hall, near the exit doors. Certified Nurse Aide D stated Resident #1 had been in the secure unit for a couple of months and he had eloped a couple of times before. Certified Nurse Aide D stated when she worked in the secure unit, she always kept an eye on Resident #1 to ensure that she knew where he was at all times. Certified Nurse Aide D stated Resident #1 liked to sit in the dining room, listen to music, and drink coffee. Certified Nurse Aide D stated rounds are done at least every 2 hours, but more frequently in the secure unit. Certified Nurse Aide D stated 2 CNA's and 1 nurse covered the secure unit. <BR/>During an interview on 1-2-23 at 10:29 AM, Certified Nurse Aide M stated she had been trained on elopement procedures. Certified Nurse Aide M stated she worked in the secure unit with Resident #1 and when he was upset, he would attempt to leave the secure unit through the exit doors. Certified Nurse Aide M stated Resident #1 had been redirected away from the exit doors. Certified Nurse Aide M stated Resident #1 had been verbally aggressive when he was angry or agitated. Certified Nurse Aide M stated rounds are done at least every 2 hours but more frequently in the secure unit. Certified Nurse Aide M stated 2 CNA's and 1 nurse covered the secure unit. Certified Nurse Aide M stated 16 residents resided on the secure unit. <BR/>During an interview on 1-2-23 at 10:36 AM, Licensed Vocational Nurse A stated she had been trained in elopement procedures. Licensed Vocational Nurse A stated she had been working the secure unit on 1-2-23 and Resident #1 attempted to push the exit doors open. Licensed Vocational Nurse A stated Resident #1 stated, I figured it out as he attempted to push the exit door open. Licensed Vocational Nurse A stated she and Certified Nurse Aide B stood in front of the exit door to prevent Resident #1 from eloping. Licensed Vocational Nurse B stated Resident #1 was agitated and high strung because he had a family visit the day before [1-1-23] and he kept stating he wanted to go home. Licensed Vocational Nurse A stated the exit door push bar had to be held for 15 seconds before the door was unlocked and released. Licensed Vocational Nurse A stated the exit door alarm will beep loudly during the 15 seconds. Licensed Vocational Nurse A stated the beeping could be heard at the nurse's station located outside the secure unit. Licensed Vocational Nurse A stated after 15 seconds the door will open and the alarm will sound at which time all available staff is to respond to the opened door. Licensed Vocational Nurse A stated she sits at the nurse's desk located outside the clear doors of the secure unit. Licensed Vocational Nurse A stated a doorbell is located on the left side of the wall next to the clear doors leading to the secure unit and the doorbell had to be pushed to release the lock and open the doors to the secure unit. Licensed Vocational Nurse A stated a code to the keypad is needed to exit the secure unit.<BR/>During an interview on 1-2-23 at 10:50 AM, Certified Nurse Aide D stated she had been trained on elopement procedures. Certified Nurse Aide D stated she had worked the secure unit and cared for Resident #1. Certified Nurse Aide D stated Resident #1 had a history of being agitated after family visits and would attempt to exit through the back exit doors. Certified Nurse Aide D stated when she worked the secure unit, Resident #1 was with her or within eyesight because of his past history of elopement. Certified Nurse Aide D stated Resident #1 did respond to redirection when he is upset and wanting to go home. Certified Nurse Aide D stated Resident #1 pressed the push bar and when she heard the beeping she immediately responded to the exit door and redirected him to activity room. Certified Nurse Aide D stated Resident #1 is very strong and can be physically/verbally aggressive when upset. Certified Nurse Aide D stated she had been told Resident #1 ran very fast when he eloped from the facility. Certified Nurse Aide D stated rounds in the secure unit are completed at least every 2 hours, but she did them every 30 minutes because some residents like to walk up and down the hallway. Certified Nurse Aide D stated the doorbell outside the secure unit must be pressed and it will open the door. Certified Nurse Aide D stated when the push bar on the exit door is held it will beep for 15 seconds then the door is opened and the alarm will sound. Certified Nurse Aide D stated the alarm can be heard outside the doors of the secure unit and all available staff are to respond. She stated the code, to the keypad, is needed to exit through the clear doors located at the front of the secure unit. <BR/>During an interview on 1-2-23 at 10:59 AM, the Maintenance Supervisor stated he checked all exit doors every other day. The Maintenance Supervisor stated he checked all keypads daily to make sure they were working. The Maintenance Supervisor stated he did not keep a daily log of the checks, but if a repair is needed, it will be logged in the system and then show up on a report when it is completed. The Maintenance Supervisor stated the push bar to the exit doors, in the secure unit, is very sensitive and will beep if it is touched and the constant beeping will sound when the push bar is held and the alarm will go off when the door is opened. The Maintenance Supervisor stated the push bar had to be held for 15 seconds, before it would open and set off the alarm. The Maintenance Supervisor stated the alarm in the memory care unit is loud and can be heard through the clear doors of the unit. The Maintenance Supervisor stated a code is needed to exit through the door that leads to the courtyard in the secure unit. The Maintenance Supervisor stated staff and visitors must press a doorbell located on the right side of the wall and someone from inside the facility will come to the front door and open it. The Maintenance Supervisor stated a red push button located on the right side of the wall near the front doors had to be pressed before the doors will open automatically. The Maintenance Supervisor stated a code is not needed to exit the facility through the front doors.<BR/>On 1-2-23 at 11:05 AM an observation revealed the exit door to beep when touched and then a long beeping sound when the push bar was held for 15 seconds before being opened. The exit doors led to the side of the building and a sidewalk that leads to the facility parking lot. On the other side of the sidewalk is a grassy area which leads to an open part of the fence that leads to a private property. The sidewalk ends at the parking lot. A sidewalk is located between the facility parking lot and a street. The street was observed to be busy with traffic. <BR/>On 1-2-23 at 11:08 AM an observation revealed a red button located on top of a blue handicap mount was located on the wall near the front entrance doors.<BR/>During an interview on 1-3-23 at 10:00 AM, Certified Nurse Aide D stated she had been trained on elopement procedures and worked in the secure unit with Resident #1. Certified Nurse Aide D stated Resident #1 had a history of exit seeking behaviors and would attempt to leave the facility when upset or agitated after family visits. Certified Nurse Aide D stated she had not worked in the secure unit on 12-16-22, when Resident #1 eloped. Certified Nurse Aide D stated the facility had been short staffed during the month of December 2022, and she worked the secure unit alone a few times because of staffing issues. Certified Nurse Aide D stated at least 2 Certified Nurse Aides needed to work the secure unit to meet the residents needs and ensure they get proper care. <BR/>During an interview on 1-3-23 at 10:20 AM, Certified Nurse Aide G stated he had been trained in elopement procedures and worked in the secure unit at the facility. Certified Nurse Aide G stated Resident #1 had a history of elopement and had eloped from the secure unit back in July 2022. Certified Nurse Aide G stated Certified Nurse Aide D was the only person working on the secure unit on that day. Certified Nurse Aide G stated the facility was short staffed and there had been times where only one person worked the secure unit. Certified Nurse Aide G stated Resident #1 is fast and no one here can catch him once he gets to running. Certified Nurse Aide G stated all staff are aware Resident #1 will be upset after family visits and will try to leave the facility. Certified Nurse Aide G stated Resident #1 can be redirected sometimes but when he was upset he would not listen. <BR/>During an interview on 1-3-23 at 12:45 PM, the Director of Nursing stated she and all staff had been trained on elopement procedures. The Director of Nursing stated she had worked on 12-16-22 when Resident #1 eloped from the facility. The Director of Nursing stated Resident #1 eloped through the exit doors of the secure unit. The Director of Nursing stated Certified Nurse Aide F ran after Resident #1 and kept him within eyesight. The Director of Nursing stated she and other staff members ran down the sidewalk next to a busy street and finally reached Resident #1 on the opposite side of the street in a private driveway. The Director of Nursing stated there was a steady flow of traffic on the street located next to the facility. The Director of Nursing stated Resident #1 was transported back to the facility by Licensed Vocational Nurse I. Resident #1 was assessed from head to toe with no injuries noted, vitals were taken, he had been given fluids for hydration, and then had dinner. Resident #1 was placed on a one to one watch for the next 72 hours. The Director of Nursing stated Resident #1's room was located at the end of the hallway near the exit doors in the secure unit, but he was moved on 12-30-22 because the facility needed that room for a new admission. The Director of Nursing stated Resident #1 would have been able to stay in his room located at the end of the hall near the exit doors if the facility had not needed it for a new admission. The Director of Nursing stated rounds were done every 2 hours and more frequently in the secure unit and there are 2 Certified Nurse Aides and 1 Medication Aide assigned to the secure unit on a daily basis. The Director of Nursing stated 1 Licensed Vocational Nurse is stationed outside the secure unit and will conduct rounds and coverage as needed. The Director of Nursing stated the Licensed Vocational Nurse is responsible for performing rounds throughout the facility and there will be times when she is not at the nurse's station to keep an eye on the secure unit. The Director of Nursing stated that the doorbell must be pressed before the entry doors to the secure unit are opened and an exit code on the keypad is needed to exit. The Director of Nursing stated the press bar, located at the end of the hallway on the secure unit, must be held for 15 seconds before it is released and it will beep until opened at which time the alarm sounds and all available staff are to respond to the door. The Director of Nursing stated there is always a risk that a resident will elope from the secure unit. <BR/>During an interview on 1-3-23 at 8:55 AM, the Administrator stated she and all staff were trained in elopement procedures. The Administrator stated Resident #1 eloped through the exit doors located in the secure unit on 12-16-22. The Administrator stated Resident #1 had a history of exit seeking behaviors and would attempt to leave the facility when upset after family visits. The Administrator stated a family member had visited Resident #1 the day before and he had been upset since the visit. The Administrator stated Resident #1 was placed on one to one monitoring for 72 hours after the elopement. The Administrator stated Resident #1's room was located at the end of the hall next to the exit doors but was moved to the first room at the beginning of the hallway close to the nurses station because his room was needed for a new admission. <BR/>Record review of Resident #2's undated admission record reflected, Resident #2 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistent feeling of sadness and loss of interest and can interfere with your daily), primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and asthma (disease that affects your lungs. It causes repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing).<BR/>Record review of Resident #2's MDS assessment, dated 12-21-2022, revealed Resident #2's BIMS score was blank which indicated it could not be completed. The MDS further reflected Resident #2 had a behavior of wandering that occurred daily during the look-back period of the assessment. Resident #2 required any assistive mobility devices. The MDS reflected daily decision making as being severely impaired. <BR/>Record review of Resident #2's care plan, initiated on 9-8-22, reflected Resident #2 is at risk for wandering, and at shift change if staff see resident outside, staff will invite resident to come inside. Resident #2 hadcognitive function/dementia or impaired thought processes Dementia, communication problem, and impaired visual function. <BR/>Record review of Resident #2's progress note, dated 5-15-22, reflected, Resident #2 remained tearful and continues to ask to go home and went back to her room to get her belongings. Resident #2 wandering the halls and was found on hall 3 tearful and upset with a bag in her hand that contained her belongings. Urine sample was taken and 15-minute checks will be done until reports are back from the lab. <BR/>Record review of Resident #2's elopement risk assessment, dated 6-13-22, reflected she was not on a secured unit and ambulated independently or with a device. Assessment also indicated Resident #2 stated and/or threatened to leave the facility, frequent request to go home, confused expression related to tasks to complete, and verbalizes anger and frustration in reference to placement. Resident #2 did not recognize stop lights and signs and does not know precautions when crossing the street. <BR/>Record review of Resident #2's Event Nurse Note 12 hour-Elope or Attempt, dated 6-13-22, reflected Resident #2 was sitting outside with another staff around 6:30 PM when night shift nurse came on. Around 7:00 PM staff noticed that Resident #2 was not in the building and went outside to get her she was not sitting where she had been. Resident #2 was found in the parking lot next door. Resident #2 had been missing for 30 minutes; no injures resulted from elopement. Resident #2 was brought back inside to her room and given something to drink. Cognition/Behavior at the time of event were marked cognitive impairment, wanders and requires cueing.<BR/>Record review of Resident #2's progress note, dated 9-14-22, reflected Resident #2 was brought back from the porch area at approximately 3:30 PM. She went to the bathroom and then back to the nurses station. At 4:00 PM, Resident #2 was informed not to go back outside at which time she continued to go outside. Licensed Vocational Nurse B was informed that Resident #2 was down the street from the facility. Licensed Vocational Nurse B got into her car and went to look for Resident #2. Certified Nurse Aide E and Human Resources were walking around and looking for Resident #2. Licensed Vocational Nurse B stated she received a call from Human Resources that Resident #2 was found near the community hospital. Licensed Vocational Nurse B stated Resident #2 refused to get into her vehicle and was escorted back to the facility by Certified Nurse Aide E and Human Resources. Resident #1 was assessed upon return, no injuries, hydrated and he was moved to the secure area. <BR/>On 12-28-22 at 1:24 PM, an observation revealed the community hospital area where Resident #2 was found was approximately .17 mile from the facility. There was a steady flow of traffic on the road that led from the facility to the hospital.<BR/>Record review of the posted speed limit on the busy street in front of the facility to be 30 miles per hour.<BR/>During an interview on 1-2-23 at 11:48 AM, the Dishwasher stated she had been trained in elopement procedures. The Dishwasher stated on 9-14-22, she had finished her shift and clocked out at 4:00 PM and ran some errands. The Dishwasher she had traveled down the busy street located in front of the facility and saw Resident #2 walking on the opposite side of the street near a private residence and called the facility and notified them of what she had seen. The Dishwasher stated Resident #2 was approximately half a block away from the facility on the opposite side of the street. The Dishwasher stated Resident #2 had to have crossed the busy street to end up in front the house where she saw her. The Dishwasher stated the street located in front of the facility was busy at all times of the day. The Dishwasher stated she was in an uber car when she saw Resident #2 down the street from the facility. The Dishwasher stated she had not asked the uber driver to stop when she saw Resident #2. <BR/>During an interview on 1-2-23 at 12:33 PM, Certified Nurse Aide E stated he was trained in elopement procedures. Certified Nurse Aide E stated he was working in the facility on 9-14-22 when Resident #2 eloped from the facility. Certified Nurse Aide E stated he was told by another staff member that Resident #2 had left the facility and was next door at a grocery store. Certified Nurse Aide E stated he and Human Resources left the facility and began looking for Resident #2 and did not see her in the parking lot of the grocery store near the facility. Certified Nurse Aide E stated he looked across the busy street, located next to the facility, and saw Resident #2 across the street near the community hospital. Certified Nurse Aide E stated he and Human Resources ran across the street and up a side road and stopped Resident #2 near a county owned building. Certified Nurse Aide E stated Resident #2 was walking on the sidewalk next to the community hospital. Certified Nurse Aide E stated Resident #2 required the assistance of her walker to elope from the facility. Certified Nurse Aide E that at some unknown point Resident #2 had to have crossed the busy street located in front of the facility to end up in front of the community hospital. Certified Nurse Aide E stated the street in front of the facility was a busy street and there is traffic on it at all times of the day. Certified Nurse Aide E stated Resident #2 stated she left the facility because she was going to visit family. Certified Nurse Aide E and Human Resources had to cross the busy street and walked Resident #2 back to the facility which took about 10 minutes. Certified Nurse Aide E stated Resident #2 was assessed by the nursing staff. Certified Nurse Aide E stated Resident #2 lived in the non-secure part of the facility on the day she eloped. Certified Nurse Aide E stated Resident #2 had to have left the facility through the front door of the facility. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for one of three ([NAME] Hall) medication carts reviewed for medication storage. The facility failed to ensure [NAME] Hall medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors. This failure could place residents at risk of having unauthorized access to prescription, biologicals, and over-the-counter medications. Findings included: Observation on 07/01/2025 at 8:35 AM revealed an unlocked medication cart 1 across from station one nurses station and near the entrance to [NAME] hallway. The back of the cart was against the wall with the drawers facing the nurse's station. The locking mechanism was protruding outward on the medication cart. The state surveyor opened the drawers and captured photos. The nursing staff or any staff was not near the nurse's station or the unlocked medication cart. Observation on 07/01/2025 at 8:43 AM revealed RN A walking from the Mc [NAME] Hall toward the unlocked medication cart 1. Interview on 07/01/2025 at 8:44 AM RN A stated he did leave the medication cart unlocked. He stated he was in a resident room assisting with a transfer. He stated the medication cart was not in view where he was in a resident room. Interview on 07/01/2025 at 9:10 AM RN A stated the medication cart was to always be locked except when he was dispensing medications from the medication cart. He stated it was his responsibility to ensure the medication cart was locked and secure. RN A stated the key to the medication cart was in his pocket. He stated if residents had accessed the medication cart they could have overdosed, taken wrong medication, had an allergic reaction, and could require admission to the hospital. He stated he had previously been in-serviced on locking the medication carts and could not recall the specific date. He stated he was aware the medication cart should have been locked. RN A stated the narcotics was locked in the medication cart 1. He stated there was PRN medications, glucose monitor, and blood pressure cuff. Interview on 07/01/2025 at 4:45 PM the Director of Nurses stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. The Director of Nurses stated she did not the exact date of the in-service. She stated residents, other staff, and visitors would have access to the medications in the unlocked medication cart. She stated if a resident ingested medications not prescribed to them, there was a potential the resident may have an allergic reaction or may need to be admitted to the hospital. She stated it was the nurse responsibility to ensure the medication cart was locked when not dispensing a resident's medication. The Director of Nurses stated she was responsible for monitoring the nurse supervisor. Interview on 07/01/2025 at 5:05 PM the Administrator stated her expectations was for the medication carts to be locked when the nurses were not administering medications from the carts. She stated there was a possibility a resident may get medications out of the medication cart. The Administrator stated if a resident did take the medications by mouth there was a possibility a resident may have an allergic reaction. She stated it depended on the medication the resident ingested. She stated the nurse assigned to the medication cart was responsible for locking the medication cart after administering medications to a resident. The Administrator stated the Director of Nurses was responsible to monitor the nurse supervisor. Review of the facility's Policy on Medication Storage in the Facility, dated 2025, reflected Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services by sufficient numbers of nurse aides and licensed nurses on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 6 of 8 shifts (04/19/25 06:00 AM-06:00 PM, 04/19/25 06:00 PM-06:00 AM, 04/20/25 06:00 AM-06:00 PM, 04/20/25 06:00 PM-06:00 AM , 04/21/25 06:00 AM-06:00 PM , and 04/22/25 06:00 AM-06:00 PM) reviewed for sufficient nurse staffing. <BR/>The facility failed to schedule nurse aides and licensed nurses in numbers consistent with the posted nurse staffing during the following shifts: 04/19/25 06:00 AM-06:00 PM, 04/19/25 06:00 PM-06:00 AM, 04/20/25 06:00 AM-06:00 PM, 04/20/25 06:00 PM-06:00 AM , 04/21/25 06:00 AM-06:00 PM , and 04/22/25 06:00 AM-06:00 PM.<BR/>This failure placed residents at risk of not having their needs for assistance with activities of daily living and their medical needs met. <BR/>Findings included:<BR/>Review of the posted nurse staffing for 04/20/25, 04/21/25, and 04/22/25 reflected the resident census was 58. The day shift reflected the required staffing was one RN, two LVNs, one medication aide, and four nurse aides. The night shift required one RN, one LVN, and five nurse aides.<BR/>Review of staffing schedules for 04/19/25 through 04/22/25 reflected the following staff were scheduled:<BR/>04/19/25 06:00 AM-06:00 PM three nurse aides, one medication aide, and one RN (missing one nurse aide and one LVN according to the posted nurse staffing)<BR/>04/19/25 06:00 PM-06:00 AM two nurse aides, two LVNs (missing three nurse aides according to the posted nurse staffing)<BR/>04/20/25 06:00 AM-06:00 PM three nurse aides, one medication aide, two LVNs (missing one nurse aide according to the posted nurse staffing)<BR/>04/20/25 06:00 PM-06:00 AM four nurse aides, one LVN, and one RN (missing one nurse aide according to the posted nurse staffing)<BR/>04/21/25 06:00 AM-06:00 PM two nurse aides, one medication aide, one LVN, and one RN (missing two nurse aides according to the posted nurse staffing)<BR/>04/21/25 06:00 PM-06:00 AM five nurse aides, one LVN, one RN (sufficient staffing according to the posted nurse staffing)<BR/>04/22/25 06:00 AM-06:00 PM three nurse aides, one medication aide, two LVNs, and one RN (missing one nurse aide according to the posted nurse staffing)<BR/>04/22/25 06:00 PM-06:00 AM five nurse aides, one LVN, one RN (sufficient staffing according to the posted nurse staffing)<BR/>Review of time punches for the 06:00 PM to 06:00 AM shift from night of 04/20/25 to morning of 04/21/25 reflected three nurse aides, one LVN, and one RN were on duty.<BR/>Review of the facility assessment dated [DATE] reflected the average resident census was 58. <BR/>Review of Resident Council Minutes reflected the following: <BR/>Meeting dated 02/11/25<BR/>Nursing Review<BR/>Are call lights answered in a timely manner? Sometimes<BR/>Are residents receiving scheduled showers? Sometimes, other times not<BR/>Meeting dated 03/11/25<BR/>Nursing Review<BR/>Are call lights answered in a timely manner? No<BR/>Are residents receiving scheduled showers? Yes<BR/>Meeting dated 04/11/25<BR/>Nursing Review<BR/>Are call lights answered in a timely manner? No<BR/>Are residents receiving scheduled showers? Yes, but not all the time<BR/>Review of the grievance log for April 2025 reflected no related grievances.<BR/>During an interview on 04/22/25 at 02:55 PM, the DOR stated there was a staffing problem at the facility that was well known. She stated the problem was scheduled staff calling in and not working. She stated her understanding was that the schedules were made to include sufficient numbers of nursing staff, but people called in. The DOR stated she and the therapy staff had to help provide incontinent care and transfers sometimes to ensure people were ready for their therapy sessions. She stated the team worked together to meet the needs of residents, and the staff who came to work did a great job, but the facility did not pay very well, and they were having a hard time keeping staff or hiring new staff. <BR/>During a confidential interview on 04/22/25, an anonymous resident stated the staff did not answer call lights quickly or provide help quickly. They stated the staff treated them well, but there were not enough staff to provide care in a timely manner. They stated there had been no negative impact and nothing negative had occurred that they were aware of beyond the inconvenience of waiting. <BR/>During a confidential interview on 04/22/25, an anonymous resident stated the facility hardly had any help. They stated everyone had quit. They stated new nursing staff stayed two weeks and then quit because they were overworked. They stated they had to stay in bed all day sometimes because there was not enough staff to get them up (this resident was up in a wheelchair and participating in various activities during all observations). They stated they were not aware of any specific negative impact on residents or anything negative that had occurred to them as a result of the short staffing. <BR/>During a confidential interview on 04/22/25, an anonymous resident stated there was an ongoing problem with staffing at the facility, and they did not know what was causing it. They stated staff they have had working there for years had been quitting, and new staff that were hired were quitting after only a few weeks of work. They stated the other staff told them the delay in call response times was due to people calling in and quitting. They stated they had not heard of any specific negative impact of the staffing problem on residents, but everybody felt the strain. They did not elaborate on precisely what that meant. <BR/>During a confidential interview on 04/22/25, an anonymous staff person stated the facility had a problem with sufficient nursing staff that was widely known by everyone who worked there. They stated the director of nursing had quit, the administrator had been terminated that morning, and they did not know exactly who was in charge. They stated they thought the team who worked did a great job and took care of resident needs, but people kept quitting because of the pay and being overworked. They stated the staff were all on a 12-hour shift, and there were a select few who would always show up to work, and those would be called to work when someone else did not show up to work their shifts. This meant they were always working a lot of extra hours. The anonymous staff person stated there was a notification system for all the facilities in the area owned by the same company, and other buildings sent notifications that aides could receive $250 bonuses for picking up shifts, while this facility would offer $25, $50, or $75 a shift. They stated the staff were aware of the difference, and it meant they were less likely to pick up shifts and that morale at this facility was low. They stated they were afraid of being quoted in case there was retaliation and they lost their job.<BR/>During a confidential interview on 04/22/25, an anonymous staff person stated there had been staffing issues at the facility the entire time they had worked there. They stated it was not just a one-time issue that there had been fewer CNAs than were required. They stated the charge nurses provided ADL care to make up for the absence of aides, but then the nurses were not able to do everything they were supposed to do. They stated the nurses ended up working extra hours, and that meant they got burned out more quickly and left to find other places of employment. They stated the same thing happened with the CNAs. They stated everyone who came to work each shift stressed out due to not knowing if they would be fully staffed. They stated they were about ready to quit and find work elsewhere. <BR/>During a confidential interview on 04/22/25, an anonymous staff person stated the staffing was adequate as long as no one called in, but people called in frequently. They stated they did not know why people called in so often. <BR/>During a confidential interview on 04/22/25, an anonymous staff person stated they did not notice a staffing problem if no one called in, but lots of people did call in. They stated the 12-hour shifts were hard for people, so the facility had a hard time keeping staff.<BR/>During a confidential interview on 04/22/25, an anonymous staff person stated they were one of many staff people who came to work at the facility after being promised a sign on bonus of $2500 that would be distributed in monthly increments. They stated the bonus was never given, and when they inquired about it, they were told it was a mistake for the previous manager to have offered it. They stated they did not remember who they spoke to about the bonus, and they did not take pictures of the offer letter, because they did not know they needed to. They stated they trusted the management that hired them. They stated the CNAs made much less than CNAs at other facilities. They stated people always called in, so the facility was always short-staffed, and that made people quit or call in even more. They stated they were almost out the door.<BR/>During a confidential interview on 04/22/25, an anonymous staff person stated people were quitting, because they were tired of being left at the facility with not enough help for more hours than they should have had to work. They stated they were afraid of retaliation if they spoke openly and allowed their name to be used. They stated the facility had adequate staffing currently because the State Agency was conducting an investigation.<BR/>Observations on 04/22/25 between 09:30 AM to 03:30 PM revealed call lights were answered within two minutes, residents were up and engaged in activities, and there were no residents observed in soiled garments or with other needs going unmet.<BR/>During an interview on 04/22/25 at 03:57 pm, the Area Director/Acting Administrator (AD/AA) stated the previous DON's last day was Friday 04/18/25 and the previous administrators had come in earlier that morning to be terminated. The AD/AA stated she had a role in staffing at the facility as of that day, 04/22/25. The AD/AA stated she had just gone over the schedule to see where they were for tonight and ensure the facility was fully staffed for that night and the rest of the week. She stated they were offering a sign on bonus and had staff appreciation events monthly at which they fed all the staff on all shifts. She stated the facility did have to run the staff which were listed on the posted nurse staffing, as they determined that was the sufficient number of staff to ensure all resident needs among the current census were met. <BR/>Observation on 04/22/25 from 07:30 PM to 08:30 PM revealed the facility was quiet with no unpleasant odors present. Most residents were in their rooms, and the ones not in their rooms were visiting with staff. CNAs B, C, D, E, and F were present caring for residents. Call lights were being answered and resident care was being provided swiftly during the observation. LVN G and RN H were present in the building and providing resident care. MA I was also present and passing out medication. RN A was still at the facility sitting in front of a computer. <BR/>During an interview on 04/22/25 at 07:30 PM, RN A stated she was still at the facility because she had charting to do that she could not do during her 12-hour shift from 06:00 AM-06:00 PM. She stated this was because they had been short a CNA on the day shift, and she had been helping with ADL tasks when needed. She stated the facility experienced chronic short staffing, because everyone who worked there was so overworked they often called in or just did not show up. She stated this included RNs, LVNs, and CNAs who did not work their shifts. She stated it would only get worse as people became more and more worn out. <BR/>During an interview on 04/23/25 at 10:27 AM, the AD/AA stated any sign on bonuses that were promised should have been delivered as agreed. She stated she was not aware of any concerns related to sign on bonuses and was not aware of an overall staffing shortage in the facility, but she would be conducting her own investigation into the matter and would rectify any problems she discovered. She stated the facility administrator and DON had been responsible for ensuring sufficient staffing in the facility, but they were both no longer employed, so now the responsibility would be hers until a new administrator and DON were hired. She stated the potential negative impact of not having enough nurse aides in the building was that resident needs might not be met. <BR/>Review of facility policy titled :Facility Assessment and dated 08/08/24 reflected the following: <BR/>The facility will use this facility assessment to:<BR/>Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in &sect; 483.35(a)(3).<BR/>Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.<BR/>Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.<BR/>Develop and maintain a plan to maximize recruitment and retention of direct care staff.<BR/>Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 3 of 6 residents (Residents #1, #2, & #3) reviewed for resident rights in that: <BR/>Residents #1, #2, & #3 's call lights was not within reach on 01/30/2025.<BR/>This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. <BR/>Findings included: <BR/>1.Record review of Resident #1's admission record dated 01/30/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 diagnosis of Alzheimer's Disease (a brain disorder that causes memory and thinking skills to decline over time.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 01/22/2025, revealed the resident had a BIMS score of 03, which indicated severe impairment. The MDS also revealed Resident #1 was dependent in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. <BR/>Record review of Resident #1's care plan, dated 01/30/2025, revealed Resident #1 was care planned for communication problems r/t dx of Alzheimer's/Dementia, cognitive deficit, minimal hearing deficit and had an intervention of call light in reach. <BR/>During an observation and interview on 01/30/2025 at 8:50am., Resident #1's call light was observed behind the head of her bed and out of her reach. Resident #1 stated she did not know where her call light was or how long it was behind her bed. Resident #1's stated she could not reach her call light. <BR/>2.Record review of Resident #2's admission record dated 01/30/2025, reflected an [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #2 diagnoses included: hemiplegia affecting right nondominant side (paralysis on one side of the body), reduced mobility (limited ability to move but can do so under certain circumstances), contracture of muscle (when a muscle becomes permanently shortened and tight, making it difficult to move the joint it's connected to), repeated falls (falling multiple times, usually within a short period), and muscle weakness (when your muscles don't have the strength they normally do).<BR/>Record review of Resident #2's Quarterly MDS assessment, dated 12/21/2024, reflected the resident had a BIMS score of 10, which indicated moderated cognitive impairment. The MDS also revealed Resident #2 was dependent in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. <BR/>Record review of Resident #2's care plan, dated 01/30/2025, revealed Resident #2 was care planned for risk of falls r/t confusion, unaware of safety needs and had an intervention be sure Resident #2 call light was within reach and encourage the resident to use it for assistance as needed. <BR/>During an observation and interview on 01/30/2025 at 9:00am., Resident #2's call light was observed behind the head of his bed and out of his reach. Resident #2 stated he could not reach his call light and he would have to wait for someone to come by his room for assistance. Resident #2 stated his call light was often out of reach. <BR/>3. Record review of Resident #3's face sheet dated 01/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included: unspecified dementia (a condition that cause a decline in thinking, memory, and reasoning abilities) and aphasia (a language disorder that makes it difficult to communicate) <BR/>A record review of Resident #3's Quarterly MDS assessment, dated 01/12/2025, reflected the resident had a BIMS score of 12, which indicated mildly impaired. Resident #3's Quarterly MDS reflected she required partial/moderate assistance for shower/bathe self and supervision or touch assistance for personal hygiene. <BR/>A record review of Resident #3's care plan, dated 01/30/2025, reflected Resident #3 was care planned for communication problem r/t aphasia with an intervention of ensure/provide a safe environment: call light in reach. Resident #3's care plan also reflected she was care planned for falls d/t confusion, poor safety awareness r/t dementia with an intervention of be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>During an interview and observation with Resident #3 at 01/30/2025 at 9:06am, Resident #3's call light was observed on floor by the left side of her recliner and out of her reach. Resident #3 stated she could not reach her call light and was not aware it was on the floor next to her recliner. Resident #3 stated she would have to wait for staff to come in her room for assistance due to her call light being out of reach. <BR/>During an interview with the CNA A on 01/30/2025 at 1:15pm, CNA A stated that CNAs make round every two hour or as needed. CNA A stated during rounds CNAs are taught to ensure the resident call lights are in reach. <BR/>During an interview with the DON on 01/30/2025 at 3:50pm, the DON stated all residents call lights should be always within reach. The DON stated it everyone's responsibility to ensure residents call lights are always within reach. The DON stated if a resident's call light was not within reach the resident would not be able to receive assistance if they needed it. <BR/>During an interview with the RCN on 01/30/2025 at 4:00pm, the RCN stated that call lights should always be within reach. The RCN stated that it was everyone's responsibility to ensure the call light are within reach. The RNC stated that if a resident call light was not within reach, then the resident may not be able to call for assistance. The RNC stated her expectation were for all resident's call lights to be always within reach. <BR/>The facility does not have a call light policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 6 residents (Resident #4) reviewed for care plans.<BR/>The facility failed to ensure Resident #4's care plan was updated to reflect the resident's recent falls on 12/20/2024, 01/24/2025 & 01/25/2025.<BR/>This failure could place residents at risk of not receiving appropriate care to meet their current needs. <BR/>Findings include: <BR/>Record review of a facility face sheet for Resident #4 dated 01/30/2025, reflected a [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #4's diagnoses included: unspecified dementia ((a condition that cause a decline in thinking, memory, and reasoning abilities), repeated falls (falling multiple times, usually within a short period), lack of coordination (not being able to move different parts of your body smoothly together), and muscle weakness (when your muscles don't have the strength they normally do).<BR/>Record review of Resident #4's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 99, which indicated severe cognitive impairment. Resident #4's Quarterly MDS reflected he was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #4's MDS Section J1800 reflected that Resident #4 has had falls since admission/entry or reentry or the prior assessment with no injuries. <BR/>Record review of Resident #4s Care Plan dated 01/30/2025 revealed Resident #4 was care planned for risks of falls, dx of dementia and has impaired cognition, and dx of epilepsy. Resident #4's care plan did not reflect he had falls on 12/20/2024. 01/24/2025, & 01/26/2025. <BR/>Record review or Resident #4's progress notes dated 12/20/2024, reflected Resident #4 was observed on the fall mat next to his low bed by CNA. No injuries noted.<BR/>Record review of Resident #4's progress noted dated 01/24/2025, reflected Resident #4 on floor near w/c with over bed table in his hand laying on his back on the floor, smiling. No injuries noted. <BR/>Record review of Resident #4's progress noted dated 01/26/2025, reflected Resident #4 on knees beside bed. Assisted back to bed with assist of 2 staff members. No injuries noted. <BR/>Attempted to interview Resident #4 on 01/30/2025 at 1:45pm but was not successful due to his severe cognitive impairment. <BR/>During an interview with the DON on 01/30/2025 at 3:50pm, the DON stated that Resident #4's care plan should have been updated to reflect his most recent falls. The DON stated if a resident's care plan was updated then the resident might not be getting the most efficient care. <BR/>During an interview with the RCN on 01/30/2025 at 4:00pm, the RCN stated that Resident #4's care plan should have been updated after each fall. The RCN stated that a care plan needs to be updated so the additional intervention could be added to prevent the resident from falling. The RCN stated the facility currently doesn't have a MDS coordinator so it's the IDT's responsibility to update a resident's care plan. The RCN stated if a resident's care is not updated after a fall the resident would not be receiving the highest level of care. <BR/>A record review of the facility's Comprehensive Care Planning policy, not dated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but not limited to resident [NAME] records, baseline care plans, and task listings. <BR/>The comprehensive care plan will describe the following-<BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;<BR/>Comprehensive Care Plans <BR/>A comprehensive Care Plan will be -<BR/>The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions <BR/>

Based on observation, interview, and record review the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for five of six residents (confidential residents) reviewed for grievances.<BR/>The facility failed to post the grievance procedure in a prominent and accessible locations throughout the facility; provide residents with access to grievance forms, and instruction on how to file an anonymous grievance.<BR/>This failure could place residents at risk by limiting their access to the grievance process, which may result on unresolved concerns that impact their well-being and overall quality of care.<BR/>Findings include:<BR/>Observation on June 4, 2025, at 10:38 AM, revealed the facility's grievance procedure posted in the first hallway near the front entrance. The notice was affixed approximately nine feet above the floor, which made it difficult to read. The height rendered it inaccessible to residents who use wheelchairs or those who were shorter in height, and it was not positioned in a way that supported easy viewing by all residents, resident's representatives, staff, or visitors. A walkthrough of other hallways and common areas revealed one additional posting located at the station 2 nurse's station. The posting was positioned on the wall behind the nurse's station desk, in a small area not accessible to residents. Due to the confined space and placement behind staff work areas, residents would not be able to view or access the information independently.<BR/>During a confidential resident interview five of six residents stated they had not received information regarding the process for filing grievances or concerns within the facility. The residents reported they were unaware of their right to formally voice concerns or complaints and did not know who to contact or where to find grievance forms or related resources.<BR/>An interview was conducted with the ADM on June 4, 2025 at 3:43 PM, the ADM stated residents were provided information regarding the grievance process and how to file grievances by the facility conducting daily Champion Rounds, during which department managers were assigned to check in with different residents to ask how they were doing and if they had any concerns. She also stated grievance information was included in the admission packet and added, Hopefully it's posted on the open board. The ADM was then led to the open board in the front entry hallway. She experienced some difficulty locating the grievance posting. The state surveyor pointed it out and asked if she believed the posting was accessible to residents or family members, considering its high placement on the wall. The ADM responded the posting needs to be brought down to be more accessible. The ADM was also shown the second grievance posting located behind Nurse's Station #2. When asked if this posting was accessible to residents, she stated, That is mostly for the nurses to have the information to provide if a family member asks how to file. She would work on making the grievance signs more available to residents and families.<BR/>Record review of the facility's Grievance Policy dated November 2, 2016, reflected, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal .The facility will notify residents on how to file a grievance orally, in writing, or anonymously with postings in prominent locations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 5 of 10 residents (Resident #3, Resident #4, Resident #20, Resident #46, and Resident #61) reviewed for ADL's. <BR/>A) The facility failed to ensure assistance was provided for repositioning and incontinent care every 2 hours for Resident #4, and Resident #20. <BR/>B) The facility failed to ensure Resident #3, Resident # 46 and Resident #61's nails were cleaned.<BR/>These failures placed residents at risk for a decline in health, skin breakdown, loss of self-esteem, and a diminished quality of life and could result in health-related issues from lack of hygiene. <BR/>Findings Included:<BR/>A) Review of Resident #4's face sheet dated 05/07/2024 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Acute Kidney Failure (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue.), Hemiplegia (Hemiplegia is a symptom that involves one-sided paralysis) and Diabetes Mellitus Type II (A condition results from insufficient production of insulin, causing high blood sugar).<BR/>Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 was assessed to not have a BIMS score conducted indicating severe cognitive impairment. Resident #4 was assessed to have functional limitations in range of motion for both upper and lower extremities. Resident #4 was assessed to be dependent on staff for all ADLs and was assessed to be incontinent of bowel and bladder.<BR/>Review of Resident #4's comprehensive care plan reflected a focus area dated 02/23/2021 Resident #4 is incontinent of bowel and bladder. Interventions included incontinent care at least every 2 hours and apply moisture barrier after each episode .<BR/>Observations of Resident #4 on 05/07/2024 hourly from 8:00 AM till 3:35 PM revealed Resident #4 was in her room in her Geri chair (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl) in the same position sitting upright on her coccyx.<BR/>In an interview on 05/07/2024 at 3:20 PM, CNA E stated she had not done incontinent care for Resident #4 since she had gotten her up around 8:00 AM or 8:30 AM due to needing help to transfer them. When asked if she had asked for help CNA E stated she did not. When asked why she shrugged her shoulders.<BR/>Observation on 05/07/2024 at 3:40 PM, revealed CNA F and CNA E in Resident #4's room to put her to bed. The CNAs using the Hoyer lift placed her in bed. Resident #4 was observed to have saturated pants with a strong urine odor. The CNAs removed her pants to reveal a saturated brief with a foul odor. Peri care was provided to Resident #4. The CNAs turned Resident #4 on her side to reveal no redness or skin breakdown. <BR/>Review of Resident #20's face sheet dated 05/07/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Multiple sclerosis (A disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body.), and hemiplegia and hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body).<BR/>Review of Resident #20's Quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 7 indicating severe cognitive impairment. Resident #20 was assessed to be dependent on staff for ADLs. Resident #20 was assessed to have impairment in ROM on one side for her upper extremities and both sides for her lower extremities. Resident #20 was further assessed to be incontinent of bowl and bladder. <BR/>Review of Resident #20's comprehensive care plan reflected a focus area dated 10/14/2021 and revised on 07/26/2023 Resident #20 has hemiplegia/ hemiparesis. Interventions included reposition at least every 2 hours. Further review reflected a focus area dated 10/14/2021 and revised on 07/26/2023 Resident #20 is incontinent of bowl and bladder. Interventions did not include incontinent care every 2 hours. <BR/>In an interview on 05/07/2024 at 3:20 PM, CNA E stated she had not done incontinent care for Resident #20 since she had gotten her up around 8:00 AM or 8:30 AM due to needing help to transfer them. When asked if she had asked for help CNA E stated she did not. When asked why she shrugged her shoulders.<BR/>Observation on 05/07/2024 at 3:45 PM, revealed CNA F and CNA E in Resident #20's room to put her to bed. The CNA's using the Hoyer lift placed her in bed. Resident #4 was observed to have saturated pants with a strong urine odor. The CNA's removed her pant to reveal a saturated brief with a foul odor. Peri care was provided to Resident #20. The CNA's turned Resident #20 on her side to reveal no redness or skin breakdown. <BR/>In an interview on 05/08/2024 at 2:13 PM, the DON stated she expected staff to check on residents every two hours and do position changes and incontinent care if needed. She stated CNA E should have asked for help and did not know why she did not. The DON stated she expected the nursing staff to make rounds as well to ensure the CNAs are doing their jobs. She stated failure to do so could cause skin breakdown. <BR/>Review of the facility' policy Perineal care dated 04/27/2022 reflected An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible . Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. One form of early skin breakdown is maceration or the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes soggy texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations. Skin erosion is the loss of some or all of the epidermis (comparable to a deep chemical peel), leaving a slightly depressed area of skin. Because frequent washing with soap and water can dry the skin, the use of a perineal rinse may be indicated. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition .<BR/>B) Record review of Resident # 3's Face Sheet dated, 05/08/2024, reflected an [AGE] year-old admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia, unspecified affecting right nondominant side (the loss of muscle function on the right side of the body due to tissue damage to the brain or spinal cord), lack of coordination ( uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), and muscle weakness ( when full effort does not produce a normal muscle contraction or movement). <BR/>Record review of Resident #3's annual MDS Assessment, dated, 01/22/2024, reflected resident had a BIMS score of 10 which indicated the resident's cognition was moderately impaired. Resident #3 did not refuse care. He required assistance with ADLs from staff such as personal hygiene, dressing, toileting, showers/ bathing, and transfers. <BR/>Record review of Resident #3's Comprehensive Care Plan, dated 04/03/2024, reflected Resident #3 had an ADL self-care performance deficit related to limited range of motion. Intervention: Resident #3 required extensive assistance of one staff with personal hygiene. <BR/>Observation on 05/06/2024 at 7:17 AM, Resident # 3 was lying in bed. There was a thick black substance underneath all fingernails on his left hand and underneath the nails on his middle finger and fore finger on his right hand. <BR/>Interview on 05/06/2024 at 7:20 AM Resident #3 stated he asked someone to clean his nails few days ago and the person stated they would come back and clean his nails. He stated no one had offered to clean them and he had not asked anyone else. He stated he did not recall the person's name or what date he requested his nails to be cleaned. <BR/>Observation and interview on 05/08/2024 at 10:50 AM, Resident #3 had blackish substance underneath all of his nails on his right hand. Resident #3 stated he asked someone to clean his nails a few days ago and the person said they would come back and clean his nails. He stated no one had cleaned his nails after he asked someone to do it for him. Resident #3 stated he did not know the person's name. <BR/>Record review of Resident #46's Face Sheet dated, 05/08/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of lymphedema, not elsewhere classified (swelling in the body's tissues), major depressive disorder, single episode, unspecified ( is used when the symptoms of depression cause significant distress or impairment in social, occupational, or other important areas of functioning but do not meet the full criteria for any of the depressive disorder diagnoses - Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your normal daily activity), and unspecified dementia, and unspecified severity, with psychotic disturbance (a mild cognitive impairment has yet to be diagnosed with behaviors).<BR/>Record review of Resident #46's Quarterly MDS Assessment, dated on 04/13/2024 reflected Resident #46 had a BIMS score of 10 which indicated the resident's cognition was moderately impaired. Resident #46 did not reject care. She was also assessed to require assistance from staff with ADLs such as: personal hygiene, dressing, bathing, toileting, chair to bed/ bed to chair transfers, toilet transfers, and shower transfers. <BR/>Record review of Resident #46's Comprehensive Care Plan, dated 04/20/2024, reflected Resident #46 was at risk for falls. She had an ADL self-care performance deficit. Intervention: Hygiene resident is able to rinse and spit, brush teeth and partials (does not mention other hygiene in the care plan). <BR/>Observation on 05/06/2024 at 9:02 AM, Resident # 46 was in her room sitting in the recliner. There was a black hard substance underneath her ring finger, and middle fingernails on her left hand. She also had blackish substance underneath her middle finger, ring finger and fore fingernails on her right hand. <BR/>Observation on 05/08/2024 at 10:21 AM, Resident #46 was lying in bed. There was black hard substance underneath her ring finger, and middle fingernails on her left hand. She also had blackish substance underneath her middle finger, ring finger and forefinger nails on her right hand. <BR/>Record review of Resident # 61's Face Sheet dated, 05/08/2024, reflected a 60- year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of mandibulofacial dysostosis ( a rare syndrome characterized by underdeveloped factional bones and a very small lower jaw and chin), unspecified visual loss ( vision that cannot be corrected with glasses or contact lenses), and deaf nonspeaking, not elsewhere classified (unable to hear or speak).<BR/>Record review of Resident #61's Quarterly MDS Assessment, dated 04/14/2024 reflected Resident #61 rarely/never understood others. Her cognitive assessment was completed by staff. She was assessed to have poor short-and long-term memory recall and her decision-making ability was severely impaired. Resident #61 did not have any behavior problems such as rejection of care. Resident # 61 required assistance with ADLs such as: personal hygiene, dressing, eating, toileting, and showers.<BR/>Record review of Resident #61's Comprehensive Care Plan, revised on 05/06/2024, reflected Resident #61 had impaired visual function. She was legally blind in both eyes. Resident #61 had communication problem related to being deaf and non-verbal. Intervention: anticipate and meet needs. Resident #61 also had an ADL self-care performance deficit. Intervention: Resident #61 required extensive assistance with personal hygiene. <BR/>Observation on 05/06/2024 at 9:19 AM, revealed Resident # 61 was standing in the hallway. She held her hands in front of her. Resident #63 had blackish substance underneath her middle finger, ring finger and forefinger nails on her right hand. Resident was not interviewable. <BR/>In an interview on 05/08/2024 at 9:15 AM, LVN C stated the nurses and CNAs were responsible for nail care. She stated the nurses were responsible to clean all resident's nails with a diagnosis of diabetes. LVN C stated it was the CNA's responsibility to clean all other residents' nails. She stated the nurses' made rounds and checked residents, with diabetic nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated the blackish/ brownish substance possibility may had feces or any type of bacteria underneath the resident's nails. LVN C stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated. She also stated she had been in- serviced on nail care and infection control. She stated she was not aware of Resident #3, Resident #61 or Resident #46 refusing nail care.<BR/>In an interview on 05/08/2024 at 08:53 AM, the ADON stated it was the nurses ( LVN or RN's) responsibility to clean residents with a diagnosis of diabetes. She stated CNAs were expected to give nail care to other residents during showers or as needed. She stated if a resident had blackish substance underneath the nails and the resident ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. The ADON stated if staff saw a blackish substance underneath a resident's nails, she expected the nails to be cleaned immediately. She stated only nurses were assigned to clean resident's nails with a diagnosis of diabetes. <BR/>In an interview on 05/08/2024 at 9:05 AM, LVN C stated the nurses and CNAs were responsible for nail care. She stated the nurses were responsible to clean all resident's nails with a diagnosis of diabetes. LVN C stated it was the CNA's responsibility to clean all other residents' nails. She stated the nurses' made rounds and checked residents, with diabetic nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated the blackish/ brownish substance possibility may had feces or any type of bacteria underneath the resident's nails. LVN C stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated. She also stated she had been in- serviced on nail care and infection control. She stated she was not aware of Resident #3, Resident #61 or Resident #46 refusing nail care.<BR/>In an interview on 05/08/2024 at 9:15 AM, CNA J stated CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually cleaned nails during showers or when needed. CNA J stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails. CNA J stated the blackish substance may be bacteria from feces underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated there was a possibility a Resident may need to be assessed at the emergency room if they became severely ill. CNA J stated she gave care to Resident # 3, Resident #46 and Resident #61 and she was not aware of any refusal of nail care from any of these residents. <BR/>In an interview on 05/09/2024 at 9:30 AM, the Administrator stated the CNAs was responsible for nail care during the residents' showers and as needed except for residents with diagnosis of diabetes. She stated the nurses performed all fingernail care for the diabetic residents. The Administrator also stated if a resident swallowed any type of blackish substance and it was determined to be bacteria, there was a potential a resident may become ill with a stomach infection. She also stated the resident may have symptoms of diarrhea and possible dehydration.<BR/>Record review of the facility's policy on Nail Care, dated 2003, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nail care will be performed regularly and safely. The resident will free from abnormal nail conditions. The resident will be free from infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 14 residents (Residents #1 and 2) reviewed for quality of care. <BR/>The facility failed to ensure TLVN and LVN C assessed and reported a new new skin injury to Resident #1's first two toes of the right foot and a new skin injury to Resident #'s first and fifth toes of the right foot. <BR/>An Immediate Jeopardy (IJ) situation was identified on 03/06/24. While the IJ was removed on 03/08/24 at 03:00 PM., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure placed residents at risk of new or worsening pressure ulcers.<BR/>Findings included:<BR/>1. Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses of quadriplegia (paralysis of all four limbs), type two diabetes mellitus with diabetic polyneuropathy (nerve damage causing weakness, numbness, and/or tingling), and history of transient ischemic attack and cerebral infarction (stroke).<BR/>Review of the Discharge MDS for Resident #1, dated 02/18/24, reflected she could not participate in the brief interview for mental status. The section for Functional Status reflected in the activities of rolling left to right and transfer from chair to bed that she was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The section related to Skin Conditions reflected she did not have any unhealed pressure ulcers.<BR/>Review of the care plan for Resident #1, dated 02/17/24, reflected the following: Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. It also reflected the following: The resident has a pressure ulcer or potential for pressure ulcer development: The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Monitor nutritional status. Serve diet as ordered, monitor intake and record.<BR/>Review of the initial skin assessment for Resident #1, dated 02/08/24, and completed by the LVN C, reflected she had no skin issues noted. <BR/>Review of the weekly skin assessment for Resident #1, dated 02/14/24, and completed by LVN C, reflected she had no skin issues noted. <BR/>Review of the Braden Scale for Predicting Pressure Sore Risk, dated 02/08/24, and completed by the TLVN, reflected she had a score of 7, which indicated a severe risk for pressure ulcers.<BR/>Review of physician's orders for Resident #1, on 03/05/24, reflected there were no orders related to prevention of pressure ulcers. <BR/>Review of the skin observation tool in the CNA documentation portal for Resident #1, dated 02/16/24, reflected a new skin tear on the buttocks and discoloration on the left lower foot, documented by CNA A. <BR/>Review and observation of hospital records for Resident #1, dated 02/18/24, reflected a photograph, taken on 02/18/24 at 09:11 PM, of her right anterior foot showing a red discoloration of the first and second toes. The first toe also had a partial thickness opening in the center of the reddened area that had a yellow tint.<BR/>An attempt was made on 03/06/24 at 08:30 AM at the hospital to identify and interview the nurse who took the photograph of wounds on Resident #1's foot on 02/18/24, was unsuccessful. An attempt was made to interview the hospital physician who saw Resident #1 in the ER on [DATE], but the hospital administrator would not provide direct contact information for him. <BR/>During an interview on 03/06/24 at 09:58 AM, LVN C stated her process for conducting a skin assessment was during an initial skin, she looked at the resident's entire body, starting at their neck, to go down their legs to their feet and looked at their heels and then turned them over to look at their front, under the breasts, and in the perineal area. LVN C stated she looked between their toes and fingers, as well. LVN C stated when she conducted the initial skin assessment for a new resident, she did not know who cared for the resident or what state their skin might have been in, so she checked very carefully. LVN C stated the toes and feet were important during skin checks due to them being areas vulnerable to injury and skin breakdown. LVN C stated she conducted the initial skin assessment for Resident #1 on 02/08/24 and the weekly skin assessment on 02/14/24. She stated she did not see any new skin issues during either procedure. LVN C stated she had gotten Resident #1 dressed on the morning of 02/18/24 when she was sent to the hospital, and LVN C had not seen any marks or skin issues on Resident #1's legs or feet. LVN C stated she did not know what anyone was talking about when they asked her about wounds on Resident #1's feet. LVN C stated if she thought she would have seen any marks on Resident #1 especially if they were on the front, because she helped her dress. LVN C stated Resident #1 required total assistance with all of her activities of daily living, so they had a large amount of observation of and contact with her body. <BR/>During an interview on 03/06/24 at 11:40 AM, CNA A stated she and her coworker, CNA B, showered Resident #1 on 02/16/24 and noticed a scratch under her right buttock, a blister on her big toe, and redness on both her big toe and her second toe. CNA A stated she and CNA B reported the skin changes to LVN C that day. CNA A stated she cared for Resident #1 while she was in the facility, and Resident #1 sat mostly in her chair and only got in bed at night. CNA A stated Resident #1 seemed uncomfortable in her chair, but the resident's FM had insisted she be placed in her chair during the day. CNA A stated she and her colleagues floated Resident #1's heels while she was in bed, but in the chair, they could not float her heels. CNA A stated was taught to place wheelchair leg rests at a 45 degree angle when the resident did not use them, but CNA A noticed Resident #1's feet, which were very contracted so the toes almost faced downward, would graze the foot rests sometimes on the tops of her toes. CNA A stated she and CNA B removed the footrests while Resident #1 was at rest in her chair and not being moved so her feet would not hit the footrests. CNA A stated she thought it was possible the wounds on Resident #1's right foot had occurred that way. CNA A stated after Resident #1's shower on 02/16/24, she and CNA B took Resident #1 to the dining room for her meal, and they stopped and showed the new wounds on her right foot to LVN C. CNA A stated she also documented the wounds in the CNA documentation portal. She stated the notations in the Skin Observation tool for 02/16/24 referred to the new wounds she saw on Resident #1's right foot. <BR/>During an interview on 03/06/24 at 11:50 AM, CNA B stated on 02/16/24, which was a Friday, she and her coworker CNA A showered Resident #1 and saw marks on her. CNA B stated that day she saw a water blister on her big toe and a red mark on the next toe where the bone was. CNA B stated the injuries might have been from the footrest on the wheelchair, but she was not sure how they occurred, because the FM would not let Resident #1 stay in bed during the day. CNA B stated the day they discovered the wounds on Resident #1's toe, they were bringing her to lunch, and LVN C was sitting at the second nurse's station. CNA B stated they showed the toe wounds to LVN C. CNA B stated she did not remember LVN C being distracted or talking on the phone or to anyone else at the nurse's station. CNA B stated she thought the TLVN was sitting at the nurse's station with LVN C. CNA B stated CNA A did most of the documentation for Resident #1, but CNA B was pretty sure the new skin problems were documented in the skin observation tool by CNA A. CNA B stated they showed LVN C the toe wounds and told her about the scratch under Resident #1's buttock. <BR/>Review of the, undated, face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia, cerebral vascular disease (a condition that affects blood flow to the brain), type two diabetes mellitus, and hemiplegia affecting right dominant side (paralysis on one side of the body).<BR/>Review of the quarterly MDS for Resident #2, dated 02/24/24, reflected her cognition was too poor to take part in the brief interview for mental status. The section for Functional Status reflected in the activities of rolling left to right and transfer from chair to bed that she was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The section related to Skin Conditions reflected she was at risk of pressure ulcers but did not have any unresolved pressure ulcers. <BR/>Review of the Braden Scale for Predicting Pressure Sore Risk for Resident #2, dated 10/23/23, and completed by LVN F, reflected she had a score of 10, which indicated a high risk for pressure ulcers.<BR/>Review of the care plan for Resident #2, dated 01/17/24, reflected the following: Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Weekly skin assessments.<BR/>Review of physician's orders for Resident #2 on 03/06/24 reflected no order for treatment of any wounds on her foot. <BR/>Review of the skin observation tool for Resident #2 reflected a discoloration on the right lower leg or foot was documented on 02/14/24, 02/15/24, 02/19/24, 02/20/24, 02/24/24, 02/25/24 and 02/28/24 by CNA E. An additional documentation of a right leg or foot discoloration was documented on 02/27/24 by CNA D. <BR/>Review of the weekly skin assessment for Resident #2, dated 02/26/24, and completed by the TLVN, reflected the following notes 2x1cm open area to left shin below knee, no drainage noted, skin-prep applied; 4x2cm open area to left leg, no drainage noted, skin-prep applied and LUQ Peg tube. The answers to the following questions Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete The Ulcer Assessment and Are there any new areas that have not been communicated to the physician/NP or family? was marked as No. As of 03/06/24, this was the most recent skin assessment. <BR/>Review of wound physician progress notes, dated 03/06/24, reflected Resident #2 received wound care and assessment for a non-pressure wound of the left leg- full thickness. It also reflected the following: Chief Complaint Patient has wounds on her left leg; left shin. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. She has condition(s) as listed above. Details about current wound(s) and any skin<BR/>conditions are outlined below. There is no indication of pain associated with this condition. There was no mention of any wound on the toes of her right foot. <BR/>Record review of the most recent podiatry progress note for Resident #2, dated 01/10/24, reflected no skin issues on either foot. The podiatrist marked the resident had diabetes and peripheral vascular disease.<BR/>During observation on 03/06/24 at 12:10 PM, CNA D removed Resident #2's socks and shoes to observe Resident #2's feet. The fifth (pinky) toe of Resident #2's foot had black tissue covering the entire toe, and her first (big) toe was black surrounding the proximal nail fold (part of the nail bed closet to the rest of the foot and ankle) and a portion of the skin around the distal nail plate (part of the nail bed farthest away from the rest of the foot and ankle). <BR/>During an interview on 03/06/24 at 12:10 PM, CNA D stated the wounds on Resident #2's feet were very black, and they were there for several months. CNA D stated she had not seen Resident #2 receive any treatment for the injuries on her right toes. CNA D stated she had not been the person to initially report the injuries to a charge nurse, but she had documented the injuries on the Skin Observation tool. CNA D stated she did not know who discovered the injuries, but she thought they were well known, because the CNAs were documenting them in the Skin Observation for quite some time. <BR/>During observation and an interview on 03/06/24 at 12:30 PM, the DON observed the injuries on Resident #2's right toes. The DON touched the injuries on Resident #2's fifth toe and watched the resident's reaction. Resident #2 did not wince or exhibit any other sign of pain. The DON stated the black area on the pinky toe was hard like a scab. She stated the injuries should not necessarily have been documented in a weekly skin assessment because they were not open areas but instead were scabbed. <BR/>During an interview on 03/06/24 at 12:56 PM, the MD stated he expected a resident with Resident #1's clinical condition would develop pressure ulcers given the protein status, poor immunity and immobility. He stated the important thing was for new wounds to be identified and treated so they did not worsen. The MD stated he was not aware of any wounds that had developed on Resident #1 during her stay in the facility. The MD stated he expected to be notified of new skin conditions. He stated he could not say how a wound like the one Resident #1 had could worsen over a two-day period without being addressed, but any medical diagnosis needed intervention as early as possible. The MD stated he did look at residents' feet normally when he did an exam or an assessment. The MD stated Resident #1 was only in the facility for ten days, and he had not done an in-person exam with her. The MD stated he was not aware of any black wounds on Resident #2's feet. The MD stated he did not have his computer and could not say exactly when the last time he performed a physical exam with Resident #2, but she did not have any wounds on her feet at that time. The MD stated most of her skin assessments were being done by the WCD. The MD stated once wound care was involved with a resident, it was a professional courtesy to defer to the WCD for decision-making. <BR/>An attempt was made on 03/06/24 at 01:12 PM to interview the POD by telephone. A voicemail was left on the clinic's main phone line.<BR/>An attempt was made on 03/06/24 at 01:14 PM to interview CNA E about Resident #2's skin observations. A voicemail was left.<BR/>During an interview on 03/06/24 at 01:44 PM, the WCD stated he saw Resident #2 earlier that day. He stated they did not conduct a full skin assessment. The WCD stated Resident #2 had a wound on her shin that he was treating. The WCD stated he did not think he saw her feet recently and was sure he did not see her feet that day. The WCD stated he saw Resident #2 on and off for pressure ulcers and skin tears. The WCD stated no one from the facility reported any new skin issue to him on Resident #2. The WCD looked at a photograph of Resident #2's toe wounds taken by the State Surveyor, and he stated he could not diagnose from a photograph, but the wound on her fifth toe looked like it was probably a pressure or arterial wound. The WCD stated the treatment for that type of wound would like be Betadine or something similar. He stated the rest of her foot looked healthy, and he was not very aggressive with debriding so he would probably only monitor and treat with Betadine. <BR/>During an interview on 03/06/24 at 02:16 PM, the TLVN stated her protocol when she saw a wound like the ones on Resident #2's toes was to refer to the physician, the wound care surgeon and notify the family. She stated she had not noticed an alert that would notify her a CNA had documented a skin observation. The TLVN stated she had not seen the wounds on Resident #2's toes prior to the State Surveyor pointing them out to her, but she had now gone to look at the wounds, and she thought they might be purpura (a condition of red or purple discolored spots on the skin that do not blanch on applying pressure). The TLVN stated she did not see the wounds a few weeks ago. The TLVN stated she would not document something like that on the weekly skin assessment, because it was a scab. The TLVN stated the wound was a closed wound and had never been opened and had not bled and was not from trauma, so it did not quality as a wound to be documented on the weekly skin assessments. The TLVN stated the wound might have been a pressure or arterial ulcer, and she would have documented a pressure or arterial ulcer on the skin assessment. The TLVN stated she was not qualified to diagnose a wound and only the physician could diagnose. The TLVN stated she should have reported the wound to the nurse management team and the physician. She could not or would not say why she did not do so and stated she was very nervous. The TLVN stated potential negative outcomes of not addressing a skin issue immediately were infection and ultimately, amputation.<BR/>During an interview on 03/06/24 at 03:20 PM, the DON stated she monitored for new wound and skin conditions by discussing any new issues with the IDT and communicating frequently. The DON stated CNAs communicated new skin observations in the point of care documentation system, an alert showed up on the EMR dashboard, and the IDT pulled the records describing the new skin issue every shift. The DON stated the people responsible for noticing the alerts on the EMR were her, the ADON, the TLVN, and the charge nurses. She stated the CNAs were instructed to document in the EMR instead of relying on a verbal notification of a new skin issue. The DON stated she was mistaken when she stated the wound on Resident #2's fifth toe had not needed to be documented on the weekly skin assessments. The DON stated she called the MD when she learned of the wound on Resident #2's toe, and he ordered a venous doppler (a special ultrasound technique that evaluates blood as it flowed through a blood vessel) to ensure the toes were still receiving blood flow. The DON stated the wound could have been a blood blister that progressed. The DON stated she did not know why nobody noticed the alerts that should have triggered when CNAs entered skin observations for Residents #1 and #2. She stated she was still investigating why the failure occurred. The DON stated if the wounds were on Resident #2's foot for months as CNA D reported they were, then the TLVN should have seen them during previous skin assessments. The DON stated the fact the TLVN did not notice the wounds was concerning. The DON stated a potential outcome of the failures was the wounds would tend to get worse, because the body might not self-heal without medical intervention.<BR/>During an interview on 03/06/24 at 04:30 PM, the ADM stated she monitored for compliance with the skin program in the facility by discussing issues in care plan meetings and their morning meetings. The ADM stated she was notified of the unidentified wounds on Resident #2's foot. The ADM stated she had also been made aware Resident #1 had something on her foot that she thought was a blister and CNAs had documented the area but LVN C had not followed up on the wound before Resident #1 was sent to the hospital. The ADM stated Resident #1 had not returned to the facility. <BR/>The ADM stated the process for identifying new skin issues was the CNAs put the skin observation into the EMR, and it alerted for anyone to see on the EMR dashboard. The ADM stated the TLVN had access to the same information as the rest of the team, and the ADM did not know why the TLVN did not follow up on reports of either Resident #1's or Resident #2's wounds. The ADM stated a potential negative outcome of the failure was a worsening of wounds, but particularly for someone with Resident #2's clinical condition, a wound on her foot had the potential to become a major issue where it would be detrimental, possibly causing sepsis. <BR/>Review of facility policy, dated 08/12/16, and titled Pressure Injury: Prevention, Assessment and Treatment reflected the following: <BR/>Procedure:<BR/>1. <BR/>Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation and prevent, breakdown, injury, and infection.<BR/>2. <BR/>Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission, and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sores is indicated and notify the treatment nurse/design of any potential problems.<BR/>3. <BR/>Assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will:<BR/>1. Notify the physician of sore and obtain any follow any orders as directed by the physician.<BR/>2. Notify family and dietary department. Document Notification. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/06/24 at 5:00 PM. The ADM was notified . The ADM was provided with the IJ template on 03/06/24 at 05:05 PM.<BR/>The following Plan of Removal submitted by the facility was accepted on 03/07/24 at 05:30 PM: <BR/>[The facility]<BR/>Plan of Removal: 3/6/24 <BR/>On 3/5/2024 an abbreviated survey was initiated at [the facility]. 3/6/2024 the surveyor provided an Immediate Threat (I) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety.<BR/>F686 The facility failed to prevent pressure ulcers and ensure residents did not develop pressure ulcers. All residents had the potential to be affected by the deficient practice. Head to toe assessments were completed on all residents in the facility to ensure no other residents were identified. <BR/>Interventions:<BR/>Resident #1 no longer resides in the facility as of 3/6/24. <BR/>The MD was notified by the DON for resident #2 on 3/6/24. Treatment orders are in place.<BR/>All residents in the facility received a head-to-toe skin assessment by the DON/ADON/Tx Nurse. Assessments will be completed 3/6/24. No new skin issues were identified. <BR/>A 1:1 in-service was completed by the Regional Compliance Nurse with the DON/ADON/Tx Nurse on the policy for Pressure Prevention and the Completion of Skin Assessments. Completed 3/6/24. The Regional Compliance Nurse is a part of the corporate structure. <BR/>The DON /designee will review the EMR dashboard daily and throughout shifts for clinical alerts pertaining to skin issues that are documented to ensure that all skin issues have been addressed by a nurse. This will start 3/6/24 and continue indefinitely. <BR/>The DON or ADON will conduct skin rounds weekly with the treatment nurse to ensure skin issues are identified, MD/family notified, and a treatment is ordered. This will start 3/6/24 and continue indefinitely. <BR/>The Medical Director was notified of the immediate jeopardy situation on 3/6/24. <BR/>An ADHOC QAPI meeting was conducted on 3/6/24 to include the IDT Team to discuss the immediate jeopardy and subsequent plan of removal. <BR/>Identification:<BR/>All residents residing in the facility received a head-to-toe assessment by the DON/ADON and treatment nurse. No new skin issues were identified on 3/6/2024.<BR/>In-services:<BR/>All direct care staff were in-serviced on the following topics below on 3/6/24 by the DON/ADON. All staff not present for in-servicing will not be allowed to resume their scheduled assignment until in-serviced. All new hired staff will be in-serviced during facility orientation. All agency staff will be in-serviced prior to start of their shift. Verification of comprehension will be made through a post test for topics in-serviced on.<BR/>o <BR/>Pressure Prevention Policy <BR/>o <BR/>Completing Skin Assessments <BR/>o <BR/>Notification of change in condition to the charge nurse and DON including new skin issues. <BR/>Monitoring of the Plan of Removal included the following: <BR/>Review of physician's orders for Resident #2 on 03/06/24 reflected an order had been entered for Bilateral Arterial legs Ultrasound Verbal Active 03/08/2024 ultrasound of both legs. Cleanse Right 5th toe Wound W/WC or NS, Pat Dry, Apply Betadine 3xwk every 12 hours as needed for R 5th Toe Wound Phone Active 03/06/2024, 03/06/2024 Cleanse Right 5th toe Wound W/WC or NS, Pat Dry, Apply Betadine 3xwk one time a day every Mon, Wed, Fri for right 5th toe wound.<BR/>Review of the March 2024 TAR for Resident #2 reflected Betadine was administered to her right toes by the TLVN on 03/06/24 and 03/08/24.<BR/>Review of skin assessments for Residents #3-#7 and #9-#21 conducted on 03/06/24 and 03/07/24 reflected no new skin issues identified. <BR/>Review of the weekly skin assessment tool for Resident #8 completed on 03/08/24 reflected the following: Red flat rash to back; skin intact; TX PRN.<BR/>28/24<BR/>Review of physician orders for Resident #8 reflected the following with a start date of 05/28/24: Nystatin Powder 100000 UNIT/GM. Apply to affected area topically as needed for rash twice daily. <BR/>Review of the March 2024 TAR for Resident #8 reflected Nystatin powder was administered to her back on 03/08/24 at 01:35 PM. <BR/>Review of in-services conducted one-to-one with the TLVN, ADON, and DON reflected they had each signed the following in-service on 03/06/24: Pressure prevention, injury, completion of skin assessment, and treatment weekly and with changes in skin integrity.<BR/>Review of an in-service conducted by the DON on 03/06/24 reflected the following content: Notification of change in condition to the charge nurse and DON, including new skin issues. See attachment of policy and procedures. 39 staff members had signed the signature page of the in-service. An additional 29 staff were listed as being notified by phone on 03/06/24. <BR/>During an interview on 03/08/24 at 08:40 AM, the ADM stated education of staff was ongoing. She stated the staff in the facility today were in-serviced by phone and were to be tested on their knowledge today. She stated copies of in-service education and the staff who completed it were ready. She stated she was re-educated by the RCN to monitor the nursing for compliance with the plan and program. <BR/>During an interview on 03/08/24 at 09:05 AM, LVN F stated she completed in-service education in ANE and Assessment. She stated topics included skin assessment, changes in skin, reporting, documentation and informing the ADON and DON. She stated skin assessments were documented in the computer and an incident report was to be completed and forwarded to risk management. She stated as a charge nurse she was also to initiate treatment and inform the physician and family of changes. <BR/>During an interview on 03/08/24 at 09:10 AM, MA G stated she completed in-service education and testing for ANE and Assessments. She stated she was informed she was to report any skin tears, bleeding or observed skin changes to the charge nurse and the DON. She stated as a med aide she would occasionally see a skin tear. <BR/>During an interview on 03/08/24 at 09:19 AM, the RCN stated she instructed 100 percent of staff (nurses and CNAs) on ANE and Assessment at this time. She stated changes in residents were to be reported to the Administrator and DON. She stated nurses must assess residents when a change was reported and initiate treatment. Nurses must report changes to physicians and family. She stated education did not reflect any knowledge gaps among staff, and she was unsure how the IJ occurred. She stated the facility was nearing 100 percent of staff completing the posttest knowledge check. <BR/>During an interview on 03/08/24 at 09:50 AM, RN H stated she received in-service education on ANE and skin assessments. She stated she was taught about the reporting system and reporting changes to the DON and charge nurse. She stated as a nurse she would also report changes to the physician and family. She stated skin assessments were to be completed weekly, as needed and on admission. She stated she completed a test after the in-service. <BR/>During an interview on 03/08/24 at 09:55 AM, the ADON stated she was in-serviced and tested on ANE and skin assessments. She stated any changes had to be assessed, reported to the doctor and the DON and family. She stated skin assessments were to be completed weekly and incident reports were to be filled out for changes in skin condition (such as bruises, scrapes and skin tears). She stated the nurse documented the change and entered orders for treatment from the physician. <BR/>During an interview on 03/08/24 at 10:09 AM, CNA I stated he received in-service education on ANE and assessments. He stated aides were informed any changes in skin condition must be reported to the nurse, the ADON and DON. He stated if no one responded to his report he was to report to the administrator. He stated most observations were documented in the computer but the facility also utilized shower sheets to assessed resident skin health. <BR/>During observation and an interview on 03/08/24 at 10:10 AM, Resident #19 stated he had no discomfort to his below the knee amputation site. He stated he received wound care three times a week. He stated he was taking pain medications. He was observed ambulating in his wheelchair in his room. <BR/>During an interview on 03/08/24 at 10:15 AM, CNA E stated she received in-service education on ANE and skin assessments. She stated she completed a post education test, she added they always wanted to test them. She stated she would report any skin changes to the nurse, DON or Administrator. She stated the situation was as simple as see something report something. She stated any changes had to be reported as soon as they were discovered. <BR/>Observation on 03/06/24 at 11:20 AM revealed LVN F assisted to show Resident #2's right fifth toe which revealed no drainage, skin was intact and a 1.5 cm long dark black area was present on the outside of her little toe. Resident #2 did not indicate any discomfort to the area. The tip of the toenail had been removed and a purple swollen area was seen to the inside of margin of the toenail.<BR/>During an interview on 03/06/24 at 11:20 AM, LVN F stated Resident #2 was receiving betadine lotion to the site daily per instructions from the wound care physician. <BR/>During an interview on 03/08/24 at 11:27 AM, CNA J stated she received in-service education on ANE and assessments. She stated the facility emphasized skin assessments and reporting changes to the charge nurse. She stated the DON and administrator were also to be informed. She stated she had not observed any concerns among residents she worked with at the facility. <BR/>During an interview on 03/08/24 at 11:30 AM, the TLVN stated she completed the in-service education and posttest knowledge check. She stated the ANE and skin assessment requirements were known, that she needed to check the EMR for skin alerts daily, and the DON would be rounding on wounds with her for the time being. She stated she was requested to assess the toe of Resident #2 on a Wednesday. She stated she was not aware

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one of two medication carts (RN medication cart) reviewed for medication safety. <BR/>The facility failed to ensure that a loose Tramadol pill (controlled medication) in RN Medication Cart was secured, administered, and/or disposed of based on facility policy.<BR/>The failure puts residents at risk for not receiving their prescribed medication and risk of possible drug diversion. <BR/>Findings include: <BR/>Observation of the RN Medication Cart for Station II and III on 6/4/2025 at 03:10 PM with RN A revealed one loose pill on the bottom of the drawer within the locked drawers of the medication cart. It was a small, white circular pill AN 627. Medication identified by RN A as Tramadol 50 mg. The medication was put into a cup and taken to the RCN and DON. The RCN and Traveling DON were notified of the loose medication in the cart. The RCN and Traveling DON stated that they would audit the narcotic count and interview residents receiving Tramadol and dispose of the medication per their facility's policy. The RCN stated she would start an in-service on Narcotic storage. <BR/>In an interview on 6/4/25 at 03:10 PM, RN A stated that if the residents didn't get their medication, they could have unrelieved pain. She also stated that someone could have diverted the medication since it was loose. She stated it was the responsibility of the staff, providing medications, to check their carts before administering medications. She stated that all medication counts were correct that morning. She denied any previous discrepancies with the narcotics count of any medication; including Tramadol. She stated that she would complete an incident report regarding the medication. <BR/>In a group interview with the RCN, ADON, and Traveling DON on 06/04/2025 at 04:00 PM, the RCN stated that the impact to the resident of having loose medications in the medication cart was that a resident likely did not get their pain medications, and the medication could have been diverted from the cart by staff. RCN stated that an audit was performed for the two residents in the facility prescribed that medication and the count for both residents was correct. The RCN stated that the medication could have fallen out of a medication cup during the preparation process, which would not make the count off for the records. The RCN stated that there had been no narcotic discrepancies for the facility. The Traveling DON agreed with the impact to the resident and the potential for diversion stated by the RCN. Both the RCN and DON stated that it was the nurse taking the cart over that was responsible for ensuring the count was correct, and the cart was clean. The Traveling DON stated that it was the responsibility of the ADON, Traveling DON, and RCN to audit medication carts periodically, during mock surveys, and when the RCN visits. The RCN stated that pharmacy came every other month for audits of carts and medication storage. ADON agreed it was her responsibility to audit the carts. ADON stated that she agreed with the resident outcomes stated by RCN. Traveling DON, the RCN, and ADON denied any reports from the staff stating that the narcotic count was off. Traveling DON stated that she would expect staff to bring any loose medications found in the medication carts to the Nursing administration to perform a follow up investigation. <BR/>In an interview with the ADM on 06/05/2025 at 03:09 PM, the ADM stated that her expectation regarding medication administration for nurses would be that the medication, goes in the cup. She stated that that her expectation was that the controlled medications were kept in the lock box. She stated that because the loose medication was still in a locked drawer the risk to the resident were that the resident did not receive their ordered medication.<BR/>Review of the facility's Policy for Controlled Medication- Ordering and Receipt (No Date) reflected, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law are subject to special ordering, receipt, and recording requirements in the facility, in accordance with federal and state laws and regulations.<BR/>Procedure<BR/>1. <BR/>The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws regulations in handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide or obtain from an outside source dental service to meet the needs of 1 of 4 residents (Resident #33) reviewed for dental services. <BR/>The facility did not assist Resident #33, who had missing teeth and pain when she ate , with a dental service consult.<BR/>This failure could place residents at risk of oral complications, pain, difficulty eating, and diminished quality of life.<BR/>Findings included: <BR/>Record review of Resident #33's face sheet showed a 69 -year-old woman, who was admitted on [DATE]. Diagnoses included: Parkinson's disease (neurodegenerative disorder that affects movement), Protein - calorie malnutrition (inadequate intake of food (as a source of protein, calories, and other essential nutrients). Rhabdomyolysis (muscle tissue break down ).<BR/>Record Review of Resident #33 's quarterly MDS assessment dated [DATE] , reflected a BIMS score of 10 which indicted moderately impaired cogntition. MDS section L- Oral / dental status reflected no mouth or facial pain, or discomfort or difficulty chewing.<BR/>Record review of Resident #33's Care plan revised on 05/02/2025 reflected [Resident #33] has potential for oral health<BR/>problems related to having no natural teeth. GOAL: Resident #33 will be free of infection, pain or bleeding in the<BR/>oral cavity by/through review date 07/18/2025. INTERVENTION:Administer medications as ordered. Monitor for side effects and effectiveness and document as needed. Coordinate arrangements for dental care, transportation as needed/as ordered. Monitor/document/report to MD PRN s/sx of oral/dental problems needing attention:<BR/>Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions.<BR/>Review of Resident #33 's care plan conference dated 01/14/2025 reflected there was no dental consult. <BR/>Record review of Resident #33's Physician order dated 12/30/2024 reflected a regular textured diet and dental consult as needed. <BR/>Review of Resident #33's progress notes from 12/31/2024 to 06/04/2025 reflected no notes regarding dental exam. <BR/>Interview and observation on 06/03/2025 at 12:45 p.m. with Resident #33 revealed her sitting up in her hospital bed and attempting to eat steak with gravy, baked potato, and broccoli. She stated the bake potato was easier for her to chew because it was soft. She stated she like steak was delicious , but it was difficult for her to eat because she was missing teeth, and she did not want to choke. She stated some food that are hard in texture, cause her teeth to hurt when she chews. She stated she did not want to complain and try to do the best she can when eating. She stated she had not seen a dentist in 3 years and since her stay at the facility she had not seen a dentist. <BR/>Interview on 06/04/2025 at 04:32 p.m. with the Social Service Worker revealed she reviewed her dental referral records and did not know why Resident # 33 was not seen by a Dentist since her admission on [DATE]. She stated they used a mobile dentist for routine dental care, and they called their mobile dentistry unless the resident or family request to see an outside dentist and they would provide transportation. She stated she was not sure why Resident # 33 had not had a dental consult, but she would ensure she was seen . She stated the mobile dental service come to the facility every 3-6 months or during emergency visits .She stated when there was a new admission, she , the business office manager, or nursing will add the resident to a list to see the dentist. She stated dental care was usually care planned and the CNAs would review the care plan to ensure dental care was provided, and if there was a concern, they would report it to floor nurse. <BR/>In an interview on 06/05/2025 at 11:46 a.m. with CNA A , he stated if a resident had dental problems, he would let their nurse know. CNA A denied Resident # 33 complaining to him about dental pain or concerns.<BR/>In an interview on 06/05/2025 at 12:52 PM, LVN A stated that if she received a report of concerns with mouth or teeth, she would have assessed the resident, report to the MD, let the social worker know, and ask the social worker to make an appointment. LVN A stated it was important to have dental concerns addressed because a resident may not have brushed their teeth well or could have an infection, and they may have needed to be evaluated for concerns with their teeth. <BR/>In an interview on 06/05/2025 at 1:00 p.m. with the ADON, she said Social Services should have referred Resident #33 or any resident to dentistry by the nurse. She stated each department was responsible or completing assessment upon admission and the nurse was responsible for dental .She stated the nurse would send the referral to Social Services and they would ensure the resident was scheduled to see the Dentist. She stated Social Services was responsible for reaching out to the family and Resident, and make them aware of their dentist appointment or find if they would prefer to see Dentist of their choice. She stated possible consequences of a Resident not receiving dental care could lead to decrease in quality of life, and they would not be able to enjoy food. She stated there could be nutritional concerns related to weight lost and food preparation could be provided incorrectly.<BR/>In an interview with the DON on 06/05/2025 at 2:05 p.m., she said Social Services was responsible for scheduling dentist consults after the nurse completed their assessment for the IDT care plan meeting . She stated the nurses should always communicate the need for dental services to Social Services. She stated, in most cases, dental consults are standing orders, and if there was a dental issue or emergency, they would call their mobile dentist to come in and review Resident, or the Resident and family could choose to see an outside dentist of their choice. She stated social services sends the resident's face sheet and physician orders with residents. and the facility would provide transportation . She stated she would expect the Resident's needs to be met. She stated if dental was not provided to a Resident, they could develop an infection and have a need for dentures to increase their quality of life. <BR/>An interview on 06/05/2025 at 2:15 p.m. , the ADM stated social services was responsible for dental appointments. The ADM stated they have a mobile dental contract, and if a resident needed emergency services, an appointment was scheduled as well as routine dental care. The ADM stated the resident can choose to see the provider who came to the facility or in the community. The ADM stated if it was routine, a referral would be sent to the provider and the provider would provide the facility a date of when they would be at the facility next. She stated the consequences of not receiving routine dental care could lead to weight loss and malnutrition from not eating. <BR/> Record review of the facility's Dental Services policy unknown month and day , 2003 reflected , Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation: <BR/>1. Oral health services are available to meet the resident's needs.<BR/>2.Routine and emergency dental services are provided to our residents through: A contract agreement with a local dentist;<BR/>Referral to the resident's personal dentist; Referral to community dentists; or Referral to other health care organizations that provide dental services. 3.The Director of Nursing Services, or his/her designee, was responsible for notifying Social<BR/>Services of a resident's need for dental services. 4.Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary. 5.For Medicare and private pay residents, the facility was responsible for having the services available, but may bill an additional charge for the services.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation.<BR/>The facility failed to ensure food that was prepped was labeled and dated.<BR/>The facility failed to maintain proper temperatures of food before putting on the steam table.<BR/>This failure placed residents at risk of foodborne illness.<BR/>Findings included:<BR/>Observation of the kitchen on 05/06/2024 at 6:52am revealed inside the walking cooler with milk, apple juice, and orange juice were not dated or labeled with the date they were prepped. In the freezer there were two bags of round pieces of dough that were not sealed or dated as to when it was opened. There were also sausage patties that were not sealed or dated in the freezer. In the dry food storage area, there was a container of flour that did not have a date as to when it was opened. <BR/>Observation of [NAME] M on 05/06/2024 at 12:08pm revealed the temperature of the pureed meatloaf was 120 degrees when put on the steam table. The temperature of the puree peas was 142 degrees when put on the steam table. <BR/>Observation of [NAME] M on 05/06/2024 at 12:10pm revealed [NAME] M put the food back in the oven to bring to correct temperature after surveyor started asking about temperatures.<BR/>An interview with [NAME] N on 05/07/2024 at 2:14pm revealed that items were to be labeled the day they were opened. She stated that anything that was opened or prepped should be labeled. [NAME] N stated that the aides and cooks were responsible for ensuring food was labeled and dated after opened or prepped. She stated that by not labeling and dating the items it could result in the residents getting sick. She stated that she did not know why the items in the cooler, freezer, and dry storage were not labeled and dated. <BR/>An interview with Dietary Aide L on 05/07/2024 at 2:17pm revealed that items should be labeled and dated after each use. She stated that any product that the staff open, or use should be labeled and dated with the date the food was opened or prepped. She stated that the risk of not labeling, and dating was that staff would not know when the food expired. She stated that residents would get sick if the staff used food that was expired due to not dating. She stated she did not know why the items that were in the cooler, freezer, and dry storage were not labeled and dated. <BR/>An interview with the FFS on 05/07/2024 at 2:21pm revealed that food items were to be labeled and dated when they come in and when the food was opened. She stated the risk of not labeling and dating food when it was opened or prepped could cause the residents to get sick. She also stated if the food was not labeled or dated the staff would not know how long it had been there. She stated the sticker could have fallen off the items in the cooler, freezer, and dry storage. She stated that the temperatures for meat on the steam table was 185 degrees. She stated for vegetables the temperature was 165 degrees. The FFS stated by food not being at the correct temperature it could cause harm to the residents.<BR/>An interview with the Administrator on 05/08/2024 at 10:23am revealed that food items were to be labeled and dated when the food comes in off the truck. She also stated that the food should be labeled and dated when opened and that the food should have two dates on them. She stated the risk of not labeling and dating food items would grow bacteria and cause the residents to get sick. She stated the dietary director was responsible for ensuring the food was labeled and dated. The Administrator also stated the items in the cooler, freezer, and dry storage should have been dated and the dietary director should have been checking daily to ensure the food was labeled and dated. The administrator stated the proper temperature for meat on the steam table is 140 and for vegetables was also 140. The Administrator stated the risk of food not being at correct temperature could create bacteria in the food and cause people to become ill.<BR/>An interview with [NAME] M on 05/09/2024 at 8:27am revealed that she had been trained on proper temperatures. She stated the temperature for meat when put on the steam table should be 165 degrees and vegetables should be 155 degrees. She stated the risk of the food not being at proper temperature could result in someone getting sick or the food being cold. She stated she did not know why she put the food on the steam table when they were not at the correct temperature. <BR/>Record Review of the Food Safety Policy, not dated, revealed open food shall be labeled, dated, and stored properly. <BR/>Record Review of Food Storage and Supplies Policy, not dated, revealed open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. <BR/>Record Review of Food Safety Policy dated 05/2000 revealed Potentially hazardous food shall be maintained at: <BR/>41 degrees F or less, or<BR/>140 degrees F or above.<BR/>Record Review of the 2022 FDA Food Code revealed TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC (165oF).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 3 residents (Resident # 64) reviewed for wound care.<BR/>Facility failed to ensure the scissors were sanitized before using it to cut wound care supplies while providing wound care to Resident #64<BR/>This failure could place the residents at risk for cross contamination and infection.<BR/>Findings included: <BR/>Record review of Resident #64's face sheet on 03/22/23 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Type 1 Diabetes Mellitus, Hypertension, Open Left and right Foot Wound, Depression, Hyperlipidemia (excess fat in blood), chronic kidney disease and Cerebral Infarction (stroke). <BR/>Record review on 03/23/23 of Resident #64's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 out of 15 indicating the resident chose not to participate or 4 or more items were coded O because the individual chose not to answer or gave a nonsensical response.<BR/>Record review on 03/23/23 of Resident #64's care plan dated 03/21/23 reflected:<BR/>The resident has Diabetic Ulcer r/t Diabetes: Left lateral [side] foot and one of the interventions was Monitor/document wound: Size, Depth, Margins: peri wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify MD as indicated.<BR/>Record review on 03/23/23 of Resident #64's March,2023 WAR reflected: <BR/>Cleanse diabetic ulcer to the left lateral foot with NS, pat dry, pack calcium alginate into the undermining at 9:00[am], apply therahoney [medicinal honey] to wound bed and cover with optifoam [a kind of highly absorbent wound care foam]. Change daily and PRN until resolved. One time a day for wound care, Start date:03/16/2023<BR/>During an observation on 03/22/23 at 3:00 pm, LVN A performed wound care on Resident #64. LVN A washed her hands and donned gloves before performing wound care on Resident #64's ulcer on the left foot. She then removed a pair of scissors from the back pocket of her pants and cut calcium alginate wound dressing pad and silicone-based foam and applied directly on the wound after applying therahoney on the wound. LVN A did not sanitize the scissors before using it to cut these wound care supplies. <BR/>During an interview on 03/22/23 at 3:20 pm, LVN A stated she should have sanitized the scissors before using them. She said carrying scissors in the pants pocket was a wrong practice since it could contaminate the scissors and compromised infection control protocols. LVN A stated she attended in-services on infection control two weeks ago.<BR/>During an interview on 03/23/23 at 2:00 pm, DON said carrying scissors in pants pocket and using them for wound care without sanitizing compromised infection control. When the surveyor asked how the facility identified infection control deficiencies, DON stated they achieved it by direct observation. She said DON or ADON occasionally participated and observed incontinent care and wound care for identifying compromises in infection control. DON said infection control training was an ongoing program, and participation was mandatory for all the staff members. <BR/>Record review on 03/23/23 of in-service logs reflected that there was in -service training on topic Infection control and handwashing on 03/12/23 and LVN A was one of the participants. No other training on infection control was evident in the past three months. <BR/>Review of a current facility policy on 03/23/23 titled Infection control policy and procedure manual 2019: Fundamentals of infection control Precautions reflected:<BR/>A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions .Resident care equipment and articles . c. Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the representative when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights.<BR/>The facility failed to ensure Resident #1's MD was notified after she experienced swelling in her left arm. Resident #1 complained of pain 11/16/2024, the Medical Doctor was not informed. On 11/20/2024 the Medical Doctor assessed the resident and ordered an X-ray which showed no significant findings on 11/21/2024 of which the MD was not notified. On 11/26/2024 the resident requested to go to the emergency room where she was diagnosed with a ruptured left bicep tendon with instructions to keep arm elevated and free of compression. <BR/>This failure could place residents at risk of illness, injury, uncontrolled pain, and a decreased quality of life.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), type II diabetes , muscle weakness, and unspecified lack of coordination.<BR/>Review of Resident #1's quarterly MDS assessment, dated 09/11/24, reflected a BIMS score of 15, indicating she had no cognitive impairment. <BR/>Review of Resident #1's quarterly care plan, dated 11/19/24, reflected she had a potential for uncontrolled pain with an intervention of notifying the physician if interventions were unsuccessful or if current complaint was a significant change from past experience of pain. <BR/>Review of Resident #1's progress note, dated 11/16/24 and documented by LVN A, reflected the following:<BR/>[Resident #1] c/o pain on the left arm, stated 10/10 on pain scale. Left arm swollen and muscle contracte. PRN Tylentol 625mg given and applied Voltaren Gel on the pain site. Cold compress applied to the left arm and [Resident #1] expresses relief and comfort. Will continue to monitor [Resident #1].<BR/>Review of Resident #1's November 2024 MAR reflected she had a pain level of 10 on 11/16/24, was administered her PRN pain medication, and it was effective.<BR/>Review of Resident #1's progress note, dated 11/20/24 and documented by LVN B, reflected the following:<BR/>(MD) here to round today. Received new order for x-ray to left arm for swelling and pain .<BR/>Review of Resident #1's MD progress note, dated 11/20/24, reflected the following:<BR/> . She (Resident #1) has significant swelling in the left upper arm. She states it has been present for a few weeks. Nursing reports an XR is pending .<BR/>Review of Resident #1's x-ray results, dated 11/21/24, reflected no significant findings to her left arm.<BR/>Review of Resident #1's progress note, dated 11/26/24 at 10:00 AM and documented by LVN B, reflected the following:<BR/>[Resident #1]'s left arm swollen and painful. She requests to be seen at the emergency department .<BR/>Review of Resident #1's progress note, dated 11/26/24 at 8:46 PM and documented by LVN B, reflected the following:<BR/>[Resident #1] was seen at (ER) today . Final diagnosis, ruptured left bicep tendon.<BR/>Review of Resident #1's ER discharge paperwork, dated 11/26/24, reflected her final diagnosis was a ruptured left bicep tendon with special instructions to keep her arm elevated and free from compressive devices.<BR/>During an observation and interview on 12/12/24 at 11:42 AM, Resident #1 stated her left arm had been swollen for over a month and she had a ruptured tendon. She stated she did not know how it happened and no one had been rough with her or caused the swelling. She lifted her left arm which revealed it was swollen and twice the size of her right arm. <BR/>During an interview on 12/12/24 at 11:58 AM, LVN A stated he did not normally work Resident #1's floor but was working on 11/16/24 when he noticed the swelling to her left arm. Het stated he administered her Tylenol and put ice on her arm and it was effective. He stated he did not notify the NP/MD but did notify the oncoming nurse after his shift, LVN B. <BR/>During a telephone interview on 12/12/24 at 1:46 PM, Resident #1's MD stated the day she was notified of her swelling was the day she requested an x-ray (11/20/24). She stated she was doing rounds that day and observed the swelling. She stated she never got the results of the x-ray. She stated she was not made aware of the increased pain, her going to the ER, or the diagnosis of a ruptured tendon. She stated it was her expectations that she was notified of any change in condition regarding the residents. She stated she would have sent her to the ER sooner if she had been notified of the increased pain. She stated she would not have had any orders or recommendations if she had been notified of the tendon rupture, as those take time to heal. She stated she believed Resident #1's pain was being managed effectively.<BR/>During an interview on 12/12/24 at 2:39 PM, the DON stated she would have expected for the MD to have been notified sooner about Resident #1's swelling to her arm immediately. She stated she knew she was made aware but could not remember when. She stated Resident #1's pain had been effectively controlled by her scheduled and PRN pain medications. She stated she should have been notified of her increased pain, hospitalization, and final diagnosis. She stated she believed she was made aware of the ruptured tendon. She stated it was important for the MD to be notified of all changes in condition by the nurses to ensure she was fully involved in all the residents' medical care.<BR/>Review of the facility's Notifying the Physician of Change in Status Policy, revised 03/11/13, reflected the following:<BR/>1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid and incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 5 residents (Resident #3) reviewed for PASARR coordination.<BR/>The facility failed to ensure specialized OT, PT and ST evaluations and therapies were effectively requested for Resident #3 within three business days of a PASARR IDT meeting on [DATE] in which the services were agreed to be necessary.<BR/>This failure placed residents at risk of not attaining the highest practicable well-being possible.<BR/>Findings included: <BR/>Review of the undated face sheet for Resident #3 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #3 had diagnoses which included mandibulofacial dysostosis (rare disorder of skull and facial development), protein-calorie malnutrition, unspecified visual loss and deaf non-speaking.<BR/>Review of the quarterly MDS for Resident #3, dated [DATE], reflected she could not participate in the brief interview for mental status. The staff interview for mental status reflected she had short- and long-term memory problems and her cognitive skills for daily decision making were severely impaired. It reflected she received 92 minutes of ST, 90 minutes of OT, and 90 minutes of PT in the seven days prior to the assessment. <BR/>Review of the care plan for Resident #3, dated [DATE], reflected the following: [Resident #3] has DD and is PASARR Positive. will have the specialized services recommended by local authority per PASRR Specialized Services program as needed. Specialized Services will be provided per LA recommendations.<BR/>Review of the PCSP for Resident #3, dated [DATE], reflected the IDT included Resident #3, the DON, the LIDDA, the facility social worker, the previous DOR, the ADON, and two of Resident #3's FMs. It reflected the IDT agreed the following new services should have been initiated: specialized OT assessment, specialized OT, specialized PT assessment, specialized PT, specialized ST assessment, and specialized ST. It reflected a signature date of [DATE] and was signed by the LIDDA.<BR/>Review of the TMHP (portal through which PASARR NFSS are requested) entries for Resident #3, dated [DATE]-[DATE], reflected the following entries:<BR/>[DATE] NFSS form for physical therapy was not submitted within 30 days of the IDT meeting<BR/>[DATE] NFSS form for occupational therapy was not submitted within 30 days of the IDT meeting.<BR/>[DATE] Applied income requested<BR/>[DATE] Applied income request expired <BR/>[DATE] NFSS form for speech therapy was not submitted within 30 calendar days of the IDT meeting.<BR/>[DATE] Applied income requested<BR/>[DATE] Applied income request expired<BR/>[DATE] Applied income requested<BR/>[DATE] Applied income request expired<BR/>Review of the PCSP for Resident #3, dated [DATE], reflected the IDT included the LIDDA, the DOR, the MDS nurse, and Resident #3's FM. It reflected the IDT agreed the following new services should have been initiated: specialized OT assessment, specialized OT, specialized ST assessment, and specialized ST. It reflected the specialized PT assessment was complete and specialized PT was ongoing.<BR/>Review of the TMHP entries for Resident #3, dated February 2024, reflected the following entries:<BR/>[DATE] NFSS form for occupational therapy was not submitted within 30 days of the IDT meeting.<BR/>[DATE]. Each request must have its own unique and original signatures and signature page. You may not use typed or digitally, written, signatures, stamps, or copied signatures. Please complete the following steps: one. Upload of valid and completed signature page that is original, ensure signatures are legible, and the signature dates match the portal, and resubmit, two. Set all appropriate tabs that are in pending denial status to pending state review before [DATE] to avoid a system generated denial. <BR/>[DATE] Denied<BR/>[DATE] Seven days have lapsed since the request was pending denial.<BR/>[DATE] The requested service or assessment is denied.<BR/>[DATE] NFSS form for occupational therapy was not submitted within 30 days of the IDT meeting.<BR/>[DATE] Each request must have its own unique and original signatures and signature page. You may not use typed or digitally, written, signatures, stamps, or copied signatures. Please complete the following steps: one. Upload of valid and completed signature page that is original, ensure signatures are legible, and the signature dates match the portal, and resubmit, two. Set all appropriate tabs that are in pending denial status to pending state review before [DATE] to avoid a system generated denial. <BR/>[DATE] Denied<BR/>[DATE] Seven days have lapsed since the request was pending denial.<BR/>[DATE] The requested service or assessment is denied.<BR/>[DATE] NFSS form for occupational therapy was not submitted within 30 days of the IDT meeting.<BR/>[DATE] Each request must have its own unique and original signatures and signature page. You may not use typed or digitally, written, signatures, stamps, or copied signatures. Please complete the following steps: one. Upload of valid and completed signature page that is original, ensure signatures are legible, and the signature dates match the portal, and resubmit, two. Set all appropriate tabs that are in pending denial status to pending state review before [DATE] to avoid a system generated denial. <BR/>[DATE] Pending Denial<BR/>[DATE] NFSS form for speech therapy was not submitted within 30 days of the IDT meeting.<BR/>[DATE] Each request must have its own unique and original signatures and signature page. You may not use typed or digitally, written, signatures, stamps, or copied signatures. Please complete the following steps: one. Upload of valid and completed signature page that is original, ensure signatures are legible, and the signature dates match the portal, and resubmit, two. Set all appropriate tabs that are in pending denial status to pending state review before [DATE] to avoid a system generated denial. <BR/>[DATE] Pending Denial<BR/>Review of ST evaluation and notes for Resident #3 reflected evaluations on [DATE] and [DATE]. These documents also reflected Resident #3 received ST services 13 days between [DATE] and [DATE]. <BR/>Review of OT evaluation and notes for Resident #3 reflected evaluations on [DATE] and [DATE]. These documents also reflected Resident #3 received OT services 13 days between [DATE] and [DATE]. <BR/>Observation on [DATE] at 12:12 PM revealed Resident #3 seated in a recliner in her room. The SLP was seated next to her and offering her speech therapy. <BR/>During an interview on [DATE] at 12:12 PM, the SLP stated she had Resident #3 on services for over a month. The SLP stated the services were habilitative, but there was not much difference in habilitative and rehabilitative services in speech therapy. She stated she was not sure if there was a difference between the two in occupational or physical therapy. <BR/>Observation on [DATE] at 11:30 AM revealed Resident #3 seated in a recliner in her room. She did not respond when approached or addressed verbally, but when the arm of her recliner was tapped, she reached her hands out, grabbed onto the State Surveyor's arm, and stood up. CNA A entered Resident #3's room, and took the resident's hands, and they began to walk together. <BR/>During an interview on [DATE] at 09:25 PM, the DOR stated she stepped into the role of DOR in [DATE], and she figured out right away the OT and ST services for Resident #3 had not been successfully requested after the [DATE] IDT meeting. The DOR stated she requested them at that time, but there kept being issues with their requests. The DOR stated they had an issue with the doctor wanting to sign request forms electronically, and the portal would not accept the electronic signature. She stated then there was a clerical error she made but entered the wrong assessment date for the IDT meeting. She stated she did not know all the reasons the requests were denied, but the process was very overwhelming and confusing, and there was no one she could call or email to receive guidance on how to maneuver the process. The DOR stated she did not think there would be a negative outcome for Resident #3, because they were still offering the specialized services to her and the facility was eating the cost. <BR/>An attempt was made on [DATE] at 10:30 AM to interview the LIDDA by telephone. A voicemail was left. <BR/>During an interview on [DATE] at 03:20 PM, the DON stated she was not aware of the timeframes by which they must request specialized services through PASARR. The DON stated it was important Resident #3 was getting the services so she did not decline. The DON stated the MDS nurse and the DOR shared responsibility for ensuring the services were requested successfully for Resident #3, and the MDS nurse was on leave currently. The DON stated they discussed PASARR in their morning meetings, but she did not really participate in the process. <BR/>During an interview on [DATE] at 04:00 PM, the ADM stated she monitored for compliance with the PASARR process when they went over their care plan process and their morning meetings. She stated the MDS nurse let them know who was being seen and if there was a special PASARR meeting because someone from nursing needed to be present. The ADM stated the DOR and the MDS nurse were responsible for ensuring everything was uploaded into the portal, and she knew they were having trouble getting it all to work. The ADM stated Resident #3 was on services anyway until they got everything figured out. The ADM stated Resident #3 was on habilitative rather than rehabilitative services. The ADM stated the facility was currently offering the services to Resident #3 for free. The ADM stated she was not concerned about the money, as Resident #3's condition was very different from anything else they had ever seen and they did not want to risk her having accidents or a decline. The ADM provided the following policy in response to a request for PASARR. <BR/>Review of facility policy, dated [DATE], and titled PASRR Level 1 Screen Policy and Procedure reflected the following: The NF must convene an IDT meeting after the LIDDA, submits the PE, and within 14 days after admitting the individual. The IDT will determine which specialized services the resident will receive. After the IDT meeting, the NF must submit the information from the IDT meeting on the LTC online portal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 14 residents (Residents #1 and 2) reviewed for quality of care. <BR/>The facility failed to ensure TLVN and LVN C assessed and reported a new new skin injury to Resident #1's first two toes of the right foot and a new skin injury to Resident #'s first and fifth toes of the right foot. <BR/>An Immediate Jeopardy (IJ) situation was identified on 03/06/24. While the IJ was removed on 03/08/24 at 03:00 PM., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure placed residents at risk of new or worsening pressure ulcers.<BR/>Findings included:<BR/>1. Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses of quadriplegia (paralysis of all four limbs), type two diabetes mellitus with diabetic polyneuropathy (nerve damage causing weakness, numbness, and/or tingling), and history of transient ischemic attack and cerebral infarction (stroke).<BR/>Review of the Discharge MDS for Resident #1, dated 02/18/24, reflected she could not participate in the brief interview for mental status. The section for Functional Status reflected in the activities of rolling left to right and transfer from chair to bed that she was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The section related to Skin Conditions reflected she did not have any unhealed pressure ulcers.<BR/>Review of the care plan for Resident #1, dated 02/17/24, reflected the following: Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. It also reflected the following: The resident has a pressure ulcer or potential for pressure ulcer development: The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Monitor nutritional status. Serve diet as ordered, monitor intake and record.<BR/>Review of the initial skin assessment for Resident #1, dated 02/08/24, and completed by the LVN C, reflected she had no skin issues noted. <BR/>Review of the weekly skin assessment for Resident #1, dated 02/14/24, and completed by LVN C, reflected she had no skin issues noted. <BR/>Review of the Braden Scale for Predicting Pressure Sore Risk, dated 02/08/24, and completed by the TLVN, reflected she had a score of 7, which indicated a severe risk for pressure ulcers.<BR/>Review of physician's orders for Resident #1, on 03/05/24, reflected there were no orders related to prevention of pressure ulcers. <BR/>Review of the skin observation tool in the CNA documentation portal for Resident #1, dated 02/16/24, reflected a new skin tear on the buttocks and discoloration on the left lower foot, documented by CNA A. <BR/>Review and observation of hospital records for Resident #1, dated 02/18/24, reflected a photograph, taken on 02/18/24 at 09:11 PM, of her right anterior foot showing a red discoloration of the first and second toes. The first toe also had a partial thickness opening in the center of the reddened area that had a yellow tint.<BR/>An attempt was made on 03/06/24 at 08:30 AM at the hospital to identify and interview the nurse who took the photograph of wounds on Resident #1's foot on 02/18/24, was unsuccessful. An attempt was made to interview the hospital physician who saw Resident #1 in the ER on [DATE], but the hospital administrator would not provide direct contact information for him. <BR/>During an interview on 03/06/24 at 09:58 AM, LVN C stated her process for conducting a skin assessment was during an initial skin, she looked at the resident's entire body, starting at their neck, to go down their legs to their feet and looked at their heels and then turned them over to look at their front, under the breasts, and in the perineal area. LVN C stated she looked between their toes and fingers, as well. LVN C stated when she conducted the initial skin assessment for a new resident, she did not know who cared for the resident or what state their skin might have been in, so she checked very carefully. LVN C stated the toes and feet were important during skin checks due to them being areas vulnerable to injury and skin breakdown. LVN C stated she conducted the initial skin assessment for Resident #1 on 02/08/24 and the weekly skin assessment on 02/14/24. She stated she did not see any new skin issues during either procedure. LVN C stated she had gotten Resident #1 dressed on the morning of 02/18/24 when she was sent to the hospital, and LVN C had not seen any marks or skin issues on Resident #1's legs or feet. LVN C stated she did not know what anyone was talking about when they asked her about wounds on Resident #1's feet. LVN C stated if she thought she would have seen any marks on Resident #1 especially if they were on the front, because she helped her dress. LVN C stated Resident #1 required total assistance with all of her activities of daily living, so they had a large amount of observation of and contact with her body. <BR/>During an interview on 03/06/24 at 11:40 AM, CNA A stated she and her coworker, CNA B, showered Resident #1 on 02/16/24 and noticed a scratch under her right buttock, a blister on her big toe, and redness on both her big toe and her second toe. CNA A stated she and CNA B reported the skin changes to LVN C that day. CNA A stated she cared for Resident #1 while she was in the facility, and Resident #1 sat mostly in her chair and only got in bed at night. CNA A stated Resident #1 seemed uncomfortable in her chair, but the resident's FM had insisted she be placed in her chair during the day. CNA A stated she and her colleagues floated Resident #1's heels while she was in bed, but in the chair, they could not float her heels. CNA A stated was taught to place wheelchair leg rests at a 45 degree angle when the resident did not use them, but CNA A noticed Resident #1's feet, which were very contracted so the toes almost faced downward, would graze the foot rests sometimes on the tops of her toes. CNA A stated she and CNA B removed the footrests while Resident #1 was at rest in her chair and not being moved so her feet would not hit the footrests. CNA A stated she thought it was possible the wounds on Resident #1's right foot had occurred that way. CNA A stated after Resident #1's shower on 02/16/24, she and CNA B took Resident #1 to the dining room for her meal, and they stopped and showed the new wounds on her right foot to LVN C. CNA A stated she also documented the wounds in the CNA documentation portal. She stated the notations in the Skin Observation tool for 02/16/24 referred to the new wounds she saw on Resident #1's right foot. <BR/>During an interview on 03/06/24 at 11:50 AM, CNA B stated on 02/16/24, which was a Friday, she and her coworker CNA A showered Resident #1 and saw marks on her. CNA B stated that day she saw a water blister on her big toe and a red mark on the next toe where the bone was. CNA B stated the injuries might have been from the footrest on the wheelchair, but she was not sure how they occurred, because the FM would not let Resident #1 stay in bed during the day. CNA B stated the day they discovered the wounds on Resident #1's toe, they were bringing her to lunch, and LVN C was sitting at the second nurse's station. CNA B stated they showed the toe wounds to LVN C. CNA B stated she did not remember LVN C being distracted or talking on the phone or to anyone else at the nurse's station. CNA B stated she thought the TLVN was sitting at the nurse's station with LVN C. CNA B stated CNA A did most of the documentation for Resident #1, but CNA B was pretty sure the new skin problems were documented in the skin observation tool by CNA A. CNA B stated they showed LVN C the toe wounds and told her about the scratch under Resident #1's buttock. <BR/>Review of the, undated, face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia, cerebral vascular disease (a condition that affects blood flow to the brain), type two diabetes mellitus, and hemiplegia affecting right dominant side (paralysis on one side of the body).<BR/>Review of the quarterly MDS for Resident #2, dated 02/24/24, reflected her cognition was too poor to take part in the brief interview for mental status. The section for Functional Status reflected in the activities of rolling left to right and transfer from chair to bed that she was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The section related to Skin Conditions reflected she was at risk of pressure ulcers but did not have any unresolved pressure ulcers. <BR/>Review of the Braden Scale for Predicting Pressure Sore Risk for Resident #2, dated 10/23/23, and completed by LVN F, reflected she had a score of 10, which indicated a high risk for pressure ulcers.<BR/>Review of the care plan for Resident #2, dated 01/17/24, reflected the following: Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Weekly skin assessments.<BR/>Review of physician's orders for Resident #2 on 03/06/24 reflected no order for treatment of any wounds on her foot. <BR/>Review of the skin observation tool for Resident #2 reflected a discoloration on the right lower leg or foot was documented on 02/14/24, 02/15/24, 02/19/24, 02/20/24, 02/24/24, 02/25/24 and 02/28/24 by CNA E. An additional documentation of a right leg or foot discoloration was documented on 02/27/24 by CNA D. <BR/>Review of the weekly skin assessment for Resident #2, dated 02/26/24, and completed by the TLVN, reflected the following notes 2x1cm open area to left shin below knee, no drainage noted, skin-prep applied; 4x2cm open area to left leg, no drainage noted, skin-prep applied and LUQ Peg tube. The answers to the following questions Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete The Ulcer Assessment and Are there any new areas that have not been communicated to the physician/NP or family? was marked as No. As of 03/06/24, this was the most recent skin assessment. <BR/>Review of wound physician progress notes, dated 03/06/24, reflected Resident #2 received wound care and assessment for a non-pressure wound of the left leg- full thickness. It also reflected the following: Chief Complaint Patient has wounds on her left leg; left shin. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. She has condition(s) as listed above. Details about current wound(s) and any skin<BR/>conditions are outlined below. There is no indication of pain associated with this condition. There was no mention of any wound on the toes of her right foot. <BR/>Record review of the most recent podiatry progress note for Resident #2, dated 01/10/24, reflected no skin issues on either foot. The podiatrist marked the resident had diabetes and peripheral vascular disease.<BR/>During observation on 03/06/24 at 12:10 PM, CNA D removed Resident #2's socks and shoes to observe Resident #2's feet. The fifth (pinky) toe of Resident #2's foot had black tissue covering the entire toe, and her first (big) toe was black surrounding the proximal nail fold (part of the nail bed closet to the rest of the foot and ankle) and a portion of the skin around the distal nail plate (part of the nail bed farthest away from the rest of the foot and ankle). <BR/>During an interview on 03/06/24 at 12:10 PM, CNA D stated the wounds on Resident #2's feet were very black, and they were there for several months. CNA D stated she had not seen Resident #2 receive any treatment for the injuries on her right toes. CNA D stated she had not been the person to initially report the injuries to a charge nurse, but she had documented the injuries on the Skin Observation tool. CNA D stated she did not know who discovered the injuries, but she thought they were well known, because the CNAs were documenting them in the Skin Observation for quite some time. <BR/>During observation and an interview on 03/06/24 at 12:30 PM, the DON observed the injuries on Resident #2's right toes. The DON touched the injuries on Resident #2's fifth toe and watched the resident's reaction. Resident #2 did not wince or exhibit any other sign of pain. The DON stated the black area on the pinky toe was hard like a scab. She stated the injuries should not necessarily have been documented in a weekly skin assessment because they were not open areas but instead were scabbed. <BR/>During an interview on 03/06/24 at 12:56 PM, the MD stated he expected a resident with Resident #1's clinical condition would develop pressure ulcers given the protein status, poor immunity and immobility. He stated the important thing was for new wounds to be identified and treated so they did not worsen. The MD stated he was not aware of any wounds that had developed on Resident #1 during her stay in the facility. The MD stated he expected to be notified of new skin conditions. He stated he could not say how a wound like the one Resident #1 had could worsen over a two-day period without being addressed, but any medical diagnosis needed intervention as early as possible. The MD stated he did look at residents' feet normally when he did an exam or an assessment. The MD stated Resident #1 was only in the facility for ten days, and he had not done an in-person exam with her. The MD stated he was not aware of any black wounds on Resident #2's feet. The MD stated he did not have his computer and could not say exactly when the last time he performed a physical exam with Resident #2, but she did not have any wounds on her feet at that time. The MD stated most of her skin assessments were being done by the WCD. The MD stated once wound care was involved with a resident, it was a professional courtesy to defer to the WCD for decision-making. <BR/>An attempt was made on 03/06/24 at 01:12 PM to interview the POD by telephone. A voicemail was left on the clinic's main phone line.<BR/>An attempt was made on 03/06/24 at 01:14 PM to interview CNA E about Resident #2's skin observations. A voicemail was left.<BR/>During an interview on 03/06/24 at 01:44 PM, the WCD stated he saw Resident #2 earlier that day. He stated they did not conduct a full skin assessment. The WCD stated Resident #2 had a wound on her shin that he was treating. The WCD stated he did not think he saw her feet recently and was sure he did not see her feet that day. The WCD stated he saw Resident #2 on and off for pressure ulcers and skin tears. The WCD stated no one from the facility reported any new skin issue to him on Resident #2. The WCD looked at a photograph of Resident #2's toe wounds taken by the State Surveyor, and he stated he could not diagnose from a photograph, but the wound on her fifth toe looked like it was probably a pressure or arterial wound. The WCD stated the treatment for that type of wound would like be Betadine or something similar. He stated the rest of her foot looked healthy, and he was not very aggressive with debriding so he would probably only monitor and treat with Betadine. <BR/>During an interview on 03/06/24 at 02:16 PM, the TLVN stated her protocol when she saw a wound like the ones on Resident #2's toes was to refer to the physician, the wound care surgeon and notify the family. She stated she had not noticed an alert that would notify her a CNA had documented a skin observation. The TLVN stated she had not seen the wounds on Resident #2's toes prior to the State Surveyor pointing them out to her, but she had now gone to look at the wounds, and she thought they might be purpura (a condition of red or purple discolored spots on the skin that do not blanch on applying pressure). The TLVN stated she did not see the wounds a few weeks ago. The TLVN stated she would not document something like that on the weekly skin assessment, because it was a scab. The TLVN stated the wound was a closed wound and had never been opened and had not bled and was not from trauma, so it did not quality as a wound to be documented on the weekly skin assessments. The TLVN stated the wound might have been a pressure or arterial ulcer, and she would have documented a pressure or arterial ulcer on the skin assessment. The TLVN stated she was not qualified to diagnose a wound and only the physician could diagnose. The TLVN stated she should have reported the wound to the nurse management team and the physician. She could not or would not say why she did not do so and stated she was very nervous. The TLVN stated potential negative outcomes of not addressing a skin issue immediately were infection and ultimately, amputation.<BR/>During an interview on 03/06/24 at 03:20 PM, the DON stated she monitored for new wound and skin conditions by discussing any new issues with the IDT and communicating frequently. The DON stated CNAs communicated new skin observations in the point of care documentation system, an alert showed up on the EMR dashboard, and the IDT pulled the records describing the new skin issue every shift. The DON stated the people responsible for noticing the alerts on the EMR were her, the ADON, the TLVN, and the charge nurses. She stated the CNAs were instructed to document in the EMR instead of relying on a verbal notification of a new skin issue. The DON stated she was mistaken when she stated the wound on Resident #2's fifth toe had not needed to be documented on the weekly skin assessments. The DON stated she called the MD when she learned of the wound on Resident #2's toe, and he ordered a venous doppler (a special ultrasound technique that evaluates blood as it flowed through a blood vessel) to ensure the toes were still receiving blood flow. The DON stated the wound could have been a blood blister that progressed. The DON stated she did not know why nobody noticed the alerts that should have triggered when CNAs entered skin observations for Residents #1 and #2. She stated she was still investigating why the failure occurred. The DON stated if the wounds were on Resident #2's foot for months as CNA D reported they were, then the TLVN should have seen them during previous skin assessments. The DON stated the fact the TLVN did not notice the wounds was concerning. The DON stated a potential outcome of the failures was the wounds would tend to get worse, because the body might not self-heal without medical intervention.<BR/>During an interview on 03/06/24 at 04:30 PM, the ADM stated she monitored for compliance with the skin program in the facility by discussing issues in care plan meetings and their morning meetings. The ADM stated she was notified of the unidentified wounds on Resident #2's foot. The ADM stated she had also been made aware Resident #1 had something on her foot that she thought was a blister and CNAs had documented the area but LVN C had not followed up on the wound before Resident #1 was sent to the hospital. The ADM stated Resident #1 had not returned to the facility. <BR/>The ADM stated the process for identifying new skin issues was the CNAs put the skin observation into the EMR, and it alerted for anyone to see on the EMR dashboard. The ADM stated the TLVN had access to the same information as the rest of the team, and the ADM did not know why the TLVN did not follow up on reports of either Resident #1's or Resident #2's wounds. The ADM stated a potential negative outcome of the failure was a worsening of wounds, but particularly for someone with Resident #2's clinical condition, a wound on her foot had the potential to become a major issue where it would be detrimental, possibly causing sepsis. <BR/>Review of facility policy, dated 08/12/16, and titled Pressure Injury: Prevention, Assessment and Treatment reflected the following: <BR/>Procedure:<BR/>1. <BR/>Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation and prevent, breakdown, injury, and infection.<BR/>2. <BR/>Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission, and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sores is indicated and notify the treatment nurse/design of any potential problems.<BR/>3. <BR/>Assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will:<BR/>1. Notify the physician of sore and obtain any follow any orders as directed by the physician.<BR/>2. Notify family and dietary department. Document Notification. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/06/24 at 5:00 PM. The ADM was notified . The ADM was provided with the IJ template on 03/06/24 at 05:05 PM.<BR/>The following Plan of Removal submitted by the facility was accepted on 03/07/24 at 05:30 PM: <BR/>[The facility]<BR/>Plan of Removal: 3/6/24 <BR/>On 3/5/2024 an abbreviated survey was initiated at [the facility]. 3/6/2024 the surveyor provided an Immediate Threat (I) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety.<BR/>F686 The facility failed to prevent pressure ulcers and ensure residents did not develop pressure ulcers. All residents had the potential to be affected by the deficient practice. Head to toe assessments were completed on all residents in the facility to ensure no other residents were identified. <BR/>Interventions:<BR/>Resident #1 no longer resides in the facility as of 3/6/24. <BR/>The MD was notified by the DON for resident #2 on 3/6/24. Treatment orders are in place.<BR/>All residents in the facility received a head-to-toe skin assessment by the DON/ADON/Tx Nurse. Assessments will be completed 3/6/24. No new skin issues were identified. <BR/>A 1:1 in-service was completed by the Regional Compliance Nurse with the DON/ADON/Tx Nurse on the policy for Pressure Prevention and the Completion of Skin Assessments. Completed 3/6/24. The Regional Compliance Nurse is a part of the corporate structure. <BR/>The DON /designee will review the EMR dashboard daily and throughout shifts for clinical alerts pertaining to skin issues that are documented to ensure that all skin issues have been addressed by a nurse. This will start 3/6/24 and continue indefinitely. <BR/>The DON or ADON will conduct skin rounds weekly with the treatment nurse to ensure skin issues are identified, MD/family notified, and a treatment is ordered. This will start 3/6/24 and continue indefinitely. <BR/>The Medical Director was notified of the immediate jeopardy situation on 3/6/24. <BR/>An ADHOC QAPI meeting was conducted on 3/6/24 to include the IDT Team to discuss the immediate jeopardy and subsequent plan of removal. <BR/>Identification:<BR/>All residents residing in the facility received a head-to-toe assessment by the DON/ADON and treatment nurse. No new skin issues were identified on 3/6/2024.<BR/>In-services:<BR/>All direct care staff were in-serviced on the following topics below on 3/6/24 by the DON/ADON. All staff not present for in-servicing will not be allowed to resume their scheduled assignment until in-serviced. All new hired staff will be in-serviced during facility orientation. All agency staff will be in-serviced prior to start of their shift. Verification of comprehension will be made through a post test for topics in-serviced on.<BR/>o <BR/>Pressure Prevention Policy <BR/>o <BR/>Completing Skin Assessments <BR/>o <BR/>Notification of change in condition to the charge nurse and DON including new skin issues. <BR/>Monitoring of the Plan of Removal included the following: <BR/>Review of physician's orders for Resident #2 on 03/06/24 reflected an order had been entered for Bilateral Arterial legs Ultrasound Verbal Active 03/08/2024 ultrasound of both legs. Cleanse Right 5th toe Wound W/WC or NS, Pat Dry, Apply Betadine 3xwk every 12 hours as needed for R 5th Toe Wound Phone Active 03/06/2024, 03/06/2024 Cleanse Right 5th toe Wound W/WC or NS, Pat Dry, Apply Betadine 3xwk one time a day every Mon, Wed, Fri for right 5th toe wound.<BR/>Review of the March 2024 TAR for Resident #2 reflected Betadine was administered to her right toes by the TLVN on 03/06/24 and 03/08/24.<BR/>Review of skin assessments for Residents #3-#7 and #9-#21 conducted on 03/06/24 and 03/07/24 reflected no new skin issues identified. <BR/>Review of the weekly skin assessment tool for Resident #8 completed on 03/08/24 reflected the following: Red flat rash to back; skin intact; TX PRN.<BR/>28/24<BR/>Review of physician orders for Resident #8 reflected the following with a start date of 05/28/24: Nystatin Powder 100000 UNIT/GM. Apply to affected area topically as needed for rash twice daily. <BR/>Review of the March 2024 TAR for Resident #8 reflected Nystatin powder was administered to her back on 03/08/24 at 01:35 PM. <BR/>Review of in-services conducted one-to-one with the TLVN, ADON, and DON reflected they had each signed the following in-service on 03/06/24: Pressure prevention, injury, completion of skin assessment, and treatment weekly and with changes in skin integrity.<BR/>Review of an in-service conducted by the DON on 03/06/24 reflected the following content: Notification of change in condition to the charge nurse and DON, including new skin issues. See attachment of policy and procedures. 39 staff members had signed the signature page of the in-service. An additional 29 staff were listed as being notified by phone on 03/06/24. <BR/>During an interview on 03/08/24 at 08:40 AM, the ADM stated education of staff was ongoing. She stated the staff in the facility today were in-serviced by phone and were to be tested on their knowledge today. She stated copies of in-service education and the staff who completed it were ready. She stated she was re-educated by the RCN to monitor the nursing for compliance with the plan and program. <BR/>During an interview on 03/08/24 at 09:05 AM, LVN F stated she completed in-service education in ANE and Assessment. She stated topics included skin assessment, changes in skin, reporting, documentation and informing the ADON and DON. She stated skin assessments were documented in the computer and an incident report was to be completed and forwarded to risk management. She stated as a charge nurse she was also to initiate treatment and inform the physician and family of changes. <BR/>During an interview on 03/08/24 at 09:10 AM, MA G stated she completed in-service education and testing for ANE and Assessments. She stated she was informed she was to report any skin tears, bleeding or observed skin changes to the charge nurse and the DON. She stated as a med aide she would occasionally see a skin tear. <BR/>During an interview on 03/08/24 at 09:19 AM, the RCN stated she instructed 100 percent of staff (nurses and CNAs) on ANE and Assessment at this time. She stated changes in residents were to be reported to the Administrator and DON. She stated nurses must assess residents when a change was reported and initiate treatment. Nurses must report changes to physicians and family. She stated education did not reflect any knowledge gaps among staff, and she was unsure how the IJ occurred. She stated the facility was nearing 100 percent of staff completing the posttest knowledge check. <BR/>During an interview on 03/08/24 at 09:50 AM, RN H stated she received in-service education on ANE and skin assessments. She stated she was taught about the reporting system and reporting changes to the DON and charge nurse. She stated as a nurse she would also report changes to the physician and family. She stated skin assessments were to be completed weekly, as needed and on admission. She stated she completed a test after the in-service. <BR/>During an interview on 03/08/24 at 09:55 AM, the ADON stated she was in-serviced and tested on ANE and skin assessments. She stated any changes had to be assessed, reported to the doctor and the DON and family. She stated skin assessments were to be completed weekly and incident reports were to be filled out for changes in skin condition (such as bruises, scrapes and skin tears). She stated the nurse documented the change and entered orders for treatment from the physician. <BR/>During an interview on 03/08/24 at 10:09 AM, CNA I stated he received in-service education on ANE and assessments. He stated aides were informed any changes in skin condition must be reported to the nurse, the ADON and DON. He stated if no one responded to his report he was to report to the administrator. He stated most observations were documented in the computer but the facility also utilized shower sheets to assessed resident skin health. <BR/>During observation and an interview on 03/08/24 at 10:10 AM, Resident #19 stated he had no discomfort to his below the knee amputation site. He stated he received wound care three times a week. He stated he was taking pain medications. He was observed ambulating in his wheelchair in his room. <BR/>During an interview on 03/08/24 at 10:15 AM, CNA E stated she received in-service education on ANE and skin assessments. She stated she completed a post education test, she added they always wanted to test them. She stated she would report any skin changes to the nurse, DON or Administrator. She stated the situation was as simple as see something report something. She stated any changes had to be reported as soon as they were discovered. <BR/>Observation on 03/06/24 at 11:20 AM revealed LVN F assisted to show Resident #2's right fifth toe which revealed no drainage, skin was intact and a 1.5 cm long dark black area was present on the outside of her little toe. Resident #2 did not indicate any discomfort to the area. The tip of the toenail had been removed and a purple swollen area was seen to the inside of margin of the toenail.<BR/>During an interview on 03/06/24 at 11:20 AM, LVN F stated Resident #2 was receiving betadine lotion to the site daily per instructions from the wound care physician. <BR/>During an interview on 03/08/24 at 11:27 AM, CNA J stated she received in-service education on ANE and assessments. She stated the facility emphasized skin assessments and reporting changes to the charge nurse. She stated the DON and administrator were also to be informed. She stated she had not observed any concerns among residents she worked with at the facility. <BR/>During an interview on 03/08/24 at 11:30 AM, the TLVN stated she completed the in-service education and posttest knowledge check. She stated the ANE and skin assessment requirements were known, that she needed to check the EMR for skin alerts daily, and the DON would be rounding on wounds with her for the time being. She stated she was requested to assess the toe of Resident #2 on a Wednesday. She stated she was not aware

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 9 (Resident # 39) residents in 1 of 3 dining rooms.<BR/>The facility failed to promote Resident # 39's dignity while dining when staff did not serve his lunch tray for 20 minutes after his tablemate was served. <BR/>This failure could affect all residents who were eating in the dining room, by contributing to poor self-esteem, and unmet needs.<BR/>Findings included:<BR/>Record review of Resident #39's Face Sheet dated 05/08/2024 revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses of intermittent explosive disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior, or angry verbal outbursts), unspecified protein-calorie malnutrition ( a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food), and hypovolemia ( when your body doesn't have enough fluid (blood) volume due to injury. <BR/>Record review of Resident #39's Annual MDS Assessment, dated 01/14/2024, reflected the staff assessed cognitive status of Resident #39 and he had poor short- and long-term memory recall. He was able to recall the current season, the location of his room, and that he was in a nursing home. Resident #39 did not have any behavior problems. <BR/>Record review of Resident # 39's Comprehensive Care Plan dated 04/04/2024 reflected Resident # 39 had a potential to demonstrate verbally and abusive behaviors. Intervention: Assess and anticipate resident's needs such as food, thirsty, comfort level, toileting, pain, etc. Resident #39 had potential to demonstrate physical behaviors due to poor impulse control. Intervention: provide physical and verbal cues to alleviate anxiety,; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out to staff member when agitated.<BR/>Observed on 05/06/2024 at 8:45 AM Resident #3 was eating in the C Hall dining room. <BR/>Observation on 05/06/2024 at 12:17 PM revealed Resident # 39 entered the C hall dining room and was stating I am hungry. When are we going to eat. He propelled himself to a table. Resident #3 was sitting across from Resident #39. <BR/>In an interview on 05/06/2024 at 12:21 PM Resident # 39 stated he did not want to talk he wanted something to eat. He stated he was hungry and to get him some food. <BR/>Observation on 05/06/2024 at 12:23 PM revealed the staff were standing in the hallway/doorway entering C dining room and was not near Resident #39.<BR/>Observation on 05/06/2024 at 12:40 PM Resident #3 received his meal tray and was eating in front of Resident #39. Resident #39 stated he wanted some food he was hungry and why did he not have any food. <BR/>Observation on 05/06/2024 at 12:45 PM Resident #39 continued to say, I am hungry where is my food. He would continue to say he wanted something to eat. <BR/>Observation on 05/06/2024 at 12:50 PM Resident #39 watched Resident #3 eat his meal. Resident #39 became angry (his fists were clenched, furrowed brows, and tense jaws/lips) and stated, why did he not get something to eat? Resident #39 also stated, is that man (Resident #3) better than me? Why is he eating, and no one will give me any food? He also stated he felt no one was going to give him any food. <BR/>Observation on 05/06/2024 at 12:52 PM the staff continued to stand in the open area leading into the dining room. They were not near Resident #39. <BR/>Observation on 05/06/2024 at 1:00 PM the meal trays came to C dining room. <BR/>In an interview on 05/06/14 at 1:45 PM CNA P stated Resident #3 decided each day where he preferred to eat his meals in the C dining room or the dining room near the administrator's office. She stated on 05/06/2024 he decided to eat in the C dining room. She stated he had eaten breakfast in the C dining room. She stated whenever a resident eats in various areas of the facility, she was informed by nurse supervisors (different nurse supervisors over the past several months did not recall names of the supervisors) it was the nursing staff's responsibility to alert the dietary department where Resident #3 was eating his meal. She also stated this helped dietary staff to know where to send Resident #3's meal. CNA P stated she did not know why this information was not communicated with dietary staff on 5/06/24. She stated Resident # 39 can become agitated and angry very fast over anything. CNA P also stated if a resident did not have a meal tray and observed another resident eating, a resident may have felt he was not going to receive a meal tray or felt the staff did not care about him. There was a possibility Resident #39 may have feelings of anger or become agitated due to not receiving the meal and having to observe Resident #3 eating for long period of time prior to Resident # 39 received his meal. She also stated Resident #39 may have felt left out and forgotten. She also stated other residents could grab food off the other resident's tray if they were tired of waiting on their meal. CNA P stated the food the resident grabbed might not be on their diet, There was a possibility a person may choke if the resident was on a pureed diet and they grabbed a piece of meat that was not pureed. <BR/>In an interview on 05/09/2024 at 9:15 AM LVN C stated the nursing staff were expected to communicate with the dietary staff where a resident was eating their meals for the day if the resident does not always eat in the same dining room. She stated Resident #3 does change where he eats his meals. She also stated some days he will eat in the main dining room near the administrator office/ front door, or he would eat in the C hall dining room. She stated nursing staff were expected to serve meals one table at a time and ensure all residents at one table received their meals prior to serving residents at another table. She stated if a resident was not served their meal and their table mate had their meal tray, the other resident may become frustrated, feel the staff forgot about them, and possibly feel they were not going to get a meal tray. LVN also stated Resident # 39 can become easily agitated and have outbursts if he was angry or upset about anything including not receiving meal tray. She stated she was not working on 05/06/2024. She stated if someone brought Resident #3's meal tray to the dining room and observed other residents did not have a tray, that person was expected to return the tray to the dirty area of the kitchen. The staff was to request Resident #3 meal tray come out the same time as the residents in the C hall dining room. She stated she had been in- serviced on meal service and during the in-service the staff discussed each resident at one table was served their meal prior to serving residents at another table. She stated she did not recall when she received this in-service. <BR/>In an interview on 05/09/2024 at 8:53 AM the ADON stated the staff were expected to serve all residents at one table before serving residents sitting at a different table. She stated if Resident #3 was eating in C dining hall and the staff were aware he was eating there, the nurse supervisor was expected to designate someone to communicate this to the dietary staff in the kitchen. She stated if the dietary department was aware of Resident #3 eating in C dining room his meal tray would have been delivered the same time as the other residents in the C dining room. She stated the person that carried Resident #3's tray from the main dining room to C dining room was expected to notice the other residents did not have their meal trays. The staff was expected to return Resident #3's tray to the dining room dirty dish room and report to the dietary staff that Resident #3 was eating in C hall dining room. Staff was expected to request a new tray to be placed on the C hall meal tray cart. The ADON stated if Resident #39 observed Resident #3 eating and he complained of being hungry and wanted to know why he did not receive a meal, she stated there was a potential Resident #34 would have become very angry and had outburst of verbal or physical behavior. She stated Resident #34 does have outbursts of behaviors and any situation can contribute to his outbursts. The ADON also stated he may feel that the staff was ignoring him, or he may have felt he was left out of receiving any food for lunch. She stated there was a possibility he may have felt isolated from his table mate by not receiving a meal tray at the same time as his table mate. She also stated if Resident #39 waited 20 minutes before he received his meal tray that was too long, and this was a dignity issue. She stated the Nurse Supervisor was responsible for overseeing the meal service in the dining room. <BR/>In an interview on 05/09/2024 at 9:30 AM the Administrator stated the nursing staff was expected to communicate with the dietary staff where a resident was eating their meal if the resident did not always eat in the same dining room every day. She stated if Resident #3 was in the C hall dining room for lunch and the meal trays had not been delivered, the nursing supervisor was expected to designate someone to go to the kitchen and report Resident #3 was eating in C dining room for his lunch meal. She stated the kitchen staff was expected to place Resident #3's tray in the dirty dish area and request a new tray to be carried to Resident #3 if the meal cart was full the same time the meal cart was delivered to the C hall dining room. She stated if Resident #39 sat and watched his tablemate eat his meal approximately 20 minutes prior to him getting his meal, Resident #39 had a potential of feeling angry, or like staff were ignoring him, or he may have felt he was not going to get a meal. She stated it was the nurse supervisor's responsibility to monitor the dining room. The Administrator stated the expectations were that each resident received their meal at the same table before serving meals to another table. She stated this was the facility expectations of meal service. She also stated this was against Resident #39's resident rights of dignity. She stated she there were several resident rights affected in this situation and she was not going to elaborate on anything else about this situation. <BR/>Record Review of Facility Policy on Guidelines on Dining Room Etiquette, not dated, reflected please serve all residents at one table before moving on to another table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 3 of 6 residents (Residents #1, #2, & #3) reviewed for resident rights in that: <BR/>Residents #1, #2, & #3 's call lights was not within reach on 01/30/2025.<BR/>This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. <BR/>Findings included: <BR/>1.Record review of Resident #1's admission record dated 01/30/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 diagnosis of Alzheimer's Disease (a brain disorder that causes memory and thinking skills to decline over time.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 01/22/2025, revealed the resident had a BIMS score of 03, which indicated severe impairment. The MDS also revealed Resident #1 was dependent in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. <BR/>Record review of Resident #1's care plan, dated 01/30/2025, revealed Resident #1 was care planned for communication problems r/t dx of Alzheimer's/Dementia, cognitive deficit, minimal hearing deficit and had an intervention of call light in reach. <BR/>During an observation and interview on 01/30/2025 at 8:50am., Resident #1's call light was observed behind the head of her bed and out of her reach. Resident #1 stated she did not know where her call light was or how long it was behind her bed. Resident #1's stated she could not reach her call light. <BR/>2.Record review of Resident #2's admission record dated 01/30/2025, reflected an [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #2 diagnoses included: hemiplegia affecting right nondominant side (paralysis on one side of the body), reduced mobility (limited ability to move but can do so under certain circumstances), contracture of muscle (when a muscle becomes permanently shortened and tight, making it difficult to move the joint it's connected to), repeated falls (falling multiple times, usually within a short period), and muscle weakness (when your muscles don't have the strength they normally do).<BR/>Record review of Resident #2's Quarterly MDS assessment, dated 12/21/2024, reflected the resident had a BIMS score of 10, which indicated moderated cognitive impairment. The MDS also revealed Resident #2 was dependent in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. <BR/>Record review of Resident #2's care plan, dated 01/30/2025, revealed Resident #2 was care planned for risk of falls r/t confusion, unaware of safety needs and had an intervention be sure Resident #2 call light was within reach and encourage the resident to use it for assistance as needed. <BR/>During an observation and interview on 01/30/2025 at 9:00am., Resident #2's call light was observed behind the head of his bed and out of his reach. Resident #2 stated he could not reach his call light and he would have to wait for someone to come by his room for assistance. Resident #2 stated his call light was often out of reach. <BR/>3. Record review of Resident #3's face sheet dated 01/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included: unspecified dementia (a condition that cause a decline in thinking, memory, and reasoning abilities) and aphasia (a language disorder that makes it difficult to communicate) <BR/>A record review of Resident #3's Quarterly MDS assessment, dated 01/12/2025, reflected the resident had a BIMS score of 12, which indicated mildly impaired. Resident #3's Quarterly MDS reflected she required partial/moderate assistance for shower/bathe self and supervision or touch assistance for personal hygiene. <BR/>A record review of Resident #3's care plan, dated 01/30/2025, reflected Resident #3 was care planned for communication problem r/t aphasia with an intervention of ensure/provide a safe environment: call light in reach. Resident #3's care plan also reflected she was care planned for falls d/t confusion, poor safety awareness r/t dementia with an intervention of be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>During an interview and observation with Resident #3 at 01/30/2025 at 9:06am, Resident #3's call light was observed on floor by the left side of her recliner and out of her reach. Resident #3 stated she could not reach her call light and was not aware it was on the floor next to her recliner. Resident #3 stated she would have to wait for staff to come in her room for assistance due to her call light being out of reach. <BR/>During an interview with the CNA A on 01/30/2025 at 1:15pm, CNA A stated that CNAs make round every two hour or as needed. CNA A stated during rounds CNAs are taught to ensure the resident call lights are in reach. <BR/>During an interview with the DON on 01/30/2025 at 3:50pm, the DON stated all residents call lights should be always within reach. The DON stated it everyone's responsibility to ensure residents call lights are always within reach. The DON stated if a resident's call light was not within reach the resident would not be able to receive assistance if they needed it. <BR/>During an interview with the RCN on 01/30/2025 at 4:00pm, the RCN stated that call lights should always be within reach. The RCN stated that it was everyone's responsibility to ensure the call light are within reach. The RNC stated that if a resident call light was not within reach, then the resident may not be able to call for assistance. The RNC stated her expectation were for all resident's call lights to be always within reach. <BR/>The facility does not have a call light policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 5 of 10 residents (Resident #3, Resident #4, Resident #20, Resident #46, and Resident #61) reviewed for ADL's. <BR/>A) The facility failed to ensure assistance was provided for repositioning and incontinent care every 2 hours for Resident #4, and Resident #20. <BR/>B) The facility failed to ensure Resident #3, Resident # 46 and Resident #61's nails were cleaned.<BR/>These failures placed residents at risk for a decline in health, skin breakdown, loss of self-esteem, and a diminished quality of life and could result in health-related issues from lack of hygiene. <BR/>Findings Included:<BR/>A) Review of Resident #4's face sheet dated 05/07/2024 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Acute Kidney Failure (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue.), Hemiplegia (Hemiplegia is a symptom that involves one-sided paralysis) and Diabetes Mellitus Type II (A condition results from insufficient production of insulin, causing high blood sugar).<BR/>Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 was assessed to not have a BIMS score conducted indicating severe cognitive impairment. Resident #4 was assessed to have functional limitations in range of motion for both upper and lower extremities. Resident #4 was assessed to be dependent on staff for all ADLs and was assessed to be incontinent of bowel and bladder.<BR/>Review of Resident #4's comprehensive care plan reflected a focus area dated 02/23/2021 Resident #4 is incontinent of bowel and bladder. Interventions included incontinent care at least every 2 hours and apply moisture barrier after each episode .<BR/>Observations of Resident #4 on 05/07/2024 hourly from 8:00 AM till 3:35 PM revealed Resident #4 was in her room in her Geri chair (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl) in the same position sitting upright on her coccyx.<BR/>In an interview on 05/07/2024 at 3:20 PM, CNA E stated she had not done incontinent care for Resident #4 since she had gotten her up around 8:00 AM or 8:30 AM due to needing help to transfer them. When asked if she had asked for help CNA E stated she did not. When asked why she shrugged her shoulders.<BR/>Observation on 05/07/2024 at 3:40 PM, revealed CNA F and CNA E in Resident #4's room to put her to bed. The CNAs using the Hoyer lift placed her in bed. Resident #4 was observed to have saturated pants with a strong urine odor. The CNAs removed her pants to reveal a saturated brief with a foul odor. Peri care was provided to Resident #4. The CNAs turned Resident #4 on her side to reveal no redness or skin breakdown. <BR/>Review of Resident #20's face sheet dated 05/07/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Multiple sclerosis (A disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body.), and hemiplegia and hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body).<BR/>Review of Resident #20's Quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 7 indicating severe cognitive impairment. Resident #20 was assessed to be dependent on staff for ADLs. Resident #20 was assessed to have impairment in ROM on one side for her upper extremities and both sides for her lower extremities. Resident #20 was further assessed to be incontinent of bowl and bladder. <BR/>Review of Resident #20's comprehensive care plan reflected a focus area dated 10/14/2021 and revised on 07/26/2023 Resident #20 has hemiplegia/ hemiparesis. Interventions included reposition at least every 2 hours. Further review reflected a focus area dated 10/14/2021 and revised on 07/26/2023 Resident #20 is incontinent of bowl and bladder. Interventions did not include incontinent care every 2 hours. <BR/>In an interview on 05/07/2024 at 3:20 PM, CNA E stated she had not done incontinent care for Resident #20 since she had gotten her up around 8:00 AM or 8:30 AM due to needing help to transfer them. When asked if she had asked for help CNA E stated she did not. When asked why she shrugged her shoulders.<BR/>Observation on 05/07/2024 at 3:45 PM, revealed CNA F and CNA E in Resident #20's room to put her to bed. The CNA's using the Hoyer lift placed her in bed. Resident #4 was observed to have saturated pants with a strong urine odor. The CNA's removed her pant to reveal a saturated brief with a foul odor. Peri care was provided to Resident #20. The CNA's turned Resident #20 on her side to reveal no redness or skin breakdown. <BR/>In an interview on 05/08/2024 at 2:13 PM, the DON stated she expected staff to check on residents every two hours and do position changes and incontinent care if needed. She stated CNA E should have asked for help and did not know why she did not. The DON stated she expected the nursing staff to make rounds as well to ensure the CNAs are doing their jobs. She stated failure to do so could cause skin breakdown. <BR/>Review of the facility' policy Perineal care dated 04/27/2022 reflected An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible . Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. One form of early skin breakdown is maceration or the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes soggy texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations. Skin erosion is the loss of some or all of the epidermis (comparable to a deep chemical peel), leaving a slightly depressed area of skin. Because frequent washing with soap and water can dry the skin, the use of a perineal rinse may be indicated. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition .<BR/>B) Record review of Resident # 3's Face Sheet dated, 05/08/2024, reflected an [AGE] year-old admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia, unspecified affecting right nondominant side (the loss of muscle function on the right side of the body due to tissue damage to the brain or spinal cord), lack of coordination ( uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), and muscle weakness ( when full effort does not produce a normal muscle contraction or movement). <BR/>Record review of Resident #3's annual MDS Assessment, dated, 01/22/2024, reflected resident had a BIMS score of 10 which indicated the resident's cognition was moderately impaired. Resident #3 did not refuse care. He required assistance with ADLs from staff such as personal hygiene, dressing, toileting, showers/ bathing, and transfers. <BR/>Record review of Resident #3's Comprehensive Care Plan, dated 04/03/2024, reflected Resident #3 had an ADL self-care performance deficit related to limited range of motion. Intervention: Resident #3 required extensive assistance of one staff with personal hygiene. <BR/>Observation on 05/06/2024 at 7:17 AM, Resident # 3 was lying in bed. There was a thick black substance underneath all fingernails on his left hand and underneath the nails on his middle finger and fore finger on his right hand. <BR/>Interview on 05/06/2024 at 7:20 AM Resident #3 stated he asked someone to clean his nails few days ago and the person stated they would come back and clean his nails. He stated no one had offered to clean them and he had not asked anyone else. He stated he did not recall the person's name or what date he requested his nails to be cleaned. <BR/>Observation and interview on 05/08/2024 at 10:50 AM, Resident #3 had blackish substance underneath all of his nails on his right hand. Resident #3 stated he asked someone to clean his nails a few days ago and the person said they would come back and clean his nails. He stated no one had cleaned his nails after he asked someone to do it for him. Resident #3 stated he did not know the person's name. <BR/>Record review of Resident #46's Face Sheet dated, 05/08/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of lymphedema, not elsewhere classified (swelling in the body's tissues), major depressive disorder, single episode, unspecified ( is used when the symptoms of depression cause significant distress or impairment in social, occupational, or other important areas of functioning but do not meet the full criteria for any of the depressive disorder diagnoses - Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your normal daily activity), and unspecified dementia, and unspecified severity, with psychotic disturbance (a mild cognitive impairment has yet to be diagnosed with behaviors).<BR/>Record review of Resident #46's Quarterly MDS Assessment, dated on 04/13/2024 reflected Resident #46 had a BIMS score of 10 which indicated the resident's cognition was moderately impaired. Resident #46 did not reject care. She was also assessed to require assistance from staff with ADLs such as: personal hygiene, dressing, bathing, toileting, chair to bed/ bed to chair transfers, toilet transfers, and shower transfers. <BR/>Record review of Resident #46's Comprehensive Care Plan, dated 04/20/2024, reflected Resident #46 was at risk for falls. She had an ADL self-care performance deficit. Intervention: Hygiene resident is able to rinse and spit, brush teeth and partials (does not mention other hygiene in the care plan). <BR/>Observation on 05/06/2024 at 9:02 AM, Resident # 46 was in her room sitting in the recliner. There was a black hard substance underneath her ring finger, and middle fingernails on her left hand. She also had blackish substance underneath her middle finger, ring finger and fore fingernails on her right hand. <BR/>Observation on 05/08/2024 at 10:21 AM, Resident #46 was lying in bed. There was black hard substance underneath her ring finger, and middle fingernails on her left hand. She also had blackish substance underneath her middle finger, ring finger and forefinger nails on her right hand. <BR/>Record review of Resident # 61's Face Sheet dated, 05/08/2024, reflected a 60- year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of mandibulofacial dysostosis ( a rare syndrome characterized by underdeveloped factional bones and a very small lower jaw and chin), unspecified visual loss ( vision that cannot be corrected with glasses or contact lenses), and deaf nonspeaking, not elsewhere classified (unable to hear or speak).<BR/>Record review of Resident #61's Quarterly MDS Assessment, dated 04/14/2024 reflected Resident #61 rarely/never understood others. Her cognitive assessment was completed by staff. She was assessed to have poor short-and long-term memory recall and her decision-making ability was severely impaired. Resident #61 did not have any behavior problems such as rejection of care. Resident # 61 required assistance with ADLs such as: personal hygiene, dressing, eating, toileting, and showers.<BR/>Record review of Resident #61's Comprehensive Care Plan, revised on 05/06/2024, reflected Resident #61 had impaired visual function. She was legally blind in both eyes. Resident #61 had communication problem related to being deaf and non-verbal. Intervention: anticipate and meet needs. Resident #61 also had an ADL self-care performance deficit. Intervention: Resident #61 required extensive assistance with personal hygiene. <BR/>Observation on 05/06/2024 at 9:19 AM, revealed Resident # 61 was standing in the hallway. She held her hands in front of her. Resident #63 had blackish substance underneath her middle finger, ring finger and forefinger nails on her right hand. Resident was not interviewable. <BR/>In an interview on 05/08/2024 at 9:15 AM, LVN C stated the nurses and CNAs were responsible for nail care. She stated the nurses were responsible to clean all resident's nails with a diagnosis of diabetes. LVN C stated it was the CNA's responsibility to clean all other residents' nails. She stated the nurses' made rounds and checked residents, with diabetic nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated the blackish/ brownish substance possibility may had feces or any type of bacteria underneath the resident's nails. LVN C stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated. She also stated she had been in- serviced on nail care and infection control. She stated she was not aware of Resident #3, Resident #61 or Resident #46 refusing nail care.<BR/>In an interview on 05/08/2024 at 08:53 AM, the ADON stated it was the nurses ( LVN or RN's) responsibility to clean residents with a diagnosis of diabetes. She stated CNAs were expected to give nail care to other residents during showers or as needed. She stated if a resident had blackish substance underneath the nails and the resident ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. The ADON stated if staff saw a blackish substance underneath a resident's nails, she expected the nails to be cleaned immediately. She stated only nurses were assigned to clean resident's nails with a diagnosis of diabetes. <BR/>In an interview on 05/08/2024 at 9:05 AM, LVN C stated the nurses and CNAs were responsible for nail care. She stated the nurses were responsible to clean all resident's nails with a diagnosis of diabetes. LVN C stated it was the CNA's responsibility to clean all other residents' nails. She stated the nurses' made rounds and checked residents, with diabetic nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated the blackish/ brownish substance possibility may had feces or any type of bacteria underneath the resident's nails. LVN C stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated. She also stated she had been in- serviced on nail care and infection control. She stated she was not aware of Resident #3, Resident #61 or Resident #46 refusing nail care.<BR/>In an interview on 05/08/2024 at 9:15 AM, CNA J stated CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually cleaned nails during showers or when needed. CNA J stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails. CNA J stated the blackish substance may be bacteria from feces underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated there was a possibility a Resident may need to be assessed at the emergency room if they became severely ill. CNA J stated she gave care to Resident # 3, Resident #46 and Resident #61 and she was not aware of any refusal of nail care from any of these residents. <BR/>In an interview on 05/09/2024 at 9:30 AM, the Administrator stated the CNAs was responsible for nail care during the residents' showers and as needed except for residents with diagnosis of diabetes. She stated the nurses performed all fingernail care for the diabetic residents. The Administrator also stated if a resident swallowed any type of blackish substance and it was determined to be bacteria, there was a potential a resident may become ill with a stomach infection. She also stated the resident may have symptoms of diarrhea and possible dehydration.<BR/>Record review of the facility's policy on Nail Care, dated 2003, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nail care will be performed regularly and safely. The resident will free from abnormal nail conditions. The resident will be free from infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction in the community for 4 of 8 residents (Resident #4, Resident #20, Resident #21, and Resident # 61) reviewed for activities.<BR/>Residents #4, #20, #21, and Resident #61 were not receiving one-on-one activities or involved in group activities during the months of February, March, April, and May of 2024. <BR/>This failure could place residents at risk for a decline in social, mental, psychosocial well-being, and a diminished quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #4's face sheet, dated 05/07/2024, revealed Resident #4 was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses unspecified dementia ( the loss of cognitive functioning, thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities), hemiplegia, unspecified affecting right dominant side (unable to move certain parts of the body, on the right side of the body due to tissue damage to the brain or spinal cord), cerebrovascular disease ( a group of conditions that affect blood flow and the blood vessels in the brain), and aphasia ( a disorder that affects how you communicate). <BR/>Record review of Resident #4's Annual MDS Assessment), dated 06/23/2023, reflected Resident #4 was assessed to rarely understand others or rarely make self-understood. The staff completed the cognitive assessment on Resident #4. She had poor short- and long-term memory recall. Resident #4's decision-making ability was severely impaired. Resident #4's activity preference was assessed by the staff. Her activity interests were the following: receive showers, listen to music, and had family involved in care discussions. <BR/>Record review of Resident #4's Quarterly MDS Assessment, dated 02/24/2024, reflected Resident #4 rarely makes self-understood or understands others. The staff assessed her cognition. She had poor short- and long-term memory recall. <BR/>Record review of Resident #4's Comprehensive Care Plan revised on, 04/08/2024, reflected Resident #4 had hemiplegia (paralysis on one side of the body)/ hemiparesis (weakness that affects one side of your body). She had impaired hearing and vision. Resident #4 also had a communication problem related to aphasia. She had impaired cognitive function related to dementia. Intervention: Provide a program of activities to accommodate resident's abilities. Resident #4 needed one-on-one in room activities, socialization, and sensory stimulation. (This problem was created on 04/06/2022) Intervention: The activity director will provide Resident #4 with one-on-one visits with sensory stimulation (music, and hand massages) at least two times per week. (intervention was created on 04/06/2022).<BR/>Record Review of Resident #4's Activity Documentation in the electronic medical record reflected Resident #4 did not receive one-on-one activities or attend group activities during the months of February, March, April, and May of 2024. <BR/>Observation on 05/06/2024 at 7:40 AM Resident #4 was sitting in her Geri-chair in her room and the television was on in the room. <BR/>Observation on 05/07/2024 at 9:43 A M Resident #4 was sitting in her Geri-chair in her room. There was not any stimulation in the room. <BR/>Observation on 05/07/2024 at 12:45 PM Resident #4 was sitting in her Geri-chair in her room. The TV was on in the room. <BR/>Record review of Resident # 20's face sheet dated, 05/08/2024, reflected, Resident #20 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths- membrane covering a muscle- of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impaired speech, blurred vision, severe fatigue and impairment of muscular coordination), unspecified dementia, unspecified severity, with agitation ( the loss of cognitive functioning, thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities with behaviors), major depressive disorder, recurrent, unspecified (symptoms align with depressive disorder and result in a significant distress or impairment in daily life- a mood disorder that causes a persistent feeling of sadness and lost of interest and can interfere with your normal day-to-day activities, and sometimes feel as if life wasn't worth living), anxiety disorder due to known physiological condition ( frequent moments of worry or fear, symptoms rapid heartbeat, dizziness or feel weak), and attention and concentration deficit (forgetfulness, problems staying on task, easily distracted, easily bored, easily confused and difficulty following instructions). <BR/>Record review of Resident # 20's Annual MDS Assessment, dated 08/19/2023 reflected Resident #20 had unclear speech. She had a BIMS score of five, which indicated the residents' cognition was severely impaired. Resident #20 was assessed of feeling depressed. She was not capable of finishing the activity preferences. The staff assessed Resident #20's activity interests were the following: listening to music, doing things in groups of people, spending time outdoors, and participating in religious activities or practices. <BR/>Record review of Resident # 20's Quarterly MDS Assessment, dated 05/03/2024, reflected Resident #20 had a BIMS score of seven, which indicated the residents' cognition was severely impaired. Resident #20 was assessed to have been diagnosed with depression and anxiety. <BR/>Record review of Resident #20's Comprehensive Care Plan, reviewed on 05/06/2024, reflected Resident #20 had impaired cognitive function and dementia. Intervention: engage Resident #20 in simple, structured activities and avoid over demanding tasks. (Problem and Intervention initiated on 10/14/2021). Resident #20 had communication problem related to multiple sclerosis. She had major depressive disorder. Resident #20 had psychosocial well-being problem potential related to illness/disease. Intervention: observe and document residents' feelings related to isolation, unhappiness, and/ or anger. Resident #20 needed in room activities, socialization, and sensory stimulation. Intervention: the activity director will provide the resident with one-on-one visits with sensory stimulation (music and talking about things she can see outside her window) at least two times per week. (Problem and Intervention was initiated on 04/21/2022). Resident #20 had depression. Intervention: observe any signs or symptoms of sadness, hopelessness, tearfulness, negative statements, or anxiety. <BR/>Record Review of Resident #20's Activity Documentation in the electronic medical record reflected Resident #20 did not receive one-on-one activities or attend group activities during the months of February, March, April, and May of 2024. <BR/>Observation on 05/07/2024 at 7:50 AM Resident #20 was in her room sitting in her chair. The television was on in the room. <BR/>Observation on 05/07/2024 at 9:45 AM Resident #20 was in her room sitting in a chair. There was not any stimulation in the room. <BR/>Observation on 05/07/2024 at 12:45 PM Resident #20 was in her room and the television was on in the room. <BR/>Record review of Resident # 21's Face Sheet, dated, 05/08/2024, reflected an [AGE] year old female admitted to the facility on [DATE] with the following diagnoses depression (a constant feeling of sadness and loss of interest, which stops you from doing your normal activities), anxiety disorder (frequent moments of worry or fear, symptoms rapid heartbeat, dizziness or feel weak), unspecified dementia, unspecified severity (the loss of cognitive functioning, thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities), and senile degeneration of the brain, not elsewhere classified ( decrease in the ability to think, concentrate, or remember). <BR/>Record review of Resident #21's Annual MDS Assessment, dated 10/07/2023, reflected Resident #21 had unclear speech and minimal difficulty with hearing (difficulty in some environments). Resident #21 rarely/ never understood when others were speaking to her. She had difficulty communicating some words or finishing her thoughts but was able to if given time. Resident #21 had a BIMS score of two which indicated her cognitive status was severely impaired. Her activity preferences were the following: listen to music, doing things with groups of people, spending time outdoors, and participating in religious activities or practices. <BR/>Record review of Resident #21's Quarterly MDS Assessment, dated 03/16/2024, reflected Resident #21 sometimes made self-understood (ability was limited to making concrete requests) and rarely/ never understand others. Resident was not capable of completing cognitive section of the MDS. She was assessed to have poor short- and long-term memory recall. Resident #21 was assessed to have the following diagnoses: depression, anxiety, and dementia. <BR/>Record review of Resident #21's Comprehensive Care Plan, reviewed on 04/20/2024 reflected Resident #21 had a communication problem related to dementia. Intervention: Anticipate and meet needs. Provide a program of activities that accommodates the resident's communication abilities. Resident #21 had a potential to demonstrate physical behaviors. Intervention: Give Resident #21 as many choices as possible about her activities. She had a hearing deficit. Intervention: Speak in a clear voice and face her when speaking. Resident #21 needed in-room activities, socialization, and sensory stimulation. Intervention: The activity director will provide resident with one-on-one visits with sensory stimulation at least 2 times per week. (This intervention was initiated on 10/12/2022).<BR/>Record Review of Resident #21's Activity Documentation in the electronic medical record reflected Resident #21 did not attend group activities or receive one-on-one activities during the months of February, March, April, and May of 2024. <BR/>Observation on 05/06/2024 at 7:10 AM revealed Resident #21 was in her room sitting in her Geri- chair. The television was on in the room. <BR/> Record review of Resident # 61's Face Sheet dated, 05/08/2024, reflected a 60- year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of unspecified visual loss (vision that cannot be corrected with glasses or contact lenses), anemia (low levels of healthy red blood cells to carry oxygen throughout your body. Symptoms include fatigue, weakness, and feeling short of breath), and deaf nonspeaking, not elsewhere classified (unable to hear or speak).<BR/>Record review of Resident #61's admission MDS Assessment, dated 07/15/2023, reflected Resident #61's hearing was highly impaired, and she did not speak. She rarely/ never made self-understood or understand others. Her vision was assessed to be severely impaired. Resident #61 was not able to complete the cognitive section of the MDS. Staff assessed resident to be severely impaired with daily decision-making ability. She had poor short- and long-term memory recall. Resident #61 was assessed to enjoy caring for her personal belongings and choosing clothes to wear. <BR/>Record review of Resident #61's Quarterly MDS Assessment, dated 04/14/2024 reflected Resident #61 rarely/never was understood others. Staff completed her cognitive assessment. She was assessed to have poor short-and long-term memory recall and her decision-making ability was severely impaired. Resident #61 was assessed to have diagnoses of deaf, nonspeaking, and unspecified visual loss. <BR/>Record review of Resident #61's Comprehensive Care Plan, revised on 05/06/2024, reflected Resident #61 had impaired visual function. She was legally blind in both eyes. Intervention: do not rearrange any furniture. Resident #61 had communication problem related to being deaf and non-verbal. Intervention: anticipate and meet needs. Resident #61 had hearing deficit to both ears. Intervention: observe for hearing ability and report any changes to the physician. Resident #61 had no activity involvement with a group. She will be provided with in room activities of choice three times per week. Intervention: Use tactile sensory such as zipper, button tools, and use puzzles for vision impaired. (The activity problem and interventions were initiated on 10/24/2023). <BR/>Observation on 05/06/2024 at 9:19 AM revealed Resident # 61 was standing in the hallway with a plate in her hand and she held it up and was releasing it from her hand to fall on the floor. <BR/>Observation on 05/06/2024 at 9:24 AM revealed Resident #61 was assisted to her room by CNA P. When in her room, CNA P gave her a tactile activity item and Resident #61 immediately threw it on the floor. <BR/>Interview on 05/06/2024 at 9:26 AM CNA P stated Resident #61 did not enjoy the cloth with items attached to it. She stated when Resident #61 was given that activity item she always threw it on the floor. Resident #61 enjoyed holding hands sometimes and would smell things sometimes. She stated she did not observe activity staff doing an activity with Resident #61 in her room or in a group activity. <BR/>Observation on 05/06/2024 at 2:05 PM Resident #61 was pacing in her room and entered the hallway. She stood in hallway less than 3 minutes and walked into her room. She would sit in her chair less than 3 minutes and begin to pace again. The only activity item that was in her room was a piece of cloth with different tactile items attached to it. <BR/>Observation on 05/07/2023 at 9:15 AM Resident #61 was standing in her room. CNA P was in her room and attempted to give her the cloth with activity items on the cloth. When CNA P gave it to her, Resident #61 would immediately throw it on the floor. <BR/>Observation on 05/07/2024 at 10:50 AM Resident #61 was standing in the hall pacing sideways and then she would stand and move her head constantly. CNA P intervened and assisted Resident #61 to her room, and she assisted her to her chair. The resident sat for a few minutes and began to pace in her room. <BR/>In an interview on 05/07/2024 at 10:53 PM CNA P stated Resident #61 was difficult to re-direct at times. She stated the activity staff did not give them any other activity items to attempt with Resident #61. She stated the staff does not know what she can or can not do therefore, the activity staff did not attempt to do anything with Resident #61. <BR/>Observation on 05/08/2024 at 9:30 AM Resident #61 was in her room and would stand up from her recliner and then immediately sit on her recliner. She continued to do this for approximately 5 minutes. She began to pace in her room and would stand at the door leading to the hallway and stand for a few minutes before returning to her recliner. <BR/>In an interview on 05/08/2024 at 10:54 AM CNA F stated she had given care to Resident #4, Resident #21, and Resident #20. She stated she did not remember how many days of the week or months she had given care to these residents. CNA F also stated she had not observed the Activity Director or any staff in Resident #4, Resident #21 or Resident #20's room doing any type of activities with them. She stated she had not observed these residents attending any group activities. CNA F stated all three residents needed some type of activities . She stated it was possible for a resident become lonely and their memory may decline. <BR/>In an interview on 05/8/2024 at 2:50 PM LVN B stated she had not observed any in room activities with Resident # 4, Resident #20 or Resident #21. She stated they could benefit from having activities or some type of stimulation other than the television. She also stated these residents needed someone to talk to them or play some calm/relaxing music. LVN B stated she had not witnessed Resident #20, Resident #21, or Resident #4 attending any group activities . LVN B stated residents without any stimulation or involved in activities may become depressed or withdrawn. <BR/>In an interview on 05/09/2024 at 9:15 AM LVN C stated she had not witnessed activity staff go into Resident #61's room and do any type of one-on-one activity. She stated to her knowledge Resident #61 did not receive any type of activity in her room or in a group setting by the activity staff. LVN C stated it was difficult to interview with Resident #61 due to her being blind and deaf. She stated sometimes she allows people to hold her hand and sit with her. She stated she did not know about activities with Resident #4, Resident #20, or Resident #21. LVN C stated all residents needed activities in their room or in a group setting. She stated if a resident did not receive any type of activities, they may become lonely or feel no one cared about them. <BR/>Interview and record review on 05/09/2024 at 9:30 AM the Administrator stated she expected all the residents not leaving their rooms or attending group activities to receive some type of activity of their past or present interest in their room by the activity director. She stated she knew some of the residents' received visits in their room. The administrator stated they were unable to locate the in-room list in the activity office. The administrator stated if a resident did not leave their room and did not receive one-on-one visits there was a potential a resident may feel lonely, have a decrease in their cognitive status, develop depression, or if they had a diagnosis of depression their depression may lead to a major depressive disorder. The administrator stated she was the activity director's supervisor. She stated the activity director had not been in the facility during the survey from 05/06/2024 through 05/09/2024. She reviewed the electronic medical records of the residents identified of needing one-on-one activities (Resident #4, Resident #20, Resident #21, and Resident # 61). The administrator stated after reviewing the electronic medical records there was no documentation of these residents receiving one-on-one activities or attending any group activities for the months of February, March, April, and May of 2024 . <BR/>Interview on 05/09/2024 at 10:05 AM CNA Q stated Resident #61 would sit still and was more relaxed when someone would sit with her. She stated this did not happen all the time, but it helped more than giving her the cloth activity item. CNA Q stated she was not aware of activity staff doing any activities with Resident #61 or attempting to try different activities with Resident #61. She also stated she had not observed activity staff do activities with Resident #61 in her room or attempt to do activity with her in a group setting . She stated if a resident did not receive any type of sensory stimulation in room or out of room with activity staff the resident may become depressed or lonely. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #21) of six residents reviewed for pressure ulcers.<BR/>The facility failed to ensure Resident #21 who was at risk for skin breakdown was turned every two hours and provided incontinent care. on 05/07/2024, Resident #21 was left in the same position in her Geri-chair (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl.) for 6 and a half hours from 8:00 AM till 2:30 PM. Once Resident #21 was placed in bed she was observed to have two DTIs (A pressure-related injury to subcutaneous tissues under intact skin.) to her coccyx that were previously unidentified by the facility. <BR/>An immediate Jeopardy (IJ) situation was identified on 05/07/2024 at 5:10 PM. While the IJ was removed on 05/09/2024 at 3:12 PM, the facility remained out of compliance at a scope of isolated with no further actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>These failures placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. <BR/>Findings Include:<BR/>Review of Resident #21's face sheet dated 05/07/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) and chronic lymphocytic leukemia (is a type of cancer in which the bone marrow makes too many lymphocytes (a type of white blood cell).<BR/>Review of Resident #21's quarterly MDS dated [DATE] reflected Resident #21 was assessed to have a BIMS assessment was not conducted indicating Resident #21 had severe cognitive impairment. Resident #21 was assessed to be dependent on staff for all areas of ADL care and was assessed to be incontinent of bowel and bladder.<BR/>Review of Resident #21's comprehensive care plan reflected:<BR/>-problem dated 09/26/2022 Resident #21 is incontinent of bowel and bladder. Interventions included .Check resident every two hours and assist with toileting as needed. Provide peri care after each incontinent episode and report any skin change to nurse immediately.<BR/>-problem dated 11/22/2023 and revised 04/19/2024 Resident #21 has actual impairment to skin integrity related to fragile skin, prone to easily bruising with pressure due to chronic lymphocytic leukemia. Interventions included .Keep skin clean and dry .reposition resident to prevent pressure for body parts . further review of Resident #21's care plan reflected no plan of care for pressure ulcers.<BR/>Review of Resident #21's consolidated physician orders dated 05/07/2024 no orders for pressure ulcer wound care. Further review reflected an order dated 09/27/2022 pad all boney prominences with pillows to prevent breakdown. <BR/>Review of Resident #21's weekly skin assessment dated [DATE] and locked on 05/06/2024 reflected no MASD or pressure ulcers were identified.<BR/>Observation and interview on 05/07/2024 at 8:00 AM, revealed Resident #21 in her Geri chair in her room. Resident #21 was not interviewable.<BR/>Observation on 05/07/2024 at 9:43 AM, revealed Resident #21 in her Geri chair in the same position in her room. <BR/>Observation on 05/07/2024 at 12:00 PM, revealed CNA E passing out meal trays on Resident #21's hall. CNA E arrived at Resident #21's room at 12:25 PM and started feeding Resident #21. CNA E did not reposition Resident #21.<BR/>Observation on 05/07/2024 at 12:45 PM, revealed Resident #21 up in her Geri chair in the same position. <BR/>Observation on 05/07/2024 at 1:45 PM, revealed Resident #21 up in her Geri chair in the same position.<BR/>In an interview on 05/07/2024 at 1:54 PM, CNA E stated she had not done incontinent care or repositioned Resident #21 since she got her up at around 8:00 AM. She stated she was fixing to go get help since she was on the hall by herself, and she needed help to put her to bed.<BR/>Observation on 05/07/2024 at 2:30 PM, revealed CNA E and CNA F in Resident #1's room to put her in bed via the Hoyer lift. Observation of Resident #21's brief revealed it was saturated with urine and had a strong odor. CNA E turned Resident #21 to her right side to reveal a DTI approximately 0.1cm x 0.1cm to her right ischial tuberosity surrounded by a blanchable area of redness approximately 3 cm long and a 0.2 cm x 0.2 cm DTI to her lower coccyx area.<BR/>In an interview on 05/07/2024 at 3:00 PM, the ADON state Resident #21 did not currently have skin breakdown so any areas on her would be new. After observing the areas to Resident #21's coccyx area she stated Resident #21 did have breakdown areas on her boney prominences.<BR/>In an interview on 05/07/2024 at 3:15 PM, the DON stated she looked at Resident #21 yesterday and her skin was clear. When asked if the area could have resulted from her being up in her chair for an extended period of time she stated, I did not know she was up all day.<BR/>In an interview on 05/07/2024 at 3:20 PM, Resident #21's Hospice Nurse stated Resident #21 was at risk for breakdown and her skin was very delicate. She stated Resident #21's coccyx area was clear on her last visit a few days ago.<BR/>Observation and interview on 05/08/2024 at 10:38 AM, revealed Resident #21 in room being prepped for wound care with the Wound care physician. Observation of Resident #21's coccyx area DTIs revealed both had declined and were darker in color from 05/07/2024. Resident #21's wound care physician stated both areas on Resident #21's coccyx were DTIs. He stated the areas could definitely be caused by not being turned and being on the same bony prominences for an extended period of time. <BR/>Review of Resident #21's Physician wound evaluation and management summary dated 05/08/2024 reflected Resident #21 was assessed to have an unstageable DTI to the distal sacrum measuring 0.1cm x 0.1cm and undetermined depth. Further review reflected an unstageable DTI to the sacrum measuring 0.3cm x 0.3cm and undetermined depth.<BR/>In an interview on 05/08/2024 at 2:13 PM, the DON stated she expected the CNAs to check on the residents every 2 hours and do position changes. She stated CNA E could have asked anyone to help her and she did not. The DON stated CNA E did not give her an explanation of why she did not change Resident #21. The DON stated she expected the nurses as well to make rounds every two hours to ensure the CNAs are doing their jobs and to make sure the residents are taken care of to prevent skin breakdown. <BR/>Review of the facility policy pressure injury prevention, assessment and treatment dated 08/12/2016 reflected 1.Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems . 4. Causes of Pressure Injuries: Unrelieved pressure over a bony prominence resulting in ischemia at the area of pressure. 1.Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. 2. Do the blanching test by pressing the finger into a reddened area, a normal blood supply to the reddened area is seen when the area blanches white and then turns pink again. If the area remains red, a pressure sore is impending due to impaired circulation, keep resident off the area for 24 hours and then repeat the test.<BR/>Review of the facility' policy Perineal care dated 04/27/2022 reflected An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible . Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. One form of early skin breakdown is maceration or the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes soggy texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations. Skin erosion is the loss of some or all of the epidermis (comparable to a deep chemical peel), leaving a slightly depressed area of skin. Because frequent washing with soap and water can dry the skin, the use of a perineal rinse may be indicated. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition .<BR/>The Administrator was notified on 05/07/2024 at 5:10 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided.<BR/>The following POR was accepted on 05/09/2024 at 11:40 AM:<BR/>Date: 5/7/2024 <BR/>On 5/6/2024 an annual survey was initiated at the facility.<BR/>5/7/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the<BR/>Regulatory Services has determined that the condition at the facility constitutes an<BR/>Immediate jeopardy to resident health and safety.<BR/>Plan of Removal for F686 <BR/>Approximately 48 residents who are incontinent and/or require assistance with turning and repositioning could be affected by this deficient practice. <BR/>Problem: Failure to prevent pressure injury <BR/>Root cause analysis was conducted. CNA E failed to change the resident's brief timely. CNA E failed to reposition the resident at minimum of every two hours while in the Geri chair. This caused pressure injuries. The Administrator, DON, and ADON will review the schedule daily to include weekends. This review will include that 2 staff members will be present at all times on station #1 to assist with ADLs. The call-in process is that they call the DON's cell phone when calling in. DON is responsible for initiating finding additional coverage. The DON will utilize the PRN call list, shift bonuses, staff from nearby sister facilities, or agency staffing if needed. <BR/>Interventions:<BR/>Weekly ulcer assessments for Residents #21 were completed to include measurements by DON, ADON, and Tx Nurse on 5/7/24. Two new pressure wounds were identified, measured, and treated according to physician orders. <BR/>The MD was notified on 5/7/24 of Resident #21 new pressure wounds by the Tx Nurse. Orders were received for treatment and implemented on 5/7/24.<BR/>Wound care treatments for Residents #21 were completed as ordered by the Tx Nurse on 5/7/24. <BR/>100% skin rounds were initiated 5/7/24 by DON, ADON, Treatment Nurse. No additional pressure wounds were identified. <BR/>Administrator, DON, ADON, and Tx Nurse were in-serviced 1:1 by the Regional Compliance Nurse on 5/7/24 on the following topics. Completed 5/7/24.<BR/>Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. <BR/>Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. <BR/>Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately.<BR/>CNA E was in-serviced 1:1 by the DON on 5/7/24 for the following topics. Completed on 5/7/24. <BR/>Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. <BR/>Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. <BR/>Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The hall is adequately staffed with 1 nurse, 1 med aide, and 2 CNAs. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. <BR/>In-services:<BR/>The following in-services were initiated by Regional Compliance Nurse, DON on 5/7/24 for all clinical staff. Any clinical staff not present or in-serviced on 5/7/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. <BR/>Pressure Injury Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. <BR/>Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours while in bed or chair could result in skin breakdown which is neglect. <BR/>Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. <BR/>The Administrator, DON, and ADON/designee will be responsible for ensuring that residents are checked for incontinence, brief changed, turned, and repositioned while in bed or Geri chair. Monitoring will occur during rounds daily for 10-15 randomly selected residents 7 days per week across all shifts including weekends. Monitoring will be documented on a form will continue for a minimum of 6 weeks. <BR/>The Medical Director was notified of the immediate jeopardy situation on 5/7/24 by the administrator. <BR/>An ADHOC QAPI meeting was held with the Administrator, DON, ADON, Tx Nurse and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 5/7/24.<BR/>The Survey Team monitored the POR on 05/08/2024 through 05/09/2024 as followed:<BR/>Review of the facility's weekly wound assessment for Resident #21 reflected it was complete and conducted by the wound care physician on 05/08/2024.<BR/>Review of Resident #21's nursing progress notes and weekly wound assessment dated [DATE] reflected Resident #21's physician was notified, and orders received for treatment and consult with wound care physician.<BR/>Observation on 05/08/2024 at 10:38 AM, revealed wound care treatment conducted by the ADON and wound care physician. <BR/>Review of the facility's skin round documentation initiated on 05/07/2024 reflected skin assessments conducted on all residents without new pressure ulcers being identified. <BR/>Review of the one-on-one in-services for the Administrator, DON, ADON and Treatment Nurse dated 05/08/2024 reflected it was conducted by the RNC and covered the following areas: Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing included requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately.<BR/>In an interview on 05/08/2024 at 9:29 AM, the DON stated she was in-serviced by the RNC regarding pressure ulcer prevention, ADL care and monitoring staff to ensure care is provided. <BR/>In an interview on 05/08/2024 at 9:45 AM the Administrator stated the RNC performed the one on one inservices for her and the DON and ADON. <BR/>Review the one-on-one in-service for CNA E dated 05/08/2024 reflected it was conducted and covered the following topics: Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The hall is adequately staffed with 1 nurse, 1 med aide, and 2 CNAs. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately.<BR/>Attempts to interview CNA E on 05/09/2024 were unsuccessful.<BR/>Review of the facility conducted in-services for Pressure Injury Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024.<BR/>Review of the facility conducted in-services for Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours while in bed or chair could result in skin breakdown which is neglect was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024.<BR/>Review of the facility conducted in-services for Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024.<BR/>In an interview on 05/09/2024 at 9:18 AM, CNA H stated she had been trained on rounds. She stated that the training covered doing rounds every two hours, changing the resident, and getting them off their bottoms. She stated residents on the secure unit were changed every hour to every hour and a half. She stated that when a resident had a change in skin condition that it should be reported to the nurse. She stated she was trained on pressure injury prevention. She stated the training covered making sure the resident was not on their bottom for an extended period and to keep them dry. She felt like the facility had enough staff and that the staff could do all their tasks and showers. <BR/>In an interview on 05/09/2024 at 9:23 AM, the ADON stated she had been trained on doing rounds. She stated that the training covered turning the resident and changing the resident. She stated residents were checked every two hours. She stated that when changing a resident staff were to reposition the resident to ensure the resident was not on the same side they had been on. The ADON stated she had been trained on change in skin condition. She stated that she would take care of the resident. She said she would assess the skin, so she could get measurements. She said she would then call the wound doctor and the family about the change in skin. She stated she would get an order in place. She stated that she had been trained on pressure injury prevention. She stated the training covered making sure that the resident is turned or repositioned every two hours. She stated when the resident was in a chair staff are supposed to repositioned in the chair. She stated that she felt the facility had enough staff. She stated everyone worked together and the staff were able to get everything done. She said she felt she had enough time to do all tasks and rounds.<BR/> In an interview on 05/09/2024 at 9:37 AM, CNA G stated he was trained on rounds. He stated the training covered making sure the rounds were done every two hours and repositioned when finished changed. He stated that if the resident had a change in skin condition, he would report it to the nurse. He stated he was trained on pressure injury prevention. He stated the pressure injury prevention training covered turning the resident every two hours, making sure the resident was of the injury and put a pillow under the resident and keeping them dry. He stated he did not think the facility had enough staff. He stated he was able to complete all tasks because the shift is 12 hours. He stated he will do a shower for 30 minutes and then check the residents. He stated that the nurses and CMAs were good about helping. <BR/>In an interview on 05/09/2024 at 9:12 AM CNA I stated she has been in-serviced this morning on turning every 2 hours, abuse, and neglect, not feeding 2 patients at one time, and reporting skin issues. I asked if you see a change in skin condition what do you do? She stated she tells her charge nurse immediately. When asked her if she felt there is enough staff working on the floor. She said yes. There is always 2 people on the locked unit. She stated if someone calls in sick, they bring someone else in. <BR/>In an interview on 05/09/2024 at 9:22 AM LVN C stated she had been in-serviced this morning on abuse and neglect, pressure injury, skin breakdown, turning residents every 2 hours, not to feed 2 patients at one time and reporting skin issues. I asked if you see a change in skin condition what do you do? She told me she does an assessment, reports to the DON, lets the doctor know, and then puts treatment into place. I asked her how often she checks on residents, and she told me every 2 hours and if resident is having diarrhea more often. I asked her if she felt there is enough staff. She said for the most part yes. There is a shortage everywhere. I asked her what happens when there is not enough staff on the floor. She said there are enough resources and people come help.<BR/>In an interview on 05/09/2024 at 9:32 AM, CNA J stated she had in serviced on rounds, checking residents every 2 hours, abuse, and neglect, and who to report skin breakdown to. I asked her how often she checks on her residents she said every 2 hours. I asked her if she felt there was enough staff on the floor. She said yes. I asked her what happens when there is not enough staff. She said she does her job and does what she needs to do. <BR/>In an interview on 05/09/2024 at 9:38 AM, CMA D stated she has been in serviced this morning on not feeding 2 people at once, completing rounds every 2 hours, abuse, and neglect. I asked her if she sees a change in skin condition what she does. She reported she goes to the charge nurse. I asked her who she reports skin changes to she said the charge nurse. I asked her how often rounds are she said every 2 hours. <BR/>In an interview on 05/09/2024 at 9:42 AM, LVN B stated she has been in-serviced this morning on abuse and neglect, skin breakdown, incontinent care, cleaning glucometers. I asked her how often they check on residents. She said every 2 hours. I asked her if she felt there was enough staff she said yes. That they always call people in if someone does not come in. <BR/>In an interview on 05/09/24 at 12:55 PM, LVN K worked 6P to 6 A on 5/8 to 5/9 She stated they were in serviced on a lot last night and she was half asleep and will try to remember<BR/>1. <BR/>Incontinent care<BR/>2. <BR/>Using barrier cream<BR/>3. <BR/>Foley catheter and using PPE when giving care to Foley Catheter<BR/>4. <BR/>Abuse and Neglect<BR/>5. <BR/>Reporting any new skin concerns<BR/>6. <BR/>Pressure Ulcers<BR/>She stated there was more, but she could not remember. <BR/>In an interview on 05/09/2024 at 12:49 PM, CNA O stated she was in serviced on abuse neglect the rounds and PPE for open wound and foley. Reposition the resident every two hours with the rounds. Was in serviced on pressure injury precautions put a pillow under the resident. The resident has heel protectors on to prevent pressure. Stated she thinks there is enough. No task not able to complete has not been short in over a month. Yes, stated she can do all her rounds and shower she is the only aid for two halls. <BR/>In an interview on 05/09/2024 at 12:58 PM, CNA P stated he had been in serviced on rounds, checking residents every 2 hours, abuse, and neglect. He said he checks on residents every 2 hours and felt there was enough staff on the floor. He said they will call and see if more people come in she stated there is not enough staff.<BR/>On 05/09/2024 at 3:12 PM, the Administrator was notified the IJ was removed on 05/09/2024 at 3:12 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two of five residents (Resident #4 and Resident #20), reviewed with limited range of motion.<BR/>A) The facility failed to ensure Resident #4 had interventions in place for her bilateral hand contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her hands and failed to ensure her fingernails were trimmed. <BR/>B) The facility failed to ensure Resident #20 had interventions in place for her right-hand contracture to prevent further decline of the range of motion in her right hand. <BR/>This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. <BR/>Findings Include:<BR/>A) Review of Resident #4's face sheet dated 05/07/2024 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) , Acute Kidney Failure(A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue.), Hemiplegia (Hemiplegia is a symptom that involves one-sided paralysis) and Diabetes Mellitus Type II (A condition results from insufficient production of insulin, causing high blood sugar).<BR/>Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 was assessed to not have a BIMS score conducted indicating severe cognitive impairment. Resident #4 was assessed to have functional limitations in range of motion for both upper and lower extremities. Resident #4 was assessed to be dependent on staff for all ADLs and was assessed to be incontinent of bowel and bladder.<BR/>Review of Resident #4's comprehensive care plan reflected a focus area dated 02/23/2024 Resident #4 has hemiplegia/hemiparesis. Interventions included apply right wrist cock-up splint with finger extenders after breakfast and take off before lunch .apply left padded palm guard on after breakfast and off before lunch .clean both hands with soap and water. Provide gentle stretch and ROM to bilateral hands one time day for contracture management .reposition at least every 2 hours and PRN. Further review of Resident #4's comprehensive care plan reflected a focus area dated 02/23/2021 Resident #4 is incontinent of bowel and bladder. Interventions included incontinent care at least every 2 hours and apply moisture barrier after each episode .<BR/>Review of Resident #4's consolidated physician orders reflected orders to apply Left padded palm guard after breakfast and off before lunch, apply right wrist cock-up splint with finger extenders after breakfast and take off before lunch and to clean both hand with soap and water and provide gentle stretch and ROM to bilateral hand for contracture management. <BR/>Observation on 05/07/2024 at 9:43 AM, revealed Resident #4 had contractures to both hands. Her fingers were bent toward her palm with her fingers pushing into the palm of her hand. Resident #4 had long finger nails. No splints or palm guards were observed.<BR/>Observation on 05/07/2024 at 12:00 PM, revealed CNA E in Resident #4's room feeding her roommate Resident #20. Resident #4 bilateral hands remained without splints or palm guards. <BR/>Observation on 05/07/2024 at 12:45 PM, revealed Resident #4 remained in room bilateral hands remained without splints or palm guards. <BR/>In an interview on 05/07/2024 at 1:15 PM, CNA E stated Resident #4 should have wash cloths in her hands. She stated her fingers nails were very long and needed to be trimmed. She stated the facility did not have a shower aide, so she had to do the showers and work two halls and has not gotten around to doing Resident #4's fingernails or putting her hand rolls in because they were short staffed. She stated she was also responsible for showering Resident #4, and she stated did not get to it yesterday, but she did do it Friday.<BR/>In an interview on 05/07/2024 at 1:25 PM LVN A stated Resident #4 should have hand rolls in her hands at all times and further stated that Resident #4 fingernails were long and needed to be trimmed she stated the CNA gets behind because she has to work both halls and do showers.<BR/>Review of Resident #20's face sheet dated 05/07/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Multiple sclerosis (A disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body.), and hemiplegia and hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body).<BR/>Review of Resident #20's Quarterly MDS dated [DATE] reflected she was assessed to have a 7 BIMS score indicating severe cognitive impairment. Resident #20 was assessed to be dependent on staff for ADLs. Resident #20 was assessed to have impairment in ROM on one side for her upper extremities and both sides for her lower extremities. <BR/>Review of Resident #20's comprehensive care plan reflected a focus area dated 10/14/2021 and revised on 07/26/2023 Resident #20 has hemiplegia/ hemiparesis. Interventions included reposition at least every 2 hours. Further review reflected a focus area dated 10/14/2021 and revised on 07/26/2023 Resident #20 is incontinent of bowl and bladder. Interventions did not include incontinent care every 2 hours. Resident #20's care plan did not include interventions for her contracted right hand or use of the therapy carrot. <BR/>Review of Resident #20's consolidated physician orders reflected no orders for contracture devices. Further review reflected an order dated 04/27/2024 Pt to receive skilled OT services 3 X week X 60 days for therapeutic exercise, contracture management/education and therapeutic activities as tolerated.<BR/>Observation and interview on 05/06/2024 at 7:15 AM, revealed Resident #20 up in Geri chair alert but not interviewable. Resident #20 was observed to have a contracture to her right hand and a therapy carrot was observed in her hand.<BR/>Observation on 05/07/2024 at 9:43 AM, revealed Resident #20 in room up in Geri chair. No hand roll or device was in her right hand.<BR/>Observation on 05/07/2024 at 12:45 PM, revealed Resident #20 in room up in Geri chair. No hand roll or device was in her right hand. Further observation revealed Resident #20's therapy carrot was noted on her night stand behind her.<BR/>In an interview on 05/07/2024 at 1:15 PM, CNA E stated Resident #20 needed her therapy carrot in her hand, but she takes it out. CNA E then reached behind Resident #20 (who is unable to move on own) and retrieved the therapy carrot from her nightstand and placed it in her hand without resistance from Resident #20.<BR/>In an interview on 05/08/2024 at 2:13 PM, the DON stated regarding residents with contractures, she expected staff to do range of motion and make sure their devices are in place and the nurses need to make rounds to check on residents because it could cause increased contracture, decreased ROM and pressure.<BR/>Review of the Facilities policy Immobilization Devices, Splints/ Slings/ Collars/ Straps dated 2003 reflected immobilization devices are splints, slings, cervical collars, and clavicle straps that are applied to restrict movement, support, and preserve the integrity of an injured arm, shoulder or neck. Splints are rigid devices that can be used to treat a bone fracture, dislocation, or to prevent further damage of bones. All devices will be monitored on every two-hour schedule. Monitoring will be documented in the clinical record or flow sheet. Gradual discontinuation of the use of a device is preferred over abrupt cessation to allow for gradual muscle strengthening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for one of four residents reviewed for catheters. (Resident #18)<BR/>The facility failed to ensure Resident #18 received care to prevent urinary tract infections when they stored his catheter bag on the floor and failed to ensure a catheter secure device was in place to prevent dislodgment. <BR/>These failures could place residents with foley catheters at risk for urinary tract infections and change of condition.<BR/>Findings included:<BR/>Review of Resident #18's face sheet dated 05/08/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Cerebrovascular disease (conditions that impact the blood vessels in your brain.), bipolar disorder (A serious mental illness characterized by extreme mood swings. They can include extreme excitement episodes or extreme depressive feelings.) and benign prostatic hyperplasia (A condition in which the flow of urine is blocked due to the enlargement of prostate gland. The symptoms include increased frequency of urination at night and difficulty in urinating).<BR/>Review of Resident #18's quarterly MDS assessment dated [DATE] reflected Resident #18 was assessed to not have a BIMS score conducted indicating severe cognitive impairment. Resident #18 was assessed to not have behaviors during the assessment period. Further review reflected Resident #18 was assessed to have an indwelling urinary catheter. <BR/>Review of Resident #18's comprehensive care plan reflected a focus area dated 05/11/2023 Resident #18 has bladder incontinence. Resident #18's care plan reflected no plan of care of his indwelling urinary catheter. Further review of Resident #18's care plan reflected a focus area dated 04/08/2024 Resident #18 is non-complaint with catheter bag positioning and leaving privacy bag on. Interventions included Educated and remind resident on infection control, instructing him to keep it off the bedside table, nurses' station, etc.; Educated resident to keep catheter bag below his bladder and Remind resident to keep privacy bag on. Resident #18's care plan did not address him placing his urine collection bag on the floor, or staff interventions and monitoring to keep the collection bag off the floor, the use of a catheter secure device to prevent dislodgment or traumatic removal of his indwelling urinary catheter or monitoring for his behaviors of trying to hit staff with his urinary collection bag. <BR/>Review of Resident #18's consolidated physician orders reflected an order dated 03/27/2024 for urinary catheter 16 F (French catheter scale is commonly used to measure the outside diameter of needles and catheters 1 French is equivalent to 0.33 mm of diameter) to gravity drainage.<BR/>Observation on 05/06/2024 at 8:30 AM, revealed Resident #18 in room in bed. Resident #18's indwelling urinary catheter drainage bag was lying flat on the floor approximately 3 feet from his bed.<BR/>Observation and interview on 05/07/2024 at 10:04 AM, revealed Resident #18 in bed with his indwelling urinary catheter drainage bag on the floor flat 2 to 3 feet away from his bed. Resident #18 was not interviewable and only smiled and waved at surveyor during interview attempts.<BR/>In an interview on 05/08/2024 at 2:13 PM, the DON stated that urinary catheter drainage bags should not be on the floor because it could cause UTI's. She stated with Resident #18 it was a behavior, but the staff should be making rounds and checking on that to keep it off the floor. <BR/>Observation on 05/08/2024 at 3:33 PM, revealed CNA F and CNA G in Resident #18's room to preform catheter care. Resident #18's urinary catheter drainage bag was on the floor in the middle of the room. CNA G picked up the bag and hung it on the bed frame. The CNAs pulled down Resident #18's pants to reveal he had no catheter secure device in place. Catheter care was done with out resistance or exhibited behaviors from Resident #18.<BR/>In an interview on 05/08/2024 at 3:40 PM, CNA F stated Resident #18 did not use a catheter secure device because it got caught in his pants when they pulled his pants up and that he would miss with it.<BR/>In an interview on 05/09/2024 at 9:29 AM, the DON stated she expected all residents with catheters to have catheter secure devices in place to prevent traumatic removal. <BR/>Review of the facility's policy Catheter care dated 02/13/2007 reflected .4. When the resident is ambulatory the bag must be held lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. 5.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site. 9.Review the residents' plan of care daily for changes.<BR/>10. Be sure the catheter tubing and drainage bag are kept off the floor The facility policy did not address using catheter secure devices.

**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 displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being, for one of 12 residents (Resident #18) reviewed for residents with dementia and behaviors. <BR/>The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #18's continuous behaviors regarding his indwelling catheter.<BR/>This failure could place residents at risk for their medical, physical, and psychological needs not being met and placed residents with indwelling catheters at risk of urinary tract infections and traumatic removal of the catheter leading pain and injury.<BR/>Findings included:<BR/>Review of Resident #18's face sheet dated 05/08/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Cerebrovascular disease (conditions that impact the blood vessels in your brain.), bipolar disorder (A serious mental illness characterized by extreme mood swings. They can include extreme excitement episodes or extreme depressive feelings.) and benign prostatic hyperplasia (A condition in which the flow of urine is blocked due to the enlargement of prostate gland. The symptoms include increased frequency of urination at night and difficulty in urinating).<BR/>Review of Resident #18's quarterly MDS assessment dated [DATE] reflected Resident #18 was assessed to not have a BIMS score conducted indicating severe cognitive impairment. Resident #18 was assessed to not have behaviors during the assessment period. Further review reflected Resident #18 was assessed to have an indwelling urinary catheter. <BR/>Review of Resident #18's comprehensive care plan reflected a focus area dated 05/11/2023 Resident #18 has bladder incontinence. Resident #18's care plan reflected no plan of care of his indwelling urinary catheter. Further review of Resident #18's care plan reflected a focus area dated 04/08/2024 Resident #18 is non-complaint with catheter bag positioning and leaving privacy bag on. Interventions included Educated and remind resident on infection control, instructing him to keep it off the bedside table, nurses' station, etc.; Educated resident to keep catheter bag below his bladder and Remind resident to keep privacy bag on. Resident #18's care plan did not address him placing his urine collection bag on the floor, or staff interventions and monitoring to keep the collection bag off the floor, the use of a catheter secure device to prevent dislodgment or traumatic removal of his indwelling urinary catheter or monitoring for his behaviors of trying to hit staff with his urinary collection bag. <BR/>Review of Resident #18's consolidated physician orders reflected an order dated 03/27/2024 for urinary catheter 16 F (French catheter scale is commonly used to measure the outside diameter of needles and catheters 1 French is equivalent to 0.33 mm of diameter) to gravity drainage.<BR/>Review of Resident #18's nursing progress notes reflected an entry dated 05/04/2024 Resident approaching both nursing stations and placing his catheter collection bag on the counter after being asked numerous times not to. Very difficult to redirect- even swung like he was going to hit at this nurse . Further review reflected an entry dated 05/01/2024 Resident wandering up to nurses' station and placing his urine collection bag onto the nurses' station desk area. Attempted to redirect resident numerous times but continued to place the bag on the desktop.<BR/>Observation on 05/06/2024 at 8:30 AM revealed Resident #18 in room in bed. Resident #18's indwelling urinary catheter drainage bag was lying flat on the floor approximately 3 feet from his bed.<BR/>Observation and interview on 05/07/2024 at 10:04 AM, revealed Resident #18 in bed with his indwelling urinary catheter drainage bag on the floor flat 2 to 3 feet away from his bed. Resident #18 was not interviewable and only smiled and waved at surveyor during interview attempts.<BR/>In an interview on 05/08/2024 at 2:13 PM, the DON stated that urinary catheter drainage bags should not be on the floor because it could cause UTI's. She stated with Resident #18 it was a behavior, but the staff should be making rounds and checking on that to keep it off the floor. The DON stated the nurses should be calling Resident #18's family and getting assist from them if his behaviors are not easily redirected. The DON stated Resident #18's care plan should address his use of the urinary catheter, his behaviors, and interventions to guide staff regarding his behaviors.<BR/>In an interview on 05/08/2024 at 2:45 PM, the DON stated the facility did not have a person doing the care plans that her and the ADON were doing them. She stated Resident #18's care plan did not address his catheter and the care plan should not say bladder incontinence since he has a catheter. The DON stated his care plan should reflect his behaviors with his foley and interventions to address the behavior of placing the foley on floor and carrying it around which cause infection and lots of things. She stated they must have just missed it. <BR/>In an interview on 05/08/2024 at 3:20 PM, LVN B stated Resident #18 did have behaviors related to this urinary catheter. LVN B was not sure what interventions were in place for them. She stated they tried a leg bag but because of his pants it made it difficult. She further stated he does put the bag on the floor, but staff should monitor and get it off the floor when they see it. When asked if they document his behavior and how often they monitor his drainage bag she stated she did not know.<BR/>Observation on 05/08/2024 at 3:33 PM revealed CNA F and CNA G in Resident #18's room to preform catheter care. Resident #18's urinary catheter drainage bag was on the floor in the middle of the room. CNA G picked up the bag and hung it on the bed frame. The CNAs pulled down Resident #18's pants to reveal he had no catheter secure device in place. Catheter care was done without resistance or exhibited behaviors from Resident #18.<BR/>In an interview on 05/08/2024 at 3:40 PM CNA F stated Resident #18 did not use a catheter secure device because it got caught in his pants when they pulled his pants up and that he would miss with it.<BR/>In an interview on 05/09/2024 at 9:29 AM the DON stated she expected all residents with catheters to have catheter secure devices in place to prevent traumatic removal. <BR/>Review of the facility's policy Catheter care dated 02/13/2007 reflected .4. When the resident is ambulatory the bag must be held lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. 5.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site. 9.Review the residents' plan of care daily for changes.<BR/>10. Be sure the catheter tubing and drainage bag are kept off the floor The facility policy did not address using catheter secure devices.<BR/>Review of the facility's undated policy Dementia and Behavioral Health reflected Behavior Human behavior is the response of an individual to a wide variety of factors. Behavior is generated through brain function, which is in turn influenced by input from the rest of the body. Specific behavioral responses depend on many factors, including personal experience and past learning, inborn tendencies and genetic traits, the environment and response to the actions and reactions of other people. A condition (such as dementia) that affects the brain and the body may affect behavior . The use of any approach must be based on a careful, detailed assessment of physical, psychological, and behavioral symptoms and underlying causes as well as potential situational or environmental reasons for the behaviors. Caregivers and practitioners are expected to understand or explain the rationale for interventions/approaches, to monitor the effectiveness of those interventions/approaches, and to provide ongoing assessment as to whether they are improving or stabilizing the resident's status or causing adverse consequences. Describing the details and possible consequences of resident behaviors helps to distinguish expressions such as restlessness or continual verbalization from potentially harmful actions such as kicking, biting, or striking out at others. This description alone does not suggest that a specific intervention is or is not indicated; however, it is important information that may assist the care team (including the resident and/or family or representative) in decision-making and in matching selected interventions to the individual needs of each resident. Identifying the frequency, intensity, duration, and impact of behaviors, as well as the location, surroundings or situation in which they occur may help staff and practitioners identify individualized interventions or approaches to prevent or address the behaviors. Individualized, person-centered interventions must be implemented to address behavioral expressions of distress in persons with dementia. In many situations, medications may not be necessary; staff/practitioners should not automatically assume that medications are an appropriate treatment without a systematic evaluation of the resident. Examples of techniques or environmental modifications that may prevent certain behavior related to dementia may include (but are not limited to) . Staff must make an ongoing effort to identify and document the new onset or worsening behavioral symptoms, including whether or not the behavior presents a significant risk for adverse consequences to the resident and/or others .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation.<BR/>The facility failed to ensure food that was prepped was labeled and dated.<BR/>The facility failed to maintain proper temperatures of food before putting on the steam table.<BR/>This failure placed residents at risk of foodborne illness.<BR/>Findings included:<BR/>Observation of the kitchen on 05/06/2024 at 6:52am revealed inside the walking cooler with milk, apple juice, and orange juice were not dated or labeled with the date they were prepped. In the freezer there were two bags of round pieces of dough that were not sealed or dated as to when it was opened. There were also sausage patties that were not sealed or dated in the freezer. In the dry food storage area, there was a container of flour that did not have a date as to when it was opened. <BR/>Observation of [NAME] M on 05/06/2024 at 12:08pm revealed the temperature of the pureed meatloaf was 120 degrees when put on the steam table. The temperature of the puree peas was 142 degrees when put on the steam table. <BR/>Observation of [NAME] M on 05/06/2024 at 12:10pm revealed [NAME] M put the food back in the oven to bring to correct temperature after surveyor started asking about temperatures.<BR/>An interview with [NAME] N on 05/07/2024 at 2:14pm revealed that items were to be labeled the day they were opened. She stated that anything that was opened or prepped should be labeled. [NAME] N stated that the aides and cooks were responsible for ensuring food was labeled and dated after opened or prepped. She stated that by not labeling and dating the items it could result in the residents getting sick. She stated that she did not know why the items in the cooler, freezer, and dry storage were not labeled and dated. <BR/>An interview with Dietary Aide L on 05/07/2024 at 2:17pm revealed that items should be labeled and dated after each use. She stated that any product that the staff open, or use should be labeled and dated with the date the food was opened or prepped. She stated that the risk of not labeling, and dating was that staff would not know when the food expired. She stated that residents would get sick if the staff used food that was expired due to not dating. She stated she did not know why the items that were in the cooler, freezer, and dry storage were not labeled and dated. <BR/>An interview with the FFS on 05/07/2024 at 2:21pm revealed that food items were to be labeled and dated when they come in and when the food was opened. She stated the risk of not labeling and dating food when it was opened or prepped could cause the residents to get sick. She also stated if the food was not labeled or dated the staff would not know how long it had been there. She stated the sticker could have fallen off the items in the cooler, freezer, and dry storage. She stated that the temperatures for meat on the steam table was 185 degrees. She stated for vegetables the temperature was 165 degrees. The FFS stated by food not being at the correct temperature it could cause harm to the residents.<BR/>An interview with the Administrator on 05/08/2024 at 10:23am revealed that food items were to be labeled and dated when the food comes in off the truck. She also stated that the food should be labeled and dated when opened and that the food should have two dates on them. She stated the risk of not labeling and dating food items would grow bacteria and cause the residents to get sick. She stated the dietary director was responsible for ensuring the food was labeled and dated. The Administrator also stated the items in the cooler, freezer, and dry storage should have been dated and the dietary director should have been checking daily to ensure the food was labeled and dated. The administrator stated the proper temperature for meat on the steam table is 140 and for vegetables was also 140. The Administrator stated the risk of food not being at correct temperature could create bacteria in the food and cause people to become ill.<BR/>An interview with [NAME] M on 05/09/2024 at 8:27am revealed that she had been trained on proper temperatures. She stated the temperature for meat when put on the steam table should be 165 degrees and vegetables should be 155 degrees. She stated the risk of the food not being at proper temperature could result in someone getting sick or the food being cold. She stated she did not know why she put the food on the steam table when they were not at the correct temperature. <BR/>Record Review of the Food Safety Policy, not dated, revealed open food shall be labeled, dated, and stored properly. <BR/>Record Review of Food Storage and Supplies Policy, not dated, revealed open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. <BR/>Record Review of Food Safety Policy dated 05/2000 revealed Potentially hazardous food shall be maintained at: <BR/>41 degrees F or less, or<BR/>140 degrees F or above.<BR/>Record Review of the 2022 FDA Food Code revealed TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC (165oF).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 3 residents (Resident # 64) reviewed for wound care.<BR/>Facility failed to ensure the scissors were sanitized before using it to cut wound care supplies while providing wound care to Resident #64<BR/>This failure could place the residents at risk for cross contamination and infection.<BR/>Findings included: <BR/>Record review of Resident #64's face sheet on 03/22/23 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Type 1 Diabetes Mellitus, Hypertension, Open Left and right Foot Wound, Depression, Hyperlipidemia (excess fat in blood), chronic kidney disease and Cerebral Infarction (stroke). <BR/>Record review on 03/23/23 of Resident #64's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 out of 15 indicating the resident chose not to participate or 4 or more items were coded O because the individual chose not to answer or gave a nonsensical response.<BR/>Record review on 03/23/23 of Resident #64's care plan dated 03/21/23 reflected:<BR/>The resident has Diabetic Ulcer r/t Diabetes: Left lateral [side] foot and one of the interventions was Monitor/document wound: Size, Depth, Margins: peri wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify MD as indicated.<BR/>Record review on 03/23/23 of Resident #64's March,2023 WAR reflected: <BR/>Cleanse diabetic ulcer to the left lateral foot with NS, pat dry, pack calcium alginate into the undermining at 9:00[am], apply therahoney [medicinal honey] to wound bed and cover with optifoam [a kind of highly absorbent wound care foam]. Change daily and PRN until resolved. One time a day for wound care, Start date:03/16/2023<BR/>During an observation on 03/22/23 at 3:00 pm, LVN A performed wound care on Resident #64. LVN A washed her hands and donned gloves before performing wound care on Resident #64's ulcer on the left foot. She then removed a pair of scissors from the back pocket of her pants and cut calcium alginate wound dressing pad and silicone-based foam and applied directly on the wound after applying therahoney on the wound. LVN A did not sanitize the scissors before using it to cut these wound care supplies. <BR/>During an interview on 03/22/23 at 3:20 pm, LVN A stated she should have sanitized the scissors before using them. She said carrying scissors in the pants pocket was a wrong practice since it could contaminate the scissors and compromised infection control protocols. LVN A stated she attended in-services on infection control two weeks ago.<BR/>During an interview on 03/23/23 at 2:00 pm, DON said carrying scissors in pants pocket and using them for wound care without sanitizing compromised infection control. When the surveyor asked how the facility identified infection control deficiencies, DON stated they achieved it by direct observation. She said DON or ADON occasionally participated and observed incontinent care and wound care for identifying compromises in infection control. DON said infection control training was an ongoing program, and participation was mandatory for all the staff members. <BR/>Record review on 03/23/23 of in-service logs reflected that there was in -service training on topic Infection control and handwashing on 03/12/23 and LVN A was one of the participants. No other training on infection control was evident in the past three months. <BR/>Review of a current facility policy on 03/23/23 titled Infection control policy and procedure manual 2019: Fundamentals of infection control Precautions reflected:<BR/>A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions .Resident care equipment and articles . c. Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the residents right to request, refuse, and/or discontinue treatment for one (Resident #1) out of three residents reviewed for advanced directives, in that:<BR/>The facility failed to ensure Resident #1's DNR was signed by the MD until [DATE] when it was ready to be signed on [DATE]. Resident #1's DNR was not uploaded into the EHR, resulting in LVN A having an incomplete OOH-DNR form with which to make her determination of whether to begin CPR. This failure also resulted in Resident #1's Care Plan reflecting a now incorrect code status at the time Resident #1 became unresponsive. These failures resulted in LVN A performing CPR for 5 minutes, and in 911 being called, who continued CPR for an additional 30 minutes, intubated Resident #1 and transported Resident #1 to the hospital. <BR/>An IJ was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 06:00PM. While the POR was accepted on [DATE] at 1:40 PM and the immediacy was removed on [DATE] at 4:20 PM, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure placed residents at risk of not having their wishes known, respected, and implemented in emergency.<BR/>Findings included:<BR/>Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Chronic Combined Systolic and Diastolic Heart Failure (heart failure affect the left ventricle), Abnormalities of breathing, Chronic Obstructive Pulmonary Disease (Difficulty to breath) , Hypertension, Depressive episodes, Acute and Chronic Respiratory Failure, Paroxysmal Atrial Fibrillation ( irregular shallow heart beat), Type 2 Diabetes Mellitus, Obstructive Sleep Apnea ( breathing obstruction while sleeping) , Anemia, Mood Disorder and Cellulitis of face.<BR/>Review of Resident #1's MDS assessment dated [DATE], reflected a BIMS of 4, indicating a severe cognitive impairment. Section I (active diagnoses) reflected Resident #1's primary medical condition was debility from Cardiorespiratory Conditions.<BR/>Review of Resident #1's initial care plan, dated [DATE] reflected, Resident #1 requested a full code status, and the relevant interventions were:<BR/>Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. <BR/>Review of Resident #1's DNR revealed, it had been signed by the responsible party and notarized on [DATE] and the MD signed on it on [DATE].<BR/>Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 11:50PM, reflected the following:<BR/>Nurse called into resident's room at 6:20 PM. CNA found resident unresponsive, and very pale. Resident was lying in bed and had no response to calling of his name or to touch. CPR started at about 6:23PM. Requested that 911 be called, since resident did not have a signed DNR. Resident was on Hospice [company], also instructed that they be contacted. EMS arrived at 6:30PM and continued CPR. Upon other help arriving EMS placed resident on floor and continued working with patient. Was informed that they had a faint pulse, they prepared to transport resident to hospital at 7:02PM. Nurse thereafter contacted [family member] of resident to inform her that resident was taken to hospital by EMS, at which time she became very upset and hung up the phone. DON contacted and informed of the situation. [MD] contacted and was informed that resident was transferred to hospital, however informed nurse that resident was supposed to have DNR on file. DNR was in file however it was not signed by doctor, and resident full code was indicated on system.<BR/>Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 03:36AM, reflected: deceased .<BR/>Review of Resident #1's Death Report from the hospital dated, [DATE] reflected the resident expired on [DATE] at 7:23PM.<BR/>Review of Resident #1's hospital record dated [DATE] reflected:<BR/>Patient in cardiac arrest on arrival to emergency department. Patient in respiratory arrest on arrival to emergency department. Length of downtown time, (min) one hour. Patient intubated prior to arrival with endotracheal tube [a tube that is placed between the vocal cords through the trachea to provide oxygen and inhaled gases to the lungs.]: size (mm) 7.0, at lip(cm)21. Patient not on spinal immobilization on arrival. Blood pressure:0, pules0, respiratory rate :0, cardiac rhythm in field pulseless electrical activity .<BR/>Record review of the doctor's note at the hospital on [DATE] at 05:28AM reflected: <BR/>Patient is a [AGE] year-old male brought in by EMS after being found in cardiac arrest at the nursing home. ACLS was performed by EMS and then continued on arrival to the ER. Patient was found after the conclusion of ACLS to be in systolic and resuscitative measures were halted .<BR/> Of note on patient's physical exam there was an unusual articulation between the neck and the head when the patient had his neck turned to the side given the impression of a possible broken neck. There was a palpable discontinuity at the back of the base of the skull where it meets the cervical spine suggesting a possible cervical spine fracture. These findings were communicated to the patient's primary care physician who recommended an autopsy and also to have JP evaluate the case.<BR/>During an interview on [DATE] at 10:30AM ADM stated, the DNR was notarized and received from FM on [DATE] however was not signed by MD until [DATE]. She stated it was a mistake from the facility that DNR was not get signed by MD immediately after received from the family. She stated MD visits the facility every month and the facility was waiting for his next visit to get it signed. She added, this incident was an opportunity to learn from the mistakes. ADM stated LVN A conducted the CPR based on the DNR on the E H R, which was not signed by MD. ADM stated MD signed the DNR on [DATE] before the incident occurred however the code status was not changed in the system as soon as it got signed. ADM stated, the mistake from the facility side was, the DNR did not get signed by MD in a timely manner. <BR/>During an interview on [DATE] at 11:00AM, Resident #1's FM stated she was the responsible party for Resident#1, and she was horrified with what had happened to Resident #1. She stated, she wanted to know what had really happened and why his DNR was not respected. The FM stated after discussing various aspects of the DNR with Resident #1, it was signed by her and notarized on [DATE]. She stated she wanted to know why it was not get signed by MD immediately after the facility received it. The FM stated this negligence from the facility lead to denying Resident #1's right to have a peaceful and dignified death wished by him and the family. She stated, she heard from the facility that the medical report from the hospital stated Resident #1 had a broken neck and wanted to know how, when and where this was occurred.<BR/>During a telephone interview on [DATE] at 4:00PM MD stated he visited the residents at the facility once a month. MD reported on [DATE] he met with Resident #1 and his FM at the facility and there was no concern about Resident #1 at that time, other than his normal presentation of labored breathing. MD stated on [DATE] there was no abnormality with the neck noticed and the resident did not report of any discomfort with his neck. MD stated he interacted with Resident #1's FM too and no concerns of any kind raised by them. MD said, he heard about the report of the broken neck of the resident at the hospital on [DATE] and was looking forward for the autopsy result. MD stated he signed on Resident #1's DNR dated [DATE] on 12/04 / 23 in that afternoon and did not remember the exact time. The MD stated he was not aware of the existence of a DNR as the facility did not inform him about it, which was why the DNR was not signed immediately after it was signed and notarized on [DATE]. He stated it was a concern that the DNR was not executed on time and Resident #1's wish was not respected. <BR/>During an interview and observation on [DATE] at 6:00PM, LVN A stated she was the one who initiated CPR. She stated on [DATE] at about 6:15pm one of the staff members stated, Resident #1 was unresponsive. She said, she immediately went into E H R and confirmed his code status. She said she decided to initiate CPR since the copy of the DNR in the E H R was not duly signed by the MD and thus it was not valid. She said she did the CPR for about 5 minutes while Resident #1 was in bed and mean time ER arrived and took over. She said, they continued CPR for about 5 minutes while resident was in bed and then took him to the floor and continued the process for about 30 minutes. Later they took him to the hospital and later came to know that the resident was pronounced dead at the hospital. LVN A provided a copy of the DNR in which there was no signature of the MD. This was contrary to the copy of the DNR in the E H R uploaded on [DATE], in which there was a MD's signature. When investigator asked why there were two copies of DNR, one with and the other without MD's signature, LVN A stated the copy without MDs signature was in the E H R at the time of the incident and the one with MD's signature was uploaded to the system after the incident occurred. She sated she was an LVN for more than 30 years and she knew it was a complicated situation and that was why she decided to preserve the copy of the DNR that was effective at the time of the incident. When the investigator asked about Resident #1's broken neck, LVN A stated when she was conducting CPR there were no abnormalities noticed. <BR/>Record Review of E H R on [DATE] revealed, the copy of the DNR uploaded to the system on [DATE] was duly signed by the MD and the responsible party. <BR/>Record Review of the facility's undated policy Resident Rights reflected the following:<BR/>The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. <BR/>A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.<BR/>The facility must provide equal access to quality care regard less of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. <BR/>Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States <BR/>Self-determination: The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice <BR/> 2. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.<BR/>The ADM was notified on [DATE] at 06:00PM that an IJ situation was identified due to the above failures and the IJ template was provided. <BR/>The plan of Removal was accepted on [DATE] at 01:39PM, and included:<BR/>F578 - The facility failed to protect Resident #1's right to request, refuse, and/or discontinue treatment. All residents could be affected by this deficient practice at the facility.<BR/>Interventions: <BR/>1. <BR/>100% audit was completed for resident advance directives by the DON and ADON as of [DATE]. All DNRs are completed and signed by the resident or person acting on behalf of the resident, along with witnesses or notary and physician. All advance directive orders are care planned. No additional issues were discovered during the audit. Completed [DATE]. Once notified by medical records and/or administrative staff, nursing personnel will change the status in PCC and update care plan<BR/>2. <BR/>The Administrator and DON were in-service 1:1 on the completion and implementation of advance directives, Abuse and Neglect, and the CPR policy by the Area Director of Operations. Completed [DATE]. All nurses are certified in CPR and the team have verified that each shift has a nurse certified in CPR.<BR/>3. <BR/>The Medical Director was notified of the immediate jeopardy on [DATE] by the Administrator. <BR/>4. <BR/>An ADHOC QAPI meeting was conducted as of [DATE] to discuss the immediate jeopardy and plan of removal. <BR/>In-services:<BR/>1. <BR/>All staff were in-serviced on Abuse and Neglect by the Administrator and DON on [DATE]. All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. <BR/>2. <BR/>All Charge Nurses were in-serviced on policy for CPR and procedures for performing CPR by the Administrator and DON on [DATE]. All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. <BR/>3. <BR/>All Charge Nurses and M/R were in serviced on the process to obtain and implement a DNR by the Administrator and [NAME] on [DATE] All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. Staff will demonstration understanding/comprehension of process by teach back. A change to obtaining the physician's signature if not completed as soon as requested was put in place (Medical Records or designee will fax DNR to the physician. If not received back medical records or designee will deliver DNR to physician. Once signed medical records or designee will upload DNR to PCC. DON or designee will change status in PCC and notify staff of status change during nursing stand up. Care plan will be updated by nursing management).<BR/>Monitoring:<BR/>1. <BR/>At least 5 times per week, advance directive orders will be reviewed by Administrator/DON and/ADON and ensure that all orders are completed and entered correctly. Monitoring will start [DATE] and continue x 6 weeks. <BR/>The Survey Team monitored the Plan of Removal on [DATE]<BR/>Interview on [DATE] at 12:37PM with DON and Administrator revealed the one-on-one training was done with Compliance Nurse regarding resident rights and advance directives. The DON stated they reviewed all residents records for code status stating she reviewed DNRs and ensured the out of hospital was in the resident record and that the records reflected the DNR status she stated she also reviewed full code residents to ensure they had not initiated a DNR she stated Resident #1 was a hospice resident and hospice usually does the DNRs and stated the facility needed to ensure the records reflected the residents status. She stated the record reflected the resident was a full code and the nurse did what she was supposed to since she had no way of knowing his code status had changed.<BR/>Interview on [DATE]PM started at 12:50PM with 8 nursing staff in the facility revealed they were in serviced on resident rights, CPR, and DNRs and were able to explain the procedure for identifying a residents code status, locating the documents.<BR/>Record review of In-services revealed an Inservice for CPR/ and Code policy conducted on [DATE] and ongoing for staff coming to work which reviewed the facility ' s policy Cardiopulmonary resuscitation and inservice for steps to execute a DNR conducted on [DATE] and ongoing for staff coming to work which reviewed the facility ' s policy for out of hospital DNRs.<BR/>The ADM was notified on [DATE] at 4:30 PM that the Immediate Jeopardy was lowered, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to keep two (Resident #1, Resident #2) of sixteen residents free from accident hazards and supervision.<BR/>The facility failed to:<BR/>1. Ensure Resident #1, who had exit-seeking behaviors and resided in the secure unit, did not elope from the facility on 12-16-22. <BR/>2. Ensure Resident #2, who had exit-seeking behaviors and resided in the non-secure unit, did not elope from the facility on 09-14-22. <BR/>On 1-2-23 at 5:17 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 1-5-23 at 7:00 PM, the facility remained out of compliance at a scope of J isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>These failures placed residents at risk of abuse, harm, or hospitalization.<BR/>Findings Included:<BR/>Record review of Resident #1's undated admission record reflected, Resident #1 was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis ), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs ), and major depressive disorder (causes a persistent feeling of sadness and loss of interest and can interfere with your daily), recurrent, severe with psychotic symptoms (hallucinations, delusion, confused/disturbed thoughts).<BR/>Record review of Resident #1's MDS assessment, dated 12-21-2022, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. The MDS further reflected Resident #1 had a behavior of wandering that occurred daily during the look-back period of the assessment. Resident #1 did not require any assistive mobility devices. <BR/>Record review of Resident #1's care plan, initiated on 10-22-21, reflected Resident #1 is at risk for wandering. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system. Resident #1 had cognitive function/dementia or impaired thought processes Dementia.<BR/>Record review of Resident #1's Securecare Environment Screening Tool dated 7-18-22, reflected Resident #1 had a diagnosis of Alzheimer's disease, continued to exhibit exit seeking behavior and resident is continuously wandering and looking for an exit.<BR/>Record review of Resident #1's progress note, dated 7-23-22, reflected Resident #1 had pushed his way through the doors of the locked unit and took off running down the street. Law enforcement assistance had been required because Resident #1 was running down the road and Licensed Vocational Nurse D had to block traffic. 911 was called, resident [#1] was restrained after swinging at officers. Resident #1 had been transferred to local hospital. Resident #1 returned to the facility with a diagnosis of altered mental status with no new orders.<BR/>Record review of Resident #1's progress note, dated 7-24-22, reflected Resident #1 was increasingly agitated and commenting I'm going to the house. Resident #1 had set off the back door alarm 3 times. Staff attempted to redirect him and he charged at them with a closed fist. <BR/>Record review of Resident #1's progress note, dated 8-6-22, reflected Resident #1 had been observed due to increased agitation. Resident #1 had been walking from one door to the next, and walking away from the front door down to the hall.<BR/>Record review of Resident #1 progress note, dated 10-29-22, reflected Resident #1 tried to push the courtyard door open and stated I want to go home. Resident #1 was shaking the front doors to the secure unit and became combative with staff, and law enforcement was called. The law enforcement officer spoke to Resident #1 and Resident #1 was redirected to his room without complaints. <BR/>Record review of Resident #1 progress note, dated 12-16-22 reflected, Resident #1 had run and hit the exit doors in the secure unit which caused it to open. Resident #1 ran down the sidewalk and was followed by Certified Nurse Aide F. Resident #1 was in view of Certified Nurse Aide F at all times.<BR/>Record review of Texas Department of Aging and Disability Services Form 3613-A provided by the Administrator reflected the Investigation Findings to be confirmed. Staff were moving residents from the dining room to the day room following an activity. [Certified Nurse Aide F] was coming out of the dining room, she spotted resident [Resident #1] running down the hall toward the door. When he [Resident #1] reached the door he pushed hard on it until it released. [Certified Nurse Aide F] was running after him calling for help as she went. [Certified Nurse Aide E] was asked to help. He [Certified Nurse Aide E] told [Licensed Vocational Nurse B], what was going on and joined the pursuit. Resident [#1] was in eye sight at all times. Staff caught up with the resident [#1] (as he was running down the sidewalk), calmed him down and coaxed him into a care to return him to the facility. Resident [#1] had been taken out on a pass the day before. The form was signed by the Administrator and dated on 12-20-2022. <BR/>On 1-2-23 at 10:05 AM, an observation revealed, the nurse's station outside of the secure unit. Two locked clear doors led to the secure unit. Licensed Vocational Nurse A pressed the doorbell located on the left side of the wall and unlocked the doors to the secure unit. <BR/>On 1-2-23 at 10:07 AM, Resident #1 was observed in the secure unit at the end of the hall, trying to push the emergency doors open. Certified Nurse Aide C and Licensed Vocational Nurse A stood in front of the doors and redirected him away from the doors. Resident #1 was angry and agitated, and continued trying to push the doors open. Resident #1 continued to talk loudly and aggressively to staff as he walked away from the exit doors.<BR/>On 1-3-23 at 9:15 AM, an observation revealed the distance between the private driveway in front of the home where Resident #1 was found and the facility was .26 miles. <BR/>Record review of the posted speed limit on the busy street in front of the facility to be 30 miles per hour.<BR/>During an interview on 1-3-23 at 10:56 AM, Certified Nurse Aide E stated he had been trained in elopement procedures and had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide E stated the Maintenance Supervisor notified the nurse who in turn notified him that Resident #1 had eloped. Certified Nurse Aide E stated he ran down the sidewalk located next to a busy street and saw Resident #1 on the opposite side of the street running away from the facility. Certified Nurse Aide E stated he saw cars slowing down as Resident #1 continued to run down the street. Certified Nurse Aide E stated Resident #1 was found approximately 2 blocks away in a private driveway in front of a home. Certified Nurse Aide E stated the street located in front of the facility was very busy and there was traffic on the day Resident #1 eloped. Certified Nurse Aide E stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Certified Nurse Aide E stated Resident #1 has a history of trying to exit the facility and has witnessed him push and pull the front doors of the secure unit attempting to leave when he is mad or agitated. <BR/> During an interview on 1-3-23 at 9:04 AM, Licensed Vocational Nurse B stated she had been trained in elopement procedures and she had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Licensed Vocational Nurse B stated Resident #1 had a history of being upset after the family visited and attempted to leave the facility after those visits. Licensed Vocational Nurse B stated a family member visited Resident #1 the day before and he had been upset since then. Licensed Vocational Nurse B stated she had been told by Certified Nurse F that Resident #1 was running back and forth down the hallway of the secure unit when he hit the exit doors and they opened. Licensed Vocational Nurse B stated she and Certified Nurse Aide E ran out of the facility and saw Resident #1 running down the sideway next to a busy street. Licensed Vocational Nurse B stated Resident #1 ran fast and finally stopped near a fast food restaurant, a couple of blocks away. Licensed Vocational Nurse B stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Licensed Vocational Nurse B stated a head-to-toe assessment was done on Resident #1 and no injuries were noted, vitals were taken and all were normal. She stated he was also hydrated, and was assigned a one to one person for the next 72 hours. Licensed Vocational Nurse B stated on 12-30-22, Resident #1 was moved from his room located at the end of the hall to the first room at the beginning of the hall because the facility need his room for a new admission. <BR/>During an interview on 1-3-23 at 10:56 AM, Certified Nurse Aide E stated he had been trained in elopement procedures and had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide E stated the Maintenance Supervisor notified the nurse who in turn notified him that Resident #1 had eloped. Certified Nurse Aide E stated he ran down the sidewalk located next to a busy street and saw Resident #1 on the opposite side of the street running away from the facility. Certified Nurse Aide E stated he saw cars slowing down as Resident #1 continued to run down the street. Certified Nurse Aide E stated Resident #1 was found approximately 2 blocks away in a private driveway in front of a home. Certified Nurse Aide E stated the street located in front of the facility was very busy and there was traffic on the day Resident #1 eloped. Certified Nurse Aide E stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Certified Nurse Aide E stated Resident #1 has a history of trying to exit the facility and has witnessed him push and pull the front doors of the secure unit attempting to leave when he is mad or agitated.<BR/>During an interview on 1-3-23 at 3:38 PM, Certified Nurse Aide F stated she had been trained in elopement procedures and she had worked on the secure unit on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide F stated she was in the dining room in the secure unit when she heard the alarm door beeping and saw Resident #1 standing at the exit doors. Certified Nurse Aide F stated she knew she had 15 seconds before the door released and opened. Certified Nurse Aide F stated the door opened and Resident #1 ran out the door and it shut behind him. Certified Nurse Aide F stated when she opened the door, Resident #1 was running in a private driveway located next to the facility. Certified Nurse Aide F stated she could see Resident #1 as he ran away from the facility. Certified Nurse Aide F stated Resident #1 stopped at the grocery store near the facility.<BR/>During an interview on 1-3-23 at 10:36 AM, the Licensed Vocational Nurse I stated she had been trained in elopement procedures. Licensed Vocational Nurse I stated she was in orientation on 12-16-22 when Resident #1 eloped from the secure unit. Licensed Vocational Nurse I stated she got into her personal vehicle and traveled down the road and saw Resident #1 and other staff members across the street in the private driveway of a home. Licensed Vocational Nurse I stated she coaxed Resident #1 into her vehicle and transported him back to the facility. Licensed Vocational Nurse I stated the street had a normal flow of traffic. Licensed Vocational Nurse I stated she was stationed at the nurse's station outside of the secure unit and will do rounds every hour or as needed. <BR/>During an interview on 1-2-23 at 10:10 AM, Certified Nurse Aide D stated she had been trained on elopement procedures. Certified Nurse Aide D stated Resident #1 was agitated and attempted to push the doors open on 1-2-23. Certified Nurse Aide D stated she had redirected Resident #1 away from the door. Certified Nurse Aide D stated Resident #1 had exit seeking behaviors and had eloped from the facility in the past. Certified Nurse Aide D stated when Resident #1 is agitated, extra eyes were kept on him to prevent him from eloping. Certified Nurse Aide D stated Resident #1 had touched the exit door bar and waited for the staff to respond. Certified Nurse Aide D stated Resident #1 had acted up after past family visits. Resident #1 had been visited by family on 1-1-23 and that is what caused him to become angry and agitated. Certified Nurse Aide D stated Resident #1's room was located at the end of the hall, near the exit doors. Certified Nurse Aide D stated Resident #1 had been in the secure unit for a couple of months and he had eloped a couple of times before. Certified Nurse Aide D stated when she worked in the secure unit, she always kept an eye on Resident #1 to ensure that she knew where he was at all times. Certified Nurse Aide D stated Resident #1 liked to sit in the dining room, listen to music, and drink coffee. Certified Nurse Aide D stated rounds are done at least every 2 hours, but more frequently in the secure unit. Certified Nurse Aide D stated 2 CNA's and 1 nurse covered the secure unit. <BR/>During an interview on 1-2-23 at 10:29 AM, Certified Nurse Aide M stated she had been trained on elopement procedures. Certified Nurse Aide M stated she worked in the secure unit with Resident #1 and when he was upset, he would attempt to leave the secure unit through the exit doors. Certified Nurse Aide M stated Resident #1 had been redirected away from the exit doors. Certified Nurse Aide M stated Resident #1 had been verbally aggressive when he was angry or agitated. Certified Nurse Aide M stated rounds are done at least every 2 hours but more frequently in the secure unit. Certified Nurse Aide M stated 2 CNA's and 1 nurse covered the secure unit. Certified Nurse Aide M stated 16 residents resided on the secure unit. <BR/>During an interview on 1-2-23 at 10:36 AM, Licensed Vocational Nurse A stated she had been trained in elopement procedures. Licensed Vocational Nurse A stated she had been working the secure unit on 1-2-23 and Resident #1 attempted to push the exit doors open. Licensed Vocational Nurse A stated Resident #1 stated, I figured it out as he attempted to push the exit door open. Licensed Vocational Nurse A stated she and Certified Nurse Aide B stood in front of the exit door to prevent Resident #1 from eloping. Licensed Vocational Nurse B stated Resident #1 was agitated and high strung because he had a family visit the day before [1-1-23] and he kept stating he wanted to go home. Licensed Vocational Nurse A stated the exit door push bar had to be held for 15 seconds before the door was unlocked and released. Licensed Vocational Nurse A stated the exit door alarm will beep loudly during the 15 seconds. Licensed Vocational Nurse A stated the beeping could be heard at the nurse's station located outside the secure unit. Licensed Vocational Nurse A stated after 15 seconds the door will open and the alarm will sound at which time all available staff is to respond to the opened door. Licensed Vocational Nurse A stated she sits at the nurse's desk located outside the clear doors of the secure unit. Licensed Vocational Nurse A stated a doorbell is located on the left side of the wall next to the clear doors leading to the secure unit and the doorbell had to be pushed to release the lock and open the doors to the secure unit. Licensed Vocational Nurse A stated a code to the keypad is needed to exit the secure unit.<BR/>During an interview on 1-2-23 at 10:50 AM, Certified Nurse Aide D stated she had been trained on elopement procedures. Certified Nurse Aide D stated she had worked the secure unit and cared for Resident #1. Certified Nurse Aide D stated Resident #1 had a history of being agitated after family visits and would attempt to exit through the back exit doors. Certified Nurse Aide D stated when she worked the secure unit, Resident #1 was with her or within eyesight because of his past history of elopement. Certified Nurse Aide D stated Resident #1 did respond to redirection when he is upset and wanting to go home. Certified Nurse Aide D stated Resident #1 pressed the push bar and when she heard the beeping she immediately responded to the exit door and redirected him to activity room. Certified Nurse Aide D stated Resident #1 is very strong and can be physically/verbally aggressive when upset. Certified Nurse Aide D stated she had been told Resident #1 ran very fast when he eloped from the facility. Certified Nurse Aide D stated rounds in the secure unit are completed at least every 2 hours, but she did them every 30 minutes because some residents like to walk up and down the hallway. Certified Nurse Aide D stated the doorbell outside the secure unit must be pressed and it will open the door. Certified Nurse Aide D stated when the push bar on the exit door is held it will beep for 15 seconds then the door is opened and the alarm will sound. Certified Nurse Aide D stated the alarm can be heard outside the doors of the secure unit and all available staff are to respond. She stated the code, to the keypad, is needed to exit through the clear doors located at the front of the secure unit. <BR/>During an interview on 1-2-23 at 10:59 AM, the Maintenance Supervisor stated he checked all exit doors every other day. The Maintenance Supervisor stated he checked all keypads daily to make sure they were working. The Maintenance Supervisor stated he did not keep a daily log of the checks, but if a repair is needed, it will be logged in the system and then show up on a report when it is completed. The Maintenance Supervisor stated the push bar to the exit doors, in the secure unit, is very sensitive and will beep if it is touched and the constant beeping will sound when the push bar is held and the alarm will go off when the door is opened. The Maintenance Supervisor stated the push bar had to be held for 15 seconds, before it would open and set off the alarm. The Maintenance Supervisor stated the alarm in the memory care unit is loud and can be heard through the clear doors of the unit. The Maintenance Supervisor stated a code is needed to exit through the door that leads to the courtyard in the secure unit. The Maintenance Supervisor stated staff and visitors must press a doorbell located on the right side of the wall and someone from inside the facility will come to the front door and open it. The Maintenance Supervisor stated a red push button located on the right side of the wall near the front doors had to be pressed before the doors will open automatically. The Maintenance Supervisor stated a code is not needed to exit the facility through the front doors.<BR/>On 1-2-23 at 11:05 AM an observation revealed the exit door to beep when touched and then a long beeping sound when the push bar was held for 15 seconds before being opened. The exit doors led to the side of the building and a sidewalk that leads to the facility parking lot. On the other side of the sidewalk is a grassy area which leads to an open part of the fence that leads to a private property. The sidewalk ends at the parking lot. A sidewalk is located between the facility parking lot and a street. The street was observed to be busy with traffic. <BR/>On 1-2-23 at 11:08 AM an observation revealed a red button located on top of a blue handicap mount was located on the wall near the front entrance doors.<BR/>During an interview on 1-3-23 at 10:00 AM, Certified Nurse Aide D stated she had been trained on elopement procedures and worked in the secure unit with Resident #1. Certified Nurse Aide D stated Resident #1 had a history of exit seeking behaviors and would attempt to leave the facility when upset or agitated after family visits. Certified Nurse Aide D stated she had not worked in the secure unit on 12-16-22, when Resident #1 eloped. Certified Nurse Aide D stated the facility had been short staffed during the month of December 2022, and she worked the secure unit alone a few times because of staffing issues. Certified Nurse Aide D stated at least 2 Certified Nurse Aides needed to work the secure unit to meet the residents needs and ensure they get proper care. <BR/>During an interview on 1-3-23 at 10:20 AM, Certified Nurse Aide G stated he had been trained in elopement procedures and worked in the secure unit at the facility. Certified Nurse Aide G stated Resident #1 had a history of elopement and had eloped from the secure unit back in July 2022. Certified Nurse Aide G stated Certified Nurse Aide D was the only person working on the secure unit on that day. Certified Nurse Aide G stated the facility was short staffed and there had been times where only one person worked the secure unit. Certified Nurse Aide G stated Resident #1 is fast and no one here can catch him once he gets to running. Certified Nurse Aide G stated all staff are aware Resident #1 will be upset after family visits and will try to leave the facility. Certified Nurse Aide G stated Resident #1 can be redirected sometimes but when he was upset he would not listen. <BR/>During an interview on 1-3-23 at 12:45 PM, the Director of Nursing stated she and all staff had been trained on elopement procedures. The Director of Nursing stated she had worked on 12-16-22 when Resident #1 eloped from the facility. The Director of Nursing stated Resident #1 eloped through the exit doors of the secure unit. The Director of Nursing stated Certified Nurse Aide F ran after Resident #1 and kept him within eyesight. The Director of Nursing stated she and other staff members ran down the sidewalk next to a busy street and finally reached Resident #1 on the opposite side of the street in a private driveway. The Director of Nursing stated there was a steady flow of traffic on the street located next to the facility. The Director of Nursing stated Resident #1 was transported back to the facility by Licensed Vocational Nurse I. Resident #1 was assessed from head to toe with no injuries noted, vitals were taken, he had been given fluids for hydration, and then had dinner. Resident #1 was placed on a one to one watch for the next 72 hours. The Director of Nursing stated Resident #1's room was located at the end of the hallway near the exit doors in the secure unit, but he was moved on 12-30-22 because the facility needed that room for a new admission. The Director of Nursing stated Resident #1 would have been able to stay in his room located at the end of the hall near the exit doors if the facility had not needed it for a new admission. The Director of Nursing stated rounds were done every 2 hours and more frequently in the secure unit and there are 2 Certified Nurse Aides and 1 Medication Aide assigned to the secure unit on a daily basis. The Director of Nursing stated 1 Licensed Vocational Nurse is stationed outside the secure unit and will conduct rounds and coverage as needed. The Director of Nursing stated the Licensed Vocational Nurse is responsible for performing rounds throughout the facility and there will be times when she is not at the nurse's station to keep an eye on the secure unit. The Director of Nursing stated that the doorbell must be pressed before the entry doors to the secure unit are opened and an exit code on the keypad is needed to exit. The Director of Nursing stated the press bar, located at the end of the hallway on the secure unit, must be held for 15 seconds before it is released and it will beep until opened at which time the alarm sounds and all available staff are to respond to the door. The Director of Nursing stated there is always a risk that a resident will elope from the secure unit. <BR/>During an interview on 1-3-23 at 8:55 AM, the Administrator stated she and all staff were trained in elopement procedures. The Administrator stated Resident #1 eloped through the exit doors located in the secure unit on 12-16-22. The Administrator stated Resident #1 had a history of exit seeking behaviors and would attempt to leave the facility when upset after family visits. The Administrator stated a family member had visited Resident #1 the day before and he had been upset since the visit. The Administrator stated Resident #1 was placed on one to one monitoring for 72 hours after the elopement. The Administrator stated Resident #1's room was located at the end of the hall next to the exit doors but was moved to the first room at the beginning of the hallway close to the nurses station because his room was needed for a new admission. <BR/>Record review of Resident #2's undated admission record reflected, Resident #2 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistent feeling of sadness and loss of interest and can interfere with your daily), primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and asthma (disease that affects your lungs. It causes repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing).<BR/>Record review of Resident #2's MDS assessment, dated 12-21-2022, revealed Resident #2's BIMS score was blank which indicated it could not be completed. The MDS further reflected Resident #2 had a behavior of wandering that occurred daily during the look-back period of the assessment. Resident #2 required any assistive mobility devices. The MDS reflected daily decision making as being severely impaired. <BR/>Record review of Resident #2's care plan, initiated on 9-8-22, reflected Resident #2 is at risk for wandering, and at shift change if staff see resident outside, staff will invite resident to come inside. Resident #2 hadcognitive function/dementia or impaired thought processes Dementia, communication problem, and impaired visual function. <BR/>Record review of Resident #2's progress note, dated 5-15-22, reflected, Resident #2 remained tearful and continues to ask to go home and went back to her room to get her belongings. Resident #2 wandering the halls and was found on hall 3 tearful and upset with a bag in her hand that contained her belongings. Urine sample was taken and 15-minute checks will be done until reports are back from the lab. <BR/>Record review of Resident #2's elopement risk assessment, dated 6-13-22, reflected she was not on a secured unit and ambulated independently or with a device. Assessment also indicated Resident #2 stated and/or threatened to leave the facility, frequent request to go home, confused expression related to tasks to complete, and verbalizes anger and frustration in reference to placement. Resident #2 did not recognize stop lights and signs and does not know precautions when crossing the street. <BR/>Record review of Resident #2's Event Nurse Note 12 hour-Elope or Attempt, dated 6-13-22, reflected Resident #2 was sitting outside with another staff around 6:30 PM when night shift nurse came on. Around 7:00 PM staff noticed that Resident #2 was not in the building and went outside to get her she was not sitting where she had been. Resident #2 was found in the parking lot next door. Resident #2 had been missing for 30 minutes; no injures resulted from elopement. Resident #2 was brought back inside to her room and given something to drink. Cognition/Behavior at the time of event were marked cognitive impairment, wanders and requires cueing.<BR/>Record review of Resident #2's progress note, dated 9-14-22, reflected Resident #2 was brought back from the porch area at approximately 3:30 PM. She went to the bathroom and then back to the nurses station. At 4:00 PM, Resident #2 was informed not to go back outside at which time she continued to go outside. Licensed Vocational Nurse B was informed that Resident #2 was down the street from the facility. Licensed Vocational Nurse B got into her car and went to look for Resident #2. Certified Nurse Aide E and Human Resources were walking around and looking for Resident #2. Licensed Vocational Nurse B stated she received a call from Human Resources that Resident #2 was found near the community hospital. Licensed Vocational Nurse B stated Resident #2 refused to get into her vehicle and was escorted back to the facility by Certified Nurse Aide E and Human Resources. Resident #1 was assessed upon return, no injuries, hydrated and he was moved to the secure area. <BR/>On 12-28-22 at 1:24 PM, an observation revealed the community hospital area where Resident #2 was found was approximately .17 mile from the facility. There was a steady flow of traffic on the road that led from the facility to the hospital.<BR/>Record review of the posted speed limit on the busy street in front of the facility to be 30 miles per hour.<BR/>During an interview on 1-2-23 at 11:48 AM, the Dishwasher stated she had been trained in elopement procedures. The Dishwasher stated on 9-14-22, she had finished her shift and clocked out at 4:00 PM and ran some errands. The Dishwasher she had traveled down the busy street located in front of the facility and saw Resident #2 walking on the opposite side of the street near a private residence and called the facility and notified them of what she had seen. The Dishwasher stated Resident #2 was approximately half a block away from the facility on the opposite side of the street. The Dishwasher stated Resident #2 had to have crossed the busy street to end up in front the house where she saw her. The Dishwasher stated the street located in front of the facility was busy at all times of the day. The Dishwasher stated she was in an uber car when she saw Resident #2 down the street from the facility. The Dishwasher stated she had not asked the uber driver to stop when she saw Resident #2. <BR/>During an interview on 1-2-23 at 12:33 PM, Certified Nurse Aide E stated he was trained in elopement procedures. Certified Nurse Aide E stated he was working in the facility on 9-14-22 when Resident #2 eloped from the facility. Certified Nurse Aide E stated he was told by another staff member that Resident #2 had left the facility and was next door at a grocery store. Certified Nurse Aide E stated he and Human Resources left the facility and began looking for Resident #2 and did not see her in the parking lot of the grocery store near the facility. Certified Nurse Aide E stated he looked across the busy street, located next to the facility, and saw Resident #2 across the street near the community hospital. Certified Nurse Aide E stated he and Human Resources ran across the street and up a side road and stopped Resident #2 near a county owned building. Certified Nurse Aide E stated Resident #2 was walking on the sidewalk next to the community hospital. Certified Nurse Aide E stated Resident #2 required the assistance of her walker to elope from the facility. Certified Nurse Aide E that at some unknown point Resident #2 had to have crossed the busy street located in front of the facility to end up in front of the community hospital. Certified Nurse Aide E stated the street in front of the facility was a busy street and there is traffic on it at all times of the day. Certified Nurse Aide E stated Resident #2 stated she left the facility because she was going to visit family. Certified Nurse Aide E and Human Resources had to cross the busy street and walked Resident #2 back to the facility which took about 10 minutes. Certified Nurse Aide E stated Resident #2 was assessed by the nursing staff. Certified Nurse Aide E stated Resident #2 lived in the non-secure part of the facility on the day she eloped. Certified Nurse Aide E stated Resident #2 had to have left the facility through the front door of the facility. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the completion of a significant change assessment for 1 (Resident #34) of 8 residents reviewed for Significant Change Assessments. <BR/>The facility failed to ensure Resident #34 had a significant change assessment completed following the discharge from hospice service.<BR/>This failure could place residents at risk of not receiving adequate services and reimbursement to meet their needs. <BR/>Findings included: <BR/>Review of Resident #34's face sheet dated 03/23/23 revealed Resident #34 was a [AGE] year-old female admitted on [DATE] with diagnoses including hepatic failure, unspecified without coma (loss of brain function occurs when the liver is unable to remove toxins from the blood), hypothyroidism, unspecified (type of disorder of thyroid gland, a condition in which the production of thyroid hormone by the thyroid gland is diminished), type 2 diabetes mellitus without complications (a chronic disease affecting blood glucose regulation), unspecified protein-calorie malnutrition (disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food), anxiety disorder, unspecified (an anxiety or phobia that does not meet the exact criteria for any other anxiety disorder but is significant enough to cause distress and distress to the person), essential primary hypertension (high BP in which secondary causes such as renovascular disease, renal failure, pheochromocytoma, aldosteronism, or other causes of secondary hypertension or mendelian forms (monogenic) are not present), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), unspecified atrial flutter (a type of abnormal heart rhythm, or arrhythmia), heart failure, unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements), chronic obstructive pulmonary disease with (acute) exacerbation (sudden worsening airway function and respiratory symptoms in patients with COPD), mixed incontinence (he complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing, or coughing), dysphagia, unspecified (a disorder characterized by difficulty in swallowing), and repeated falls (more than two falls in a six-month period).<BR/>Review of the most recent MDS assessment dated [DATE] Resident #34 had a BIMS score of 3.<BR/>Review of Clinical Physician Orders on 3/22/2023 stated Resident #34 was admitted to Navasota Nursing &Rehab for Respite Hospice care under the services of Hospice Brazos Valley w/ dx: unspecified protein-calorie malnutrition. <BR/>Review of Resident #34 Hospice Brazos Valley Progress Notes reveal Resident #34 was ordered to be on hospice starting 09/03/2022 to 03/05/2023. However, there were no actual physician orders to discontinue hospice services.<BR/>During an interview on 3/22/2023 at 3:33 PM, The LVN stated the protocol when a resident was released from hospice the charge nurse will put in the progress notes and let the doctor know they need discharge orders to resume care. The LVN said the consequences would be delay in care for the resident #34. The LVN stated she does not know how the disconnect happen. The LVN stated the doctor advised her resident #34 started gaining weight and that is why she is being taken off hospice. <BR/>During an interview on 3/22/2023 3:55 PM, The DON stated the right way to update a hospice resident profile, or the way this facility way is to get an order from the hospice doctor or nurse advising that the resident is no longer on hospice. The chart nurse (The LVN) was supposed to update the resident MDS. The DON stated they would be required to request the paperwork to get the order from hospice company if they did not send the doctor orders. Once they come off hospice, they will go back to regular care. The DON stated if they do not update the Resident #34 MDS, Resident #34 was at risk for not receiving their medications properly and not receiving the care she needs.<BR/>A record of review of the facility's Significant Change in Status Assessment (SCSA) dated October 2019 stated An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice selection statement, but not earlier). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a PASRR screening was completed for residents with a mental disorder or an intellectual disability for 1 of 6 residents (Resident #25) reviewed for PASRR Level I screenings.<BR/>The facility did not ensure an accurate PL1 screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) was completed for Resident #25. <BR/>This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.<BR/>Findings included:<BR/>Record review of Resident #25's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included Bipolar Disorder, Anxiety Disorder, Hypertension, Cognitive Communication Deficit (Difficulty with thinking and how someone uses language.), Dysphagia following cerebral infarction (Difficulty to swallow resulting from a stroke), Altered Mental Status, Insomnia (Difficulty to get sleep), Schizophrenia (a serious mental illness) and Major Depressive Disorder. <BR/>Record review of Resident #25's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 out of 15 indicating the resident chose not to participate or 4 or more items were coded O because the individual chose not to answer or gave a nonsensical response.<BR/>Record review of Resident#25's care plan dated 03/28/22 reflected: <BR/>The resident requires anti-psychotic and anticonvulsant medications for dx of schizophrenia. <BR/>The relevant interventions were Administer medications as ordered, Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate, Discuss with MD, family re ongoing need for use of medication.<BR/>Record review on 03/23/23 of the Physician's order dated 03/25/22 reflected: <BR/>Refer to Sr [stimulus-Response] Psyche for treatment and evaluation for both psychological and or psychiatric services.<BR/>Record review on 03/23/23 of the Physician's order dated 02/16/2023 reflected: <BR/>Risperidone Oral Tablet 0.5 MG (Risperidone): Give 0.5 tablet by mouth one time a day related to SCHIZOPHRENIA, UNSPECIFIED<BR/>Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium): Give 1 tablet by mouth two times a day related to SCHIZOPHRENIA<BR/>Record review of Resident #25's PL 1screening dated 04/08/22 read in part, is there evidence or an indicator this is an individual that has a Mental Illness? The answer was: No.<BR/>In an interview on 03/22/23 at 3:30 p.m. with RRN, she stated the current PL l assessment was inaccurate as it supposed to be Yes instead of No. RRN said since the MDS nurse on leave, she went ahead and corrected it and then informed the PASRR team. RRN reported the PASRR informed her that they would be arriving at the facility sometime the following week to conduct PASRR Level 2 assessment on Resident#25. <BR/>In an interview on 03/23/23 at 2:56 p.m. with the MDS Coordinator, she stated Resident #25 was positive for PL 1 as Resident#25 was diagnosed with Bipolar Disorder and Schizophrenia. She stated she was not sure why the result of PL1 assessment was negative instead of positive. She said the PASRR team would come the following week and evaluate the resident to see if she was qualified for specialized services based on the rectified PL1 assessment by RRN on 03/22/23. The MDS coordinator said she and medical records staff were responsible for the accuracy of PASRR screenings. <BR/>In an interview on 03/23/23 at 3:33 p.m., the ADM said the MDS nurse was the person responsible for ensuring the accuracy of PASRR screenings. She said the purpose of the screening was to identify individuals who needed to receive services they could benefit from. She said she was unsure if there was a process to monitor for accuracy of the screenings. <BR/>Record review on 03/23/23 of the facility's PASRR Evaluation PE Policy and Procedure dated 10/30/2017 reflected: 1. Policy: It is the policy of Creative Solutions in Healthcare facilities to ensure the LIDDA and/or LMHA complete a PE within the appropriate time periods (14 days). Note: this may vary depending on the type of admission and length of stay.<BR/>2.The NF will monitor for the LA to enter the PE into the portal within 3 business days of the IDT meeting. 3.The NF will monitor the ALERTS Page daily and certify that the NF can meet the needs of the resident once the PE was completed and entered in the portal.<BR/>4.The facility reviews the PE and if able to meet resident's needs, then the Facility Will CERTIFY the PE and setup an IDT meeting . A Positive PL l will alert the LA to complete the PASRR evaluation. The PE (PASRR Evaluation) is an evaluation to confirm or deny the suspicion of ID, DD, or MI recorded on the PL l. The evaluation also determines the need for specialized services that may be beneficial to the individual if they are confirmed positive for ID, DD, or Ml. The PE is critical because it is the first identification of services an individual's need .Procedure: 1.The LA (LIDDA or LMHA) completes the PE and enters the PE into the portal. The LA is alerted to the PL l submitted by the NF except for Preadmission Type Admissions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 3 residents (Resident # 64) reviewed for wound care.<BR/>Facility failed to ensure the scissors were sanitized before using it to cut wound care supplies while providing wound care to Resident #64<BR/>This failure could place the residents at risk for cross contamination and infection.<BR/>Findings included: <BR/>Record review of Resident #64's face sheet on 03/22/23 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Type 1 Diabetes Mellitus, Hypertension, Open Left and right Foot Wound, Depression, Hyperlipidemia (excess fat in blood), chronic kidney disease and Cerebral Infarction (stroke). <BR/>Record review on 03/23/23 of Resident #64's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 out of 15 indicating the resident chose not to participate or 4 or more items were coded O because the individual chose not to answer or gave a nonsensical response.<BR/>Record review on 03/23/23 of Resident #64's care plan dated 03/21/23 reflected:<BR/>The resident has Diabetic Ulcer r/t Diabetes: Left lateral [side] foot and one of the interventions was Monitor/document wound: Size, Depth, Margins: peri wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify MD as indicated.<BR/>Record review on 03/23/23 of Resident #64's March,2023 WAR reflected: <BR/>Cleanse diabetic ulcer to the left lateral foot with NS, pat dry, pack calcium alginate into the undermining at 9:00[am], apply therahoney [medicinal honey] to wound bed and cover with optifoam [a kind of highly absorbent wound care foam]. Change daily and PRN until resolved. One time a day for wound care, Start date:03/16/2023<BR/>During an observation on 03/22/23 at 3:00 pm, LVN A performed wound care on Resident #64. LVN A washed her hands and donned gloves before performing wound care on Resident #64's ulcer on the left foot. She then removed a pair of scissors from the back pocket of her pants and cut calcium alginate wound dressing pad and silicone-based foam and applied directly on the wound after applying therahoney on the wound. LVN A did not sanitize the scissors before using it to cut these wound care supplies. <BR/>During an interview on 03/22/23 at 3:20 pm, LVN A stated she should have sanitized the scissors before using them. She said carrying scissors in the pants pocket was a wrong practice since it could contaminate the scissors and compromised infection control protocols. LVN A stated she attended in-services on infection control two weeks ago.<BR/>During an interview on 03/23/23 at 2:00 pm, DON said carrying scissors in pants pocket and using them for wound care without sanitizing compromised infection control. When the surveyor asked how the facility identified infection control deficiencies, DON stated they achieved it by direct observation. She said DON or ADON occasionally participated and observed incontinent care and wound care for identifying compromises in infection control. DON said infection control training was an ongoing program, and participation was mandatory for all the staff members. <BR/>Record review on 03/23/23 of in-service logs reflected that there was in -service training on topic Infection control and handwashing on 03/12/23 and LVN A was one of the participants. No other training on infection control was evident in the past three months. <BR/>Review of a current facility policy on 03/23/23 titled Infection control policy and procedure manual 2019: Fundamentals of infection control Precautions reflected:<BR/>A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions .Resident care equipment and articles . c. Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #3) reviewed for comprehensive care plans.<BR/>Resident #3's comprehensive care plan did not reflect Resident #3's received psych service.<BR/>This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. <BR/>Findings include:<BR/>A record review of Resident #3's face sheet dated 01/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included: unspecified dementia (a condition that cause a decline in thinking, memory, and reasoning abilities), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and aphasia (a language disorder that makes it difficult to communicate) <BR/>A record review of Resident #3's Quarterly MDS assessment, dated 01/12/2025, reflected the resident had a BIMS score of 12, which indicated mildly impaired. Resident #3's Quarterly MDS reflected she required partial/moderate assistance for shower/bathe self and supervision or touch assistance for personal hygiene. <BR/>A record review of Resident #3's care plan, dated 01/30/2025, Resident #3's care plan did not reflect she was receiving psych services. <BR/>A record review of Resident #3's physician orders dated 01/30/2025, reflected Resident #3 had a physician order date 11/01/2023 for psych services to eval and treat PRN.<BR/>A record review of Resident #3 psych services notes dated 01/06/2025 & 01/20/2025 reflected Resident #3 was seen by psych service on 01/06/2025 & 01/20/2025.<BR/>During an interview with the DON on 01/30/2025 at 3:50pm, the DON stated Resident #3 does receive psych services and the psych services should be care planned. The DON stated that the facility did not have a MDS coordinator. The DON stated he expected for all care plans to reflect the most current information so the resident can be provided the highest level of care. <BR/>During an interview with the RCN on 01/30/2025 at 4:00pm, the RCN stated that Resident #3 does receive psych service and that should have been care planned. The RCN stated the facility does not have a MDS coordinator so it would be the IDT team's responsibility to ensure that Resident #3's psych services were care planned. The RCN stated if the resident's care plan was not accurate it could cause the resident to not receive the appropriate services. The RCN stated her expectations were for all resident's care plans to be accurate so the residents at the facility could receive the highest level of care. <BR/>A record review of the facility's Comprehensive Care Planning policy, not dated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. <BR/>The comprehensive care plan will describe the following-<BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being

Based on observation, interview, and record review the facility failed to ensure residents had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility and post in a place accessible to residents, family members and legal representatives of residents, the results of the most recent survey of the facility for 6 of 57 reviewed for rights to survey results. <BR/>The facility failed to ensure survey results were not posted in a location readily accessible and visible to residents, their legal representatives, or family members.<BR/>This failure could place residents at risk of having their rights limited to access information regarding the facility's compliance with state and federal requirements.<BR/>Findings include: <BR/>During an observation conducted on June 4, 2025 at 10:41 AM, the facility's survey results book was found placed behind a plant stand with a potted plant, blocking visibility and made it difficult to locate or access. The placement of the survey book was not readily accessible to residents, their representatives, or visitors. The survey book only included the results from 5/9/2024 survey . <BR/>During a confidential group interview six residents stated they had not known where or how to access the survey results in the facility. They had not understood or been aware the survey book existed, or they were able to review the results.<BR/>An interview was conducted with the ADM on June 4, 2025, at 3:43 PM, the ADM stated it was her responsibility to maintain and update the survey book. She stated she believed only the last full book survey report was required in the survey book. The ADM stated she was unaware the book must contain survey, certification, complaint investigation reports, and plan of corrections for the three preceding years. <BR/>The ADM stated the survey book was available and accessible to everyone. The state surveyor accompanied the ADM to the location of the survey book. When asked if she believed the book was accessible, the ADM stated, It would be accessible if this plant was not in the way. The ADM then moved the plant and stated she would conduct training with staff regarding the proper placement and accessibility of the survey binder. The ADM stated it was important for residents and family members to have access to the survey book, so they could be informed of survey results and how concerns were addressed.<BR/>An interview conducted on June 5, 2025 at 7:59 AM, the ADM notified the state surveyor that she had updated the survey book with the last three survey reports. The ADM stated she found the surveys in different binders in the office, but she combined them into one book .<BR/>An interview was conducted with the ADM on June 5, 2025, at 2:18 PM, the ADM stated she could not find a written policy and that no policy had been provided to her. She further stated, I assume one does not exist.

Based on observations, interviews, and record review, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed for puree preparation. <BR/>The facility failed to follow the puree diet recipes. The puree diet meatloaf was mixed with water instead of thickener or a broth with nutrient value. <BR/>This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health.<BR/>Findings included: <BR/>Observation on 05/06/2024 at 12:08pm revealed [NAME] M pureed the meatloaf with water instead of the thickener on the counter. [NAME] M did not have any recipes out for the pureed food. <BR/>Observation of [NAME] N pureeing food on 05/07/2024 at 10:41am did not have recipes out for the pureed food.<BR/>An interview with [NAME] N on 05/07/2024 at 2:08pm revealed that [NAME] N had been trained on puree. She stated that when pureeing meat, broth or thickener was supposed to be used. She stated that when adding thickener or broth, a little at a time was added until the meat was at the proper texture. She stated she did not know the negative outcome of adding water to puree. She stated the cook was responsible for ensuring the puree was done correctly. [NAME] N stated the facility does have recipes for Puree and that she forgot to use the recipes. <BR/>An interview with the FFS on 05/07/2024 at 2:23pm revealed when pureeing food, it was supposed to be mixed with broth, or a thickener. She stated she does not use the thickener much, instead she used the juices from the cooked food. The FFS stated that the facility does have recipes for puree. She also stated that she uses a measuring cup to ensure the right amount of thickener or broth was added. She said that the negative outcome of adding water to puree was that the food would not turn out right. She stated she did not know why the cooks did not use the recipes for puree. She also stated she did not know why [NAME] M used water when pureeing the meatloaf.<BR/>An interview with the Administrator on 05/08/2024 at 10:34am revealed that staff were trained when they start working at the facility on puree by the dietary director. She stated the facility does have recipes for the cooks to follow. She stated that if staff were using the recipes, it would tell them how much thickener to use when doing puree. She stated that staff were never supposed to mix puree meat with water. She stated by using water it would take away the nutrient value and residents would not get the nutrition they need. She stated staff were supposed use broth when pureeing the meat <BR/>An interview with Administrator on 05/08/2024 at 9:23am attempted several times to get the puree policy and did not receive it at exit. <BR/>An interview with [NAME] M on 05/09/2024 at 8:37am revealed that the process for puree was to add gravy in the meat than add thickener if needed. She stated that she was trained to add thickener a little at a time until the food was at the right texture. She stated water was not supposed to be used when pureeing food. [NAME] M stated that when water was used it takes the nutrients out of the food. She stated she added water because she was trained by the previous manager to add the water to puree foods . <BR/>Record Review of Recipes to Scale dated 05/09/2024 revealed that water should not be used as a liquid to puree food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement written policies and procedures that ensured reporting of crimes in federally funded long-term care facilities in accordance with section 1150B of the Act, any incident that involved an emergency situation that posed a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected.<BR/>The facility failed to:<BR/>1. <BR/>The facility failed to report to State Survey Agency (HHSC), immediately, but not later than 24 hours, when, on [DATE], two employees witnessed another employee with a gun in the facility.<BR/>2. <BR/>The facility failed to follow their own procedures when a verbal altercation between employees occurred, and, on [DATE], one of the employees involved in the verbal altercation brought a handgun into the facility, and the incident was not immediately reported to the administrator or the DON. <BR/>3. <BR/>The facility failed to call the police and to follow its own facility protocol for an armed individual listed in the emergency preparedness manual. <BR/>4. <BR/>The facility failed to implement their written policies and procedures to ensure the reporting of crimes to State Agency and law enforcement within the appropriate timeframes. <BR/>5. <BR/>The facility failed to in-service all staff on reporting to the Administrator emergency situations including reporting handguns brought into the facility. <BR/>An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:53 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy.<BR/>This failure could place the residents at risk for unreported allegations of a threat to resident health and safety and potential for injury or death.<BR/>The findings were:<BR/>In an interview on [DATE] at 5:24 PM with CNA C revealed she saw LVN A take a gun from underneath the driver's side of her truck and put it into her lunch box and carry the lunch box into the facility and put the lunch box below the top counter on a shelf at nurses' station one. The lunch box with the gun remained there until LVN A ended her shift on [DATE] at 6:00 am. When surveyor asked why she did not call the police, LVN A said she did not seem like she was for sure going to use the gun. CNA C revealed she called her DON two times and left her a message, but the DON did not return her calls. CNA C revealed she was never told they could not bring guns into the building. She said there were no signs on the outside of the doors telling them they could not enter the facility with a gun. CNA C said it was her 2nd or 3rd day working at the facility and she did not know the rules about when it was legal to carry a gun and when it was not legal to carry a gun. She said she knew that people carried guns all the time. She said when she began working the facility front doors were under repair and there no signs posted outside the facility about the prohibition of carrying guns into the facility.<BR/>In an interview on [DATE] at 5:54 PM with CNA D revealed LVN A was having a dispute with CNA E and a lot of racial comments were made. CNA D saw LVN A's partially unzipped lunch bag and saw the butt of a gun in the lunch bag. CNA D revealed that the lunch bag was at nurses' station one on top of the desk below the counter next to the printer. CNA D revealed she heard LVN A make a statement that CNA E was going to get what was coming to her. CNA D revealed it was reported to the ADON on Friday, [DATE]. CNA D revealed she was not at all concerned about the residents' safety and thought the situation was under control. LVN A never mentioned anything about hurting the residents. <BR/>In an interview on [DATE] at 5:54 PM with CNA D when asked why she did not call the police when she knew that LVN A had a gun she said she did not see it as a threat at the time. CNA D said that LVN A always talked about having her gun with her and LVN A never made a threat of using it against the residents. When the surveyor asked CNA D if she saw the signs posted on the outside entrance to the facility reading handguns prohibited she said the signage was not posted outside, it was posted inside on the side of the wall in the lobby. She said she told the ADON next day, on [DATE], about LVN A having the gun inside the facility. <BR/>In an interview on [DATE] at 3:07 PM LVN B revealed LVN A was always a little difficult to get along with. LVN B did not see a gun. He revealed that LVN A was very racial. He revealed he was not worried about the resident safety that evening. <BR/>In an interview on [DATE] at 11:15 am with the ADON she stated the staff came and reported to her about the LVN A and a handgun during the Christmas party on [DATE]. She stated she reported it to the DON and the DON told her to in-service the staff about reporting incidents. The ADON stated she did not report it to the Administrator because it was 10 o'clock at night. <BR/>In an interview on [DATE] at 12:58 PM with LVN A revealed she was the charge nurse on station one on [DATE] and her shift began at 6:00 PM. She said that it was, bull crap that she brought in a gun into the facility and there were no racial slurs and none of this happened. LVN A revealed she knew it was a criminal offense to bring a gun into the nursing facility. <BR/>In an interview on [DATE] at 4:00 PM with the DON revealed no staff member contacted her on [DATE] and told her about LVN A having a gun in the facility. The DON revealed that on [DATE] the ADON told her that CNA D told her that LVN A brought a gun into the facility. The DON did not tell the ADM about the report of the gun in the facility until Monday, [DATE]. The DON said that if a staff member saw another staff member with a gun, that staff member should have called the police and the ADM should have been notified immediately. When the surveyor asked the DON why she did not tell the ADM about the gun in the facility until Monday she said, there was no particular reason why she did not call her. When the surveyor asked the DON about the reports of racial slurs the DON said that she did not feel it was racial. <BR/>A review of TULIP facility self-report revealed the facility investigation summary that on [DATE] at 6:30 PM a facility charge nurse was witnessed bringing a handgun into the facility and the facility first learned of the incident on [DATE]. Investigation summary reported on [DATE] LVN A brought a handgun into the facility. Two staff members reported seeing the handgun. CNA C reported she witnessed LVN A go to LVN A's vehicle, remove the handgun from under the seat of her trunk, place it in LVN A's lunch box and bring it into the building. Later, CNA D reported standing at the nurses' station and observed the gun in the green and black lunch bag when LVN A went into it to get something. LVN A denied owning a gun. <BR/>A review of TULIP revealed the HHSC TULIP reporter was contacted on [DATE], AT 4:55 PM, the date and Time of the incident: was [DATE] 6:30:00 PM. The date facility first learned of Incident was [DATE] 10:00:00 AM. The Actions and Notifications taken by the facility were statements were taken alleged perpetrator was terminated, in-services were provided, notifications were made to facility administration, police dispatcher and HHSC.<BR/>Review of written statement of CNA C, undated, revealed on [DATE] LVN A said that us white people need to stick together because there are a lot of nigger clicks out here. A resident call light went off and CNA C said she would answer the call light even though the resident was the responsibility of CNA E. CNA C revealed that LVN A told her, no let that nigger get off her ass & do something . LVN A walked to the resident's room beside CNA E and told CNA E she would take care of the resident and CNA E could clock out and go home. CNA E told LVN A she was not going to clock out and told LVN A to, stop talking crazy. LVN A and CNA E kept arguing. CNA C said she stepped in to calm down the situation. When CNA E walked away LVN A said, I wish you touched me because then it would be self-defense. CNA C asked LVN A why she did not call and the DON or ADM about CNA E not answering the call light and LVN A said the ADM had (illness) and was weak and that is why, these niggers are out of control. CNA C followed LVN A out the front door and LVN A went to her truck and took a gun from underneath the seat and put the gun in a lunchbox. CNA C revealed, I told her it was not that serious or worth her freedom and she said yes it was she would kill those niggers and LVN B. CNA C revealed LVN A was walking around CNA E's car taking pictures. CNA C asked LVN A why she did not like LVN B and LVN A said it was because, the nasty MF deals with niggers. CNA C revealed LVN A walked to LVN B's station and LVN A told him you are going to get what is coming to you. CNA C revealed in her statement, at this point myself and the other workers feel for our safety as well as the safety of the residents when LVN A is here. <BR/>Review of statement, undated, of CNA D revealed on [DATE] she observed a gun in LVN's lunch bag. CNA D revealed this was, after several incidents when her & a fella CNA had words. LVN A was, nit picking with all of the staff in a degrading racist manner. Everybody black was a nigger and I tried very hard to keep the peace. LVN A is a very confrontational nurse lies, starts mess with the patients and other staff . The lady is very delusional, suicidal, homicidal, bipolar, and she needs help. We fear for our safety and the residents when she is here. <BR/>Review of statement, undated, of CNA E revealed on [DATE] LVN A told her to go home and said negative comments about African American people. CNA E revealed that LVN A, started to walk up on me like she was going to do something so I told her to stop walking up on me or it would be an issue. CNA E revealed she told LVN A to leave her alone and stop harassing her. And LVN A told her this is my hall and CNA E will do what she tells her to do. CNA E revealed, I told her to her face I don't care who hall it is don't come tell me how to do my job. LVN A told her to go home and LVN A would do her hall and CNA E told her she would not go home. LVN A yelled from station one desk to station two desk for LVN B to send her home. CNA E revealed LVN A told her LVN B would not send her home because, yall F*ucking. CNA E revealed that she told LVN A she needed to stop harassing them and let them do their jobs that is when LVN A was making comments involving nigger this and nigger that. CNA E revealed LVN A walked outside and stayed out for about thirty minutes and came in with a lunch kit. <BR/>Review of statement dated [DATE] of CNA F revealed she, overheard LVN A making racist remarks this is not the first time if anything doesn't go her way, she gets upset and goes in a uproar. We (staff) have already came to the DON about it. It's a very hostile environment when LVN A is here.<BR/>Review of statement, undated, LVN B revealed LVN A told him, I should stick up for my own kind and LVN A pointed a finger at him and stated one day I would be sorry. <BR/>Review of statement, undated, of ADON revealed that on [DATE] she was asked to be on standby when LVN A arrived for her shift and instructed to not allow LVN A in the build, lock the door, and call non- emergency to issue LVN A criminal trespass for the handgun a that was reported to have been in the building on [DATE]. <BR/>Review of LVN A's employee time sheet revealed she worked at the facility on [DATE]. <BR/>Review of statement of ADON, undated, revealed LVN A's employment was terminated on [DATE]. <BR/>Review of inservices conducted on [DATE] reflected not all staff were in-serviced on reporting to the Administrator emergency situations including reporting handguns brought into the facility. <BR/>Review of facility employee abuse prevention proficiency test revealed that it was the responsibility of the facility to train employees, report, and investigate incidents and prevent abuse. <BR/>Review of facility reporting crimes test, undated, revealed, as an employee of the facility you are considered a covered individual. Each covered individual has an obligation to report the suspicion of a crime against a resident directly to local law enforcement and the State Survey Agency. Any other crime against a resident described in the Texas Penal code time frame requirements to report: No serious bodily injury - not later than 24 hours after forming the suspicion. If you have any questions regarding reporting of crimes contact your administrator immediately. <BR/>Review of facility reporting crimes test revealed each individual has an obligation to report the suspicion of a crime against a resident directly to local law enforcement and the State Survey Agency. <BR/>Review of facility Abuse/Neglect policy, undated revealed, all reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated per facility protocol. Investigations will be reviewed by the facility administrator and/or abuse preventionist within 24 hours of compliant. Appropriate notification to state and home office will be the responsibility of the administrator per policy.<BR/>When a suspected abused, collected, exploitative, mistreated or potential victim of misappropriation of property comes to the attention of an employee, that employee will make an immediate verbal report to the abuse preventionist or designee. If the discovery occurs outside of normal business hours, the abuse preventionist and or designee will be called. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated [DATE]. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. <BR/>Investigation<BR/>Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated.<BR/>A report to the appropriate agency will include the following:<BR/>The name and address of the suspected victim.<BR/>The name and address of the suspected victim's care giver, if known.<BR/>The nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source<BR/>The nursing facility will make an addendum to any reportable incident in its report to HHSC if the resident subsequently experiences a negative outcome.<BR/>Other pertinent information as available.<BR/>The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form.<BR/>With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation.<BR/>Abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property of residents by employees of any facility will be grounds for immediate termination.<BR/>Review of facility Corporate Code of Conduct, from facility personnel handbook dated [DATE], revealed the types of behavior this facility feels are inappropriate include having unauthorized firearms on this facilities premises or while on this facilities business. <BR/>Review of facility personnel handbook dated [DATE] revealed Weapons in the Workplace - it is not permissible for any person to carry firearms on the property in this facility. It is prohibited for anyone to possess or carry firearms. <BR/>Review of Employee Disciplinary Report Action Request for LVN A, charge nurse hire date [DATE] termination dated [DATE] date of infraction [DATE], Specific reason for the disciplinary action revealed on the [DATE]O23 a CNA witnessed [sic] LVN A take a gun from under the seat of her truck and bring it into the building in a green and black lunch bag after having several confrontations with one of the CNA's, another CNA observed the gun in her lunch bag as well. She made threatening remarks about shooting staff members due to her dislike for them. She also directly threatened the charge nurse at LVN B (because he doesn't stick with his kind). In addition to this she made racial remarks about an African American resident (deceased ) and staff. LVN A failed to adhere to the corporate code of conduct and weapons in the workplace by possession of weapons on company property. On [DATE] after making several harassing and racial remarks LVN A was seen getting a gun out of her personal vehicle and brining into the in a lunch box. The weapon was seen by at least two individuals while it was in the facility. LVN A is a threat to other staff members and is aware of the corporate code of conduct and weapons policy via her signature on the employee acknowledgment form.<BR/>Review of LVN A's [DATE] signed acknowledgement and signature that LVN A, read, understand, and agree to abide by the facilities rules of behavior for general users. <BR/>Review of in-service training attendance roster dated [DATE] revealed LVN A received a reprimand for conduct unbecoming of an employee of the company. <BR/>Review of facility armed intruder/active shooter emergency policy, undated, reflected the presence of any person on the premises with the presumed intention of harming others. Victims are family members or associates with a weapon. Oftentimes the incident is domestic in nature and targeted victims are family members or associates of the intruder. Purpose to outline steps for the facility to take, if there is a reported threat to a resident, associate, or visitor of the building, from an individual outside the facility period to also provide direction with this staff to follow, should an armed intruder enter the facility and slash or become violent with staff, residents or visitors period to ensure law enforcement is familiar with the layout of the facility by inviting law enforcement into the facility and providing a facility floor plan to enforcement. Procedure Do not confront or attempt to reason with the individual. Stay calm period call 911 and give the facility name, and your name. Give as many details of this situation as you can to the dispatcher, such as how many perpetrators, location of the armed intruder and their description, type of weapons being used, any hostages, casualties, etcetera. Announce over the pager system code white open parent security slash aggression close parent and the location of the situation. If safe passage is available, leave the area immediately, by way of the nearest exit. Move as far away from the facility as possible protecting their residents' safety. <BR/>This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 6:53 PM. The DON was notified. The DON was provided with the IJ template on [DATE] at 6:53 PM. <BR/>The following POR was accepted on [DATE] at 5:07 PM<BR/>Date: [DATE] <BR/>F609 The facility failed to develop and implement written policies and procedures that: Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act.<BR/>Interventions: <BR/>As of [DATE] the Charge Nurse suspended and terminated from the facility by the Administrator. <BR/>As of [DATE] the allegation was reported to the police and HHS by the Administrator. <BR/>As of [DATE] the DON was in-serviced 1:1 by the Regional Compliance Nurse on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. <BR/>As of [DATE] the Administrator was in-serviced 1:1 by the Area Director of Operations on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. <BR/>As of [DATE] the CNA who witnessed the handgun was in-serviced 1:1 by the Regional Compliance Nurse to call 911 and the administrator immediately. <BR/>Medical Director was notified of the immediate jeopardy on [DATE] by the DON.<BR/>An ADHOC QAPI meeting was conducted on [DATE] to discuss the immediate jeopardy and subsequent plan.<BR/>In-services: All Staff:<BR/>All staff were in-serviced on the following in-services below on [DATE] by the Regional Compliance Nurse and DON. All staff not present will be in-serviced prior to start of their shift. All new hires will be in-serviced during orientation prior to start of their assignment. All agency staff will be in-service prior to the start of their shift. <BR/>To notify 911 immediately in the event that a firearm is suspected in the facility and not with law enforcement. Then notify the Administrator and DON. <BR/>Abuse and Neglect Policy.<BR/>Timely reporting of abuse and neglect to the abuse coordinator. <BR/>Monitoring:<BR/>Monitoring was initiated on [DATE]. <BR/>Reviewed the payroll/input personnel action form that reflected LVN A's employment at the facility was involuntary terminated for bringing a gun into the facility.<BR/>Reviewed of Self-reporting ad hoc QAPI - Emergency Situation Document that reflected both law enforcement and the State of Texas were informed of the incident. <BR/>Interview with the DON revealed she had been in-serviced by the Regional Compliance Nurse on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. She stated she was also in-serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator.<BR/>Interview with the Administrator revealed she was on vacation but reached by phone on [DATE] and confirmed she was in-serviced on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion.<BR/>Interview with the CNA who witnessed the handgun confirmed that she received an in-service that if someone brings a gun into the facility, she needs to call 911 then report to the administrator immediately. <BR/>Interview with the DON revealed she contacted the Medical Director and notified him of the immediate jeopardy.<BR/>Reviewed ADHOC QAPI meeting was conducted on [DATE] to discuss the immediate jeopardy and subsequent plan.<BR/>In-services: All Staff:<BR/>All staff were in-serviced on the following in-services below on [DATE] by the Regional Compliance Nurse and DON. All staff not present will be in-serviced prior to start of their shift. All new hires will be in-serviced during orientation prior to start of their assignment. All agency staff will be in-service prior to the start of their shift. <BR/>To notify 911 immediately in the event that a firearm is suspected in the facility and not with law enforcement. Then notify the Administrator and DON. <BR/>Abuse and Neglect Policy.<BR/>Timely reporting of abuse and neglect to the abuse coordinator. <BR/>Interviews on [DATE] from 10:37AM to 12:22PM with 3 Nurses, 6 CNAs and 1 MA revealed the following:<BR/>*10:37 AM ADON J stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator.<BR/>*11:30 AM CNA H stated she was in serviced on the facility's abuse and reporting policy. She stated she was also in serviced on who and how soon you would report altercations or observations of a handgun to. She stated the abuse coordinator the administrator. <BR/>*11:40 AM LVN I stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. She further stated she was in serviced on firearm awareness and armed intruder. <BR/>*11: 45 CNA J stated she was in serviced and she would report anyone with a firearm immediately and call the police.<BR/>*11:50 AM CAN K stated she was in serviced and would immediately report anyone with gun to the administrator and the police.<BR/>*11:55 AM CNA L stated she was in serviced and would immediately report anyone with gun to the administrator and the police.<BR/>*12:00 PM CNA M stated she was in serviced yesterday on abuse reporting and who to report it to. She stated she would report to Administrator right away and if she saw someone with a gun, she would call 911.<BR/>*12:05 PM CNA M stated he was in serviced on who to call if someone had firearm and what to do if someone brought one to the facility. He stated he would let the administrator know and call the police. <BR/>*12:10 PM CNA N stated she was in serviced on the facility policy regarding reporting abuse and you would tell the administrator right away. If I saw someone with a gun, yes, I would report it and call 911.<BR/>*12:18 PM Medication Aide O stated she was in serviced and would immediately report anyone with gun to the administrator and the police.<BR/>*12: 22 PM LVN P stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. She further stated she was in serviced on firearm awareness and armed intruder.<BR/>Review of in-service records reflected the facility in serviced staff on abuse and neglect, Firearm awareness and armed intruder/active shooter.<BR/>Review of the facility's abuse and neglect policy reflected the policy included the key components of screening, training, prevention, identification, investigation, protection and reporting alleged incidents of abuse, neglect, and exploitation/misappropriation.<BR/>The Administrator/ DON/Designee will interview 15-20 staff members weekly on what they would do if a handgun was observed in the facility that doesn't belong to law enforcement. Monitoring will continue for 6 weeks. <BR/>Administrator/DON will monitor PCC documentation daily during the morning meeting for any evidence of an emergency situations to ensure timely reporting. Monitoring will begin [DATE] and will continue for 6 weeks. <BR/>Review of staff list and in service trainings reflected 80% of staff in serviced.<BR/>The DON was informed the Immediate Jeopardy was removed on [DATE] at 6:18 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #3) reviewed for comprehensive care plans.<BR/>Resident #3's comprehensive care plan did not reflect Resident #3's received psych service.<BR/>This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. <BR/>Findings include:<BR/>A record review of Resident #3's face sheet dated 01/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included: unspecified dementia (a condition that cause a decline in thinking, memory, and reasoning abilities), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and aphasia (a language disorder that makes it difficult to communicate) <BR/>A record review of Resident #3's Quarterly MDS assessment, dated 01/12/2025, reflected the resident had a BIMS score of 12, which indicated mildly impaired. Resident #3's Quarterly MDS reflected she required partial/moderate assistance for shower/bathe self and supervision or touch assistance for personal hygiene. <BR/>A record review of Resident #3's care plan, dated 01/30/2025, Resident #3's care plan did not reflect she was receiving psych services. <BR/>A record review of Resident #3's physician orders dated 01/30/2025, reflected Resident #3 had a physician order date 11/01/2023 for psych services to eval and treat PRN.<BR/>A record review of Resident #3 psych services notes dated 01/06/2025 & 01/20/2025 reflected Resident #3 was seen by psych service on 01/06/2025 & 01/20/2025.<BR/>During an interview with the DON on 01/30/2025 at 3:50pm, the DON stated Resident #3 does receive psych services and the psych services should be care planned. The DON stated that the facility did not have a MDS coordinator. The DON stated he expected for all care plans to reflect the most current information so the resident can be provided the highest level of care. <BR/>During an interview with the RCN on 01/30/2025 at 4:00pm, the RCN stated that Resident #3 does receive psych service and that should have been care planned. The RCN stated the facility does not have a MDS coordinator so it would be the IDT team's responsibility to ensure that Resident #3's psych services were care planned. The RCN stated if the resident's care plan was not accurate it could cause the resident to not receive the appropriate services. The RCN stated her expectations were for all resident's care plans to be accurate so the residents at the facility could receive the highest level of care. <BR/>A record review of the facility's Comprehensive Care Planning policy, not dated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. <BR/>The comprehensive care plan will describe the following-<BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being

Based on observation and interview, and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 7 (01/24/2025, 01/25/2025. 01/26/2025. 01/27/2025. 01/28/2025. 01/29/2025, and 01/30/2025) of 8 days reviewed for nurse staffing posting.<BR/>The facility failed to post the daily staffing information in a prominent place on 01/24/2025, 01/25/2025, 01/26/2025, 01/27/2025, 01/28/2025, 01/29/2025, and 01/30/2025.<BR/>This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.<BR/>Findings:<BR/>Record review of the facility's nursing staff information reflected the facility failed to complete and post the nursing staff information on the following dates 01/24/2025, 01/25/2025. 01/26/2025. 01/27/2025. 01/28/2025. 01/29/2025, and 01/30/2025<BR/>During an observation on 01/30/2025 at 8:50 am, revealed the nursing staffing information posted outside out the administrators office was dated 01/23/2025.<BR/>During an interview with the DON on 01/30/2025 at 3:50 pm, the DON stated he was new to long term care was not aware that he was supposed to be posting the nursing staffing information. The DON stated the resident would not be affected by the nursing information not being posted. The DON stated the nursing staffing show transparency of the number of staff present for each shift. The DON stated the facility does not have a policy about posting the nursing staff information. <BR/>During an interview with the RCN on 01/30/2025 at 4:00 pm, the RCN stated the nursing staffing information should be posted daily. RCN stated it was the DON's responsible to ensure it posted daily. The RCN stated on the weekends it was the weekend supervisor's responsibility to ensure it was posted. The RCN stated the DON has only worked in the facility for 8 days and the administrator had been posting the nursing staffing information. The RCN stated with the administrator out sick and the DON was not aware the nursing staffing information needed to be posted. The RCN stated the purpose of posting the nursing staffing information was to show that the facility had adequate staffing. The RCN stated the resident would not suffer any adverse effects if the nursing staff information was not posted. The RCN stated the facility does not have a policy regarding the posting of the nursing staff information. <BR/>The facility does not have a policy regarding posting the nursing staffing information.

Based on interview and record review the facility failed to provide a private space for residents' monthly resident council meetings and the confidential resident group meeting during survey for five of five confidential residents reviewed for resident council.<BR/>The facility did not provide a private space for resident council meetings. <BR/>The failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in a private space without uninvited staff being present.<BR/>Findings Included:<BR/>Interview on 05/07/2024 10:10 AM, the Administrator stated the residents would be in the dining area that it was located next to the nurses' station which was an open room with no doors for privacy. After speaking with the administrator, the meeting was then moved to the Activity Directors office.<BR/> A confidential resident group meeting held in the Activity Director's office on -05/08/224 at 10:30 AM with 5 residents. The residents in attendance of the resident group meeting stated they normally meet in the dining room that has no doors. The residents stated they do not meet regularly. Residents in the meeting stated they don't feel comfortable saying too much without a door to close off the room. The residents said they would like to be able to meet in private. <BR/>In an interview on 5/7/2024 at 1:00pm the Activity Director stated she had just started yesterday and was asked her where the residents normally meet. She said they should be meeting in a room with a door like the activity room so that the residents can have privacy. She told me when she has resident council meetings, she will hold the meetings in the activity office.<BR/> Asked Administrator verbally on 5/7/2024 at 1:30 PM for Resident Council minutes and they were unable to provide. On 05/07/2024 and 05/08/2024 asked the administrator a copy of the Resident Council Policy.