**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure Resident (R)424's code status was accurately reflected in the medical record. This involved one (R424) of 32 residents reviewed for advanced directives. On [DATE] at 4:05 PM, the Administrator was notified that the failure constituted Immediate Jeopardy (IJ) at F578. On [DATE] at 7:48 AM, the facility submitted an acceptable plan of removal for the IJ at F578. Implementation of the removal plan was verified on [DATE] at 11:15 AM. The IJ was verified to be removed as of [DATE]. Findings Include: Review of the facility's policy titled, Care and Treatment, Subject: Advance Directives, revised 2/2018 revealed Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care. Review of R424's electronic medical record (EMR) revealed his code status orders were CPR/Full Code- no tube feed effective [DATE]. R424's care plan reflects Full Code status. R424's EMR contained a paper Emergency Medical Services Do Not Resuscitate Order signed by R424's Responsible Party (RP) and a physician on [DATE] requesting DNR status. There was also a Physician order dated [DATE] at 1845 for DNR, which was signed by a Nurse and a Physician. On [DATE] at 12:16 PM, R424, who had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate intact cognition stated, I want to die, I don't want them to save me. During a telephone interview on [DATE] at 12:30 PM, R424's RP confirmed R424 wishes to be a DNR. During an interview on [DATE] at 2:15 PM with Licensed Practical Nurse (LPN)1 and Registered Nurse (RN)1, they stated, If there was a code, we would go to PointClickCare (PCC) and verify the code status. We will check vitals and start CPR. We then would call out for a Code Blue and then continue to monitor with CPR until EMS comes and takes over. During an interview with LPN2 on [DATE] at 2:19 PM, she stated in order to verify code status, she would check the EMR. When asked to confirm R424's code status, LPN2 went into the EMR and stated he was a Full Code. During an interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, she stated she would look under the MISC tab in the EMR for the code status and look at the doctor ' s orders. If a resident was not breathing, they would call a code blue . During an interview with the Minimum Data Set (MDS) Nurse on [DATE] at 3:20 PM, she stated the care plan should be updated related to the Resident's Physician's orders. During a consecutive interview with the DON on [DATE] at 3:32 PM, she confirmed R424 had conflicting code statuses' and she would need to look into it. Review of the facility plan of removal included the following: The following measures were immediately implemented upon notification of the facility: 1. Corrective action for residents found to have been affected by this deficiency: -Resident #424 preferred level intensity was reviewed with responsible party and order was corrected in point click care (PCC). 2. Corrective action for residents that may be affected by the deficiency: -The Medical Director was notified of the IJ on [DATE] at 4:39 PM. -All residents have the potential to be affected by the deficient practice. -On [DATE] at 4:30 PM to 8:00 PM, a full house audit of current residents was reviewed by the Director of Nursing and validated that preferred level of intensity and signed DNR order matches the order in PCC and care plan. No other residents were identified to be affected by the alleged deficiency. 3. Other Plan of Removal Actions: -On [DATE] at 4:15 PM, an in-service was prepared by the DON and initiated by the Assistant Director of Nursing (RN) for all licensed nurses, medical records personnel, and social services employees. The in-service included the advanced directives policy and how to transcribe orders correctly. -Education will be included as part of the annual skills fair and new hire orientation for licensed nurses, medical records personnel, and social services employees. -An ad hoc meeting regarding the items in the IJ template completed [DATE]. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions. -Changes in advanced directives will be reviewed daily clinical meeting 5x a week x12 weeks and monitored by Director of Nursing or Designee. -DON or Designee will report findings and analysis of reviews to the QA&A committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained. Date of Compliance: [DATE]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)170 was free from neglect. Specifically R170 sustained a femur fracture on [DATE], and was not sent out for medical treatment for an extended period of time causing prolonged, agonizing pain, and suffering for 1 of 1 resident reviewed for neglect. On [DATE], the State Agency (SA) identified that the facility's failure to ensure R170 was free from neglect instituted Immediate Jeopardy (IJ) at F600. The IJ Template was presented to the Administrator on [DATE] at 3:32 PM. The facility presented an acceptable IJ Removal plan on [DATE] at 4:02 PM. The implementation of the removal plan was verified on [DATE] and confirmed as removed on [DATE]. The facility remained out of compliance at a scope and severity of D Findings Include: Review of the facility policy titled, Resident Rights, Subject, Abuse Prevention and Prohibition, (revised 2/2018), states as the facility Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident's must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Definitions: Abuse - willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Adverse event - is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Neglect - is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility admitted R170 on [DATE] with diagnoses including, but not limited to, dementia with behaviors, anxiety, depression, and malignant neoplasm of the right kidney. The quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive deficits. Review of the progress note dated [DATE] at 07:05 AM revealed a nurse's note that stated: Acetaminophen Tablet 650 milligrams [mg], give 1 tablet by mouth every 6 hours as needed for MILD PAIN, not to exceed 3 grams in 24 hours. Review of the progress note dated [DATE] at 09:05 AM revealed a nurse's note that stated: At 06:45, CNA called nurse to room [ROOM NUMBER]. Myself and the PM nurse entered the room and noted the resident lying on his left side, beside his wheel chair. The resident was complaining of pain to his left leg and hip. His left upper leg noted to be larger than right and with a large knot on the upper front of his leg. Resident unable to move his left leg. Also noted to have a hematoma to head, front of scalp. No open areas noted to head. Neuro checks done. The DON (Director of Nursing), the physician and the personal representative notified. Order received for STAT x-ray left hip and left leg. At 07:05 AM, resident was given Tylenol for pain. Awaiting x-ray. R170 was not sent out to the hospital for treatment immediately after being found on the floor and injured and there was no documentation of the time R170 fell only the time he was found on the floor by a CNA. Review of the progress note dated [DATE] at 1406 revealed a nurse's note that stated: X-ray of left hip and left leg obtained earlier. Order received to send to ER for evaluation and treatment. Attempted several times to contact resident's son - left messages to call facility. Son, RP (Responsible Party) did return call and was told of order to send his father to ER. EMS called and here to transport resident to hospital. Report called to ER nurse. Review of the June '24 physician orders revealed that R170 only had Acetaminophen 650 mg ordered for MILD PAIN, and no other pain medications were on the MAR (Medication Administration Record) until R170 returned from the hospital on [DATE] with an order for Hospice. Review of the Comprehensive Plan of Care for R170 revealed, the resident is high risk for falls related to muscle weakness, difficulty in walking, unsteadiness on feet, encephalopathy, cognitive loss and dementia, hyperlipidemia, hypothyroidism, atrial fibrillation, hypertension, gastroesophageal reflux disease and episodes of bladder incontinence. Resident has a colostomy. Resident had an actual fall with poor communication/comprehension. Unsteady gait, and confusion. He is focused on going home and packing his items. He sundown's in the evening. He is noncompliant with safety measures with walking, sit to stand from wheelchair. There is no start date, but the problems were resolved on [DATE], after resident was deceased . Review of the radiology report dated [DATE], which resulted at 11:55:54 AM, revealed as the results of a Femur 2 views left, states, The study is somewhat limited due to the patient's condition. There is an acute moderately displaced fracture in the mid distal shaft of the left femur with some overriding of the fracture fragments. Angulation deformity is present on the lateral view. Review of a fall risk assessment dated [DATE] revealed a score of 16 which indicated R170 was high risk for falls. Review of a fall risk assessment dated [DATE] revealed a score of 13 ensuring R170 is considered a high fall risk. No other fall risk assessments were provided. Review of a physician's order dated [DATE] at 12:22 PM states, May send to ER for evaluation and treatment. Review of a the ER visit on [DATE] revealed R170 was seen on [DATE] at 13:51 and states: X-rays were obtained later in the day which demonstrated midshaft femur fracture. It is angulated and displaced. There is no evidence that the skin was violated. The hospital course states, Resident was noted to have left midshaft femur fracture and Buck's traction was applied. Orthopedics consulted however patient did have some agitation related to dementia and being unfamiliar setting requiring medications. He was to be taken for surgery however he was noted to have supraglottic tracheal mass and the procedure was canceled. Family ultimately decided for initiation of hospice care at the nursing center. During an interview on [DATE] at 04:58 PM with Certified Nursing Assistant (CNA)2 concerning the fall that R170 sustained, she stated, he laid there hollering and crying in pain for 7 hours before being sent out to the hospital and had only Tylenol for the pain. During an interview on [DATE] at 05:18 PM with the Attending Physician, he stated he remembered this resident well and stated he would expect the nursing staff to send the resident to the hospital immediately if there was any indication of an injury from a fall. During an interview on [DATE] at 10:10 AM with Licensed Practical Nurse (LPN)10 she stated, I arrived at around 06:30 AM for my shift and the resident was still on the floor. I did not hear him hollering, the CNA came and got us. When we entered the room he was leaning against the bed and his left leg was so swollen we had to cut his pants off. He was real drowsy and if you touched his leg he would yell out. We kept calling the Director of Nursing (DON) to inform her that the resident really needed to go out to the hospital. When I called the last time she stated that the doctor had ordered an x-ray to be done here in the facility. The x-ray was ordered STAT and I think they came about 11:00 AM or so. The x-ray tech asked me to look at the film and you could plainly see his femur was fractured. LPN10 stated she called the DON to come and look at the x-ray and she refused. I really have no idea what time he fell, but his leg was so swollen, I believe he had fallen earlier in the morning. During an interview on [DATE] at 11:05 AM with CNA4, she stated, I got here around 06:40 AM for my shift and I heard the night shift nurse on the phone with the CNA, she said she went to check on him, and he was fine and then the CNA went to carry out the linen, and then she saw him on the floor. He was in a low bed, so I am really not sure if he fell from the bed or from his wheel chair. CNA4 stated, I walked down there and he was sitting up leaning against the bed with his eyes closed like he was very drowsy. The DON never came and looked at him. The x-ray tech showed up about 11 or 11:30 AM. When EMS got here they had to give him IV medication because he was hurting so bad. He had 2 knots sticking up on the upper part of his leg. I'm not sure what time he fell, I was not here during the night. I work day shift. The following measures were immediately implemented upon notification of the facility: 1. Corrective action for residents found to have been affected by the deficiency: a. R170 was found to be affected by the alleged deficient practice. b. On [DATE] at 6:45 am R170 was assessed by LPN. Provider was notified of findings and STAT x-rays were ordered. c. On [DATE] at 7:05 am, Tylenol was administered for pain by LPN. d. On [DATE] at 8:00 am, follow up Tylenol administration was documented as Resident resting with eyes closed. No facial grimacing noted. e. On [DATE] STAT x-ray results were reported by Trident Mobile 11:55 am f. On [DATE] order was received to send R170 to emergency room for evaluation of fracture at 12:22 pm. g. On [DATE] R170 was assessed by Dr. at 1:51 pm at Conway Medical Center Emergency Room. 2. Corrective action for residents that may be affected by the deficiency: a. The Medical Director was notified of the IJ on [DATE] at 4:30 pm. b. All residents have the potential to be affected by the alleged deficient practice. c. Residents who had a fall in the past 24 hours ([DATE]-[DATE]) were reviewed. One resident was identified. Resident was assessed by Registered Nurse on [DATE] at 5:57 pm with no signs of pain noted. 3. Other Plan of Removal Actions: a. All licensed nurses currently working were educated on [DATE] by Director of Nursing Services about pain management. b. All certified nurse aides currently working were educated on [DATE] by Unit Manager (Registered Nurse) on the process of reporting pain to the licensed nurse on duty. c. All licensed nurses will receive education on pain management prior to the start of their next shift. d. All certified nurse aides will receive education on the process of reporting pain to the licensed nurse on duty prior to the start of their next shift. e. Education will be included as part of the annual skills fair and new hire orientation for all nursing staff. f. An adhoc QAPI meeting regarding the items in the IJ template completed on [DATE]. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions. g. The Clinical Interdisciplinary Team will review falls, including pain, 5 days a week in Morning Clinical Meeting. h. Findings will be reported to QAPI committee monthly with additional follow-up and recommendations as needed until substantial compliance is achieved and maintained. Compliance Date: [DATE]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)103's wound was properly managed, resulting in R103 acquiring maggots inside the wound bed on the resident's right heel. On 02/07/25 at 3:18 PM, the Administrator and the Director of Nursing (DON) was notified that the failure ensure R103's wound was properly managed, constituted Immediate Jeopardy (IJ) at F686. On 02/07/25 at 3:18 PM, the survey team provided the Administrator and the DON with a copy of the Centers for Medicare and Medicaid Services (CMS) IJ Template, informing the facility IJ existed as of 10/03/24. The IJ was related to 42 CFR 483.25 Quality of Care. On 02/11/25, the facility provided an acceptable IJ Removal Plan. On 02/11/25, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Noncompliance as of 10/04/24. An extended survey was conducted in conjunction with the Complaint Survey for noncompliance at F686, constituting substandard quality of care. Findings include: Review of the facility policy titled, Skin Management System revised on 01/2025, documented It is the policy of this facility that any resident .or that residents admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable. 5. A report of all wounds and their progress will be updated by the treatment nurse weekly. Review of R103's Face Sheet revealed R103 was admitted to the facility initially on 06/19/24, with a readmission on [DATE], with diagnoses including but not limited to: pressure ulcer of right heel- stage 4, osteomyelitis, ankle and foot, methicillin resistant staphylococcus aureus infection as the cause. Review of R103's Physician Orders dated 09/30/24 revealed, paint right heel with betadine, cover with ABD pad, every day shift for wound healing; cleanse right heel with dakins, apply mesalt and border every day shift for wound healing. Review of Physician Orders dated 10/03/24, revealed, cleanse right hell with Dakins solution and apply Mesalt and border gauze every day shift for wound healing and as needed. Review of R103's Progress Notes dated 10/03/24, documented, During report nurse stated resident has maggots in right heel wound. Review of Nurses Notes dated 10/03/24 at 7:10 PM, revealed, Doctor notified and new orders to send resident out for further evaluation. Review of pictures and videos provided by staff, of the wound and maggots, revealed a gauze soaked with a wet brown substance and maggots in the wound on the heel of the resident, with the center of the wound dark brown and white surrounding. Maggots were also observed moving on the bed beside the resident's foot. Review of R103's Hospital Discharge Documentation timestamped with a service date/time of 10/28/2024 at 1419 EDT indicated, Patient is an 89 y/o male with Hypertension and cartoid artery stenosis was sent from nursing home because the staff there noticed maggots on a right heel wound . During an interview on 02/04/25 at 11:24 AM, R103 revealed that he has wounds on both heels and they were only blisters when he was admitted to the facility. R103 stated that his left heel had maggots in it (later confirmed to be the right heel). R103 explained that he is not sure how the maggots got in the wound, but he knows if a fly lands on it, it lays eggs. R103 further revealed that he went to the hospital and stated, they flushed them out at the hospital. During an interview on 02/06/25 at 10:18 AM, Licensed Practical Nurse (LPN)8, revealed R103 has two pressure ulcers that are on both heels. Wound care rounds are done every week and wound care is done on Mondays, Wednesdays, and Fridays, I think. LPN8 stated, The wound doctor comes once a week. R103 wasn't admitted initially on this unit, so not sure if he was admitted with the wounds. The wounds were present when R103 was transferred to this unit. Maggots were in the wound before he came to this unit. LPN8 further revealed, The treatment for R103's wound is to clean the wound, apply hydrofera blue, and a border gauge, not wrapped with anything. LPN8 further revealed that R103 has an order for heel boots and he only wears them in bed, but when he is in his wheelchair, he likes a pillow under his feet over the foot rest. During a telephone interview on 02/06/25 at 11:14 AM, LPN6 revealed that she is familiar with R103 and confirmed there were maggots in his wound. LPN6 explained that when she came on shift she was informed by the nurse on day shift that the resident had maggots in his wound and she inquired with the nurse of what they were going to do about it. She then stated that the day shift nurse informed her that she had called the Assistant Director of Nursing (ADON) and Registered Nurse (RN)3 and was told to only dress the wound and not to clean it or do anything else. LPN6 stated that her response was that she was not going to allow that, therefore she called the DON, who informed her that she wasn't aware of the situation and advised her to call the doctor. LPN6 states that she called the doctor (whose name she could not recall) and the doctor told her to send the resident out to the ER, since they were not there to look at it. LPN6 stated she called 911. LPN6 further explained that although she had worked with the resident days before the discovery of the maggots, she was not aware that the resident had any wounds because wounds were taken care of during the day and she didn't have to do anything with them. LPN6 revealed that Certified Nursing Assistant (CNA)1 stated that it had been going on. During an interview on 02/06/25 at 1:40 PM, the ADON revealed that she was not aware of maggots in R103's wound. The ADON states I believe we saw him on Wednesday during rounds with the wound doctor and there was nothing unordinary with the wound and he was sent out a day or two later. The ADON continued to explain that a nurse, either the floor nurse or the unit manager called her to inquire if there was a change in the resident's treatment plan and she further explained that she believed that at that time the treatment was Dakins wet to moist. The ADON further states no one told me about maggots. During an interview on 02/06/25 at 3:06 PM, LPN7 revealed she was doing a dressing change with the assistance of a CNA and this was her first time working with the resident and the CNAs. LPN7 explained that when she saw the bugs, that appeared to be maggots in the resident's wound and she took a picture of just the resident's foot and sent it to RN3 via text seeking advice on how to treat. LPN7 stated that she was told that the resident had a history of parasitic infections and to treat the wound with Dakin's and dress it as best she could and that the wound nurse, who is also the ADON would take care of it the next morning when she comes in and for her not to chart it. LPN7 further explained that this incident happened around 6 PM, there was no Dakin's on hand, and she reported the incident to the night nurse when she came in. LPN7 states that she ended her shift at 7 PM and later texted the DON around 9 PM, after arriving home, to inform her of what happened. LPN7 further explains that when she saw the maggots it was only about 3-5, there was no date on the dressing she was removing, so she wasn't sure how long the dressing had been on the resident, and that the resident didn't appear to be in any pain or distress. LPN7 further revealed that she was informed that by the time the night nurse sent the resident out, the wound was swarming with maggots. During an interview on 02/07/25 at 10:53 AM, RN3 revealed that she is unable to recall the exact day but stated it was late in the day because she had already left the building. RN3 stated that she was made aware that R103 had maggots in his wound, when she received a call from LPN7 stating that she was doing a dressing change and saw maggots in the resident's wound. RN3 stated that she received a picture of the wound with maggots from LPN7 and she then sent the photo to the ADON, who is also the wound care nurse, and the ADON confirmed to her that she could see them in the photo. RN3 stated that she was not able to see the maggots at first but then zoomed in and was able to see them. RN3 stated that the ADON advised her to instruct LPN7 to clean the wound with Dakins wet to dry and change the dressing. RN3 further explains that by this time she was communicating back and forth with LPN7 and the ADON, and the ADON was communicating back and forth with the DON. During an interview on 02/07/25 at 11:28 AM, the DON revealed that she could not recall the exact conversation, and she was going by the notes entered, that it was alleged that R103 had maggots in his wound. The DON explained that she received a call from the ADON stating that she was getting an order to change the treatment and then she received a call from the night nurse informing her that she received a report that R103 had maggots in his wound and she had called the physician and was sending him out to the hospital. The DON stated that R103 was sent out the hospital and the hospital never verified there were any maggots in the wound. The following measures were immediately implemented upon notification of the facility: 1. Corrective action for residents found to have been affected by this deficiency: a. R103 was found to be affected by the alleged deficient practice. b. On 10/3/2024 at 6:50 pm LPN received report on R103. At 7:05 pm LPN notified physician of findings. Order was received to send resident to emergency room for evaluation. At 7:30 pm EMS was called and at 7:50 resident left the facility with EMS. c. On 10/4/2024 Director of Nursing Services reviewed R103 TAR (treatment administration record) for September 2024 and October 2024. Treatment administered per order. 2. Corrective action for residents that may be affected by the deficiency: a. Residents with wounds have the potential to be affected by the alleged deficient practice. b. On 10/4/2024 an audit of all wounds was completed by Assistant Director of Nursing (RN) and Unit Manager (RN). No changes were noted to any of the wounds. c. On 10/4/2024 all direct care licensed nurses received wound care education. d. On 10/4/2024 maintenance director completed facility wide observation for pests, insects, or any related issues. No issues were identified. e. Although no issues were identified during maintenance audit, facility administrator wanted to ensure every intervention was implemented due to the seriousness of the allegation. On 10/4/2024 maintenance director contacted Terminix and requested an additional preventative visit and facility administrator ordered air curtain fans for all high traffic doors. 3. Other Plan of removal actions: a. The Medical Director was notified of the IJ on 02/07/2025 at 4:30 pm. b. An adhoc QAPI meeting regarding the items in the IJ template completed on 02/07/2025. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions. c. Wound care education is included as part of the annual skills fair and new hire orientation for all licensed nurses. d. Maintenance Director completed weekly audits x8 weeks (10/10/24-11/29/2024) of facility for presence of insects, pests, or any other related issues. e. Registered nurses on nursing management team completed weekly audits x 8 weeks (10/10/24-11/29/2024) of wounds for any changes in condition. f. Findings were reported to QAPI committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained. g. The aforementioned incident was self-reported and subsequently cleared without citation on 12/4/24.