**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 26 of 26 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) reviewed for infection control. 1. The facility failed to isolate COVID-19 positive Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15, after they tested positive for COVID-19 and continued to cohort with negative tested Residents #4, #6, #16, and #17 on the same unit. Resident #4 (negative) was cohorted with Resident #12 (positive) in the same room. 2. The facility failed to ensure staff changed PPE between working with COVID-19 positive and COVID-19 negative residents. 3. The facility failed to ensure Resident #18 stayed in quarantine while being COVID-19 positive which resulted in Residents #19, #20, #21, #22, #23, #24, #25 and #26 being exposed. 4. The facility failed to ensure proper PPE was being worn by CNA-F while in Resident #19's room. 5. The facility failed to ensure proper PPE technique when CNA A failed to complete hand hygiene after providing care to a COVID-19 positive Resident #3's, and before providing care to a COVID-19 negative Resident #4. An Immediate Jeopardy (IJ) situation was identified on 10/11/24. While the IJ was removed on 10/13/24, the facility remained out of compliance at a scope of a pattern with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for exposure to COVID-19 which could result in serious illness, hospitalization and/or death. Findings Include: Side B was broken down into two units: Unit 1 from 9/24/24 to 10/4/24 was the facilities Hot zone that housed COVID positive residents. Unit 1, from 10/12/24 until time of exit was the step-down unit for the male locked unit (cold) Unit 2, starting 10/12/24 to time of exit, male locked unit was hot. During an observation on 10/10/24 at 10:35 AM Side A of the building housed one COVID 19 positive, Resident #18 and eight COVID 19 negative, Residents ##19, #20, #21, #22, #23, #24, #25 and #26. Side B of the building Unit 2 male locked unit had 16 total residents, COVID positive's #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15 and COVID negative #4, #6, #16, and #17 at this time Resident #2 had passed. 1. Record review of Resident #2's quarterly MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Cerebral ischemia, hypertension, and dementia. Record review of the facility resident tracking log, dated 10/3/24 on 10/9/24, titled COVID+ Residents, reflected Resident #2 was COVID-19 tested on [DATE], and positive test results were received on 10/3/24. Record review on 10/9/24 of Resident #2's progress notes reflected on 10/3/24 Resident #2 tested positive for COVID-19. On 10/6/24 Resident #2 was taken to local ER due to low O2 stats/saturation. On 10/7/24 Resident #2 expired associated to COVID-19. During an interview on 10/9/24 at 2:10 PM, the MD stated Resident #2 was sent to the ER on [DATE] because the resident was unresponsive. The MD stated Resident #2 was intubated and moved to the ICU at the local community hospital. The MD stated Resident #2 expired on 10/7/24 with complications associated to COVID-19. 2. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Parkinsonism, schizophrenia, and muscle weakness. Record review of the facility resident tracking log, dated 9/30/24 on 10/9/24, titled COVID+ Residents, reflected Resident #1 was COVID-19 tested on [DATE], and positive test results were received on 9/30/24. 3. Record review of Resident #3's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Metabolic encephalopathy, history of falling and altered mental status. Record review of the facility's resident tracking log, dated 10/7/24 on 10/9/24, titled COVID+ Residents, reflected Resident #3 was COVID-19 tested on [DATE], and positive test results were received on 10/7/24. 4. Record review of Resident #4's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, Schizoaffective disorder, and muscle weakness. Record review of the facility's resident tracking log, dated 9/30/24 to 10/11/24, titled COVID- Residents, reflected Resident #4 was COVID-19 tested on [DATE], and negative test results were received on 10/11/24. 5. Record review of Resident #5's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, schizoaffective disorder, and bipolar disorder. Record review of the facility's resident tracking log, dated 10/9/24 on 10/9/24, titled COVID+ Residents, reflected Resident #5 was COVID-19 tested on [DATE], and positive test results were received on 10/9/24. 6. Record review of Resident #6's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, Schizoaffective disorder, and bipolar disorder. Record review of the facility's resident tracking log, dated 9/30/24 to 10/11/24, titled COVID- Residents, reflected Resident #6 was COVID-19 tested on [DATE], and negative test results were received on 10/11/24. 7. Record review of Resident #7's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Alzheimer's Disease, type 2 diabetes mellitus and hypertension. Record review of the facility's resident tracking log, dated 10/2/24 on 10/9/24, titled COVID+ Residents, reflected Resident #7 was COVID-19 tested on [DATE], and positive test results were received on 10/2/24. 8. Record review of Resident #8's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, anxiety, and alcohol abuse. Record review of the facility's resident tracking log, dated 10/3/24 on 10/9/24, titled COVID+ Residents reflected Resident #8 was COVID-19 tested on [DATE], and positive test results were received on 10/3/24. 9. Record review of Resident #9's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Parkinsonism, type 2 diabetes mellitus and muscle weakness. Record review of the facility's resident tracking log, dated 10/3/24 on 10/9/24, titled COVID+ Residents reflected Resident #9 was COVID-19 tested on [DATE], and positive test results were received on 10/3/24. 10. Record review of Resident #10's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included traumatic subdural hemorrhage, muscle weakness and epilepsy. Record review of the facility's resident tracking log, dated 10/3/24 on 10/9/24, titled COVID+ Residents reflected Resident #10 was COVID-19 tested on [DATE], and positive test results were received on 10/3/24. 11. Record review of Resident #11's quarterly MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, cognitive communication deficit and anxiety disorder. Record review of the facility's resident tracking log, dated 10/4/24 on 10/9/24, titled COVID+ Residents reflected Resident #11 was COVID-19 tested on [DATE], and positive test results were received on 10/4/24. 12. Record review of Resident #12's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, muscle weakness and anxiety disorder. Record review of the facility's resident tracking log, dated 10/4/24 on 10/9/24, titled COVID+ Residents reflected Resident #12 was COVID-19 tested on [DATE], and positive test results were received on 10/4/24. 13. Record review of Resident #13's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included schizophrenia, bipolar disorder, and muscle weakness. Record review of the facility's resident tracking log, dated 10/7/24 on 10/9/24, titled COVID+ Residents reflected Resident #13 was COVID-19 tested on [DATE], and positive test results were received on 10/7/24. 14. Record review of Resident #14's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, type 2 diabetes mellitus and epilepsy. Record review of the facility's resident tracking log, dated 10/7/24 on 10/9/24, titled COVID+ Residents reflected Resident #14 was COVID-19 tested on [DATE], and positive test results were received on 10/7/24. 15. Record review of Resident #15's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, Metabolic encephalopathy, and muscle wasting. Record review of the facility's resident tracking log, dated 10/7/24 on 10/9/24, titled COVID+ Residents, reflected Resident #15 was COVID-19 tested on [DATE], and positive test results were received on 10/7/24. 16. Record review of Resident #16's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, muscle weakness and anxiety. Record review of the facility's resident tracking log, dated 9/30/24 to 10/11/24, titled COVID- Residents reflected Resident #16 was COVID-19 tested on [DATE], and negative test results were received on 10/11/24. 17. Record review of Resident #17's quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Dementia, type 2 diabetes mellitus and depression. Record review of the facility resident tracking log, dated 9/30/24 to 10/11/24, titled COVID- Residents reflected Resident #17 was COVID-19 tested on [DATE], and negative test results were received on 10/11/24. 18. Record review Resident #18's face sheet, dated 9/30/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Human immunodeficiency virus (HIV) disease, type 2 diabetes mellitus and obesity. Record review of Resident #18's quarterly MDS assessment, dated 9/12/24, reflected he had a BIMS score 12 out of 15, which indicated he had no cognitive impairment. During an observation on 9/27/24 at 1:10 PM, Resident #18 was observed in his wheelchair coming from hallway 6 across the nurses' station and back to hallway 2 where his room was. No mask was being worn by Resident #18 while being out of his room, touching the handrails, coughing, and touching the nurses stating, exposing Residents #19, #20, #21, #22, #23, #24, #25 and #26 to COVID-19 Record review of the facility's resident tracking log, dated 9/27/24 on 10/9/24, titled COVID Residents Testing log, reflected Residents #19, #20, #21, #22, #23, #24, #25 and #26 were all COVID negative. During an interview on 9/27/24 at 1:20 PM, Resident #18 stated he was on isolation because he was COVID positive. He stated he didn't have any symptoms and was feeling good. He stated he left his room because he could not fit onto the toilet in his room, so he went to the restroom in his old room. He stated he went to room [ROOM NUMBER] located on hall 6. He stated he didn't really ask to go to his old room to use the toilet and knew he should stay in his room but when he needed to go, he needed to go; so, he went. He stated there was no other resident in his old room. 19. Record review Resident #19's face sheet, dated 9/30/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, Parkinson's disease, and depressive disorder. Record review of Resident #19's quarterly MDS assessment, dated 8/14/24, reflected he had a BIMS score 99, which indicated he could not complete the interview. During an observation on 9/27/24 at 12:20 PM, revealed CNA-F was serving food to Resident #19 with no goggles or face shield on. During an interview on 9/27/24 at 12:25 PM, the DON stated that she was the infection preventionist and that Resident #19 was not COVID positive, but he was on isolation because his roommate was previously COVID positive, so he was considered exposed (warm). She stated that's why all the signage was on the door. She stated Resident #18 was positive for COVID and was on quarantine to protect the other residents in the building from being exposed to COVID. 20. Record review of Resident #20's face sheet, dated 9/30/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, cognitive communication deficient and bipolar disorder. Record review of Resident #20's quarterly MDS assessment, dated 9/10/24, reflected she had a BIMS score 9 out of 15, which indicated moderate cognitive impairment. 21. Record review of Resident #21's face sheet, dated 9/30/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, cognitive communication deficient and bipolar disorder. Record review of Resident #21's quarterly MDS assessment, dated 8/19/24, reflected she had a BIMS score 11 out of 15, which indicated moderate cognitive impairment. 22. Record review Resident #22's face sheet, dated 9/30/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included chronic pain due to trauma, quadriplegia, and lack of coordination. Record review of Resident #22's quarterly MDS assessment, dated 8/14/24, reflected he had a BIMS score 13 out of 15, which indicated no cognitive impairment. 23. Record review Resident #23's face sheet, dated 9/30/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included heart failure, type 2 diabetes mellitus, and acute kidney failure. Record review of Resident #23's quarterly MDS assessment, dated 8/24/24, reflected she had a BIMS score 9 out of 15, which indicated moderate cognitive impairment. 24. Record review Resident #24's face sheet, dated 9/30/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her Diagnoses included Alzheimer's disease, cognitive communication deficient and dysphagia. Record review of Resident #24's quarterly MDS assessment, dated 7/23/24, reflected she had a BIMS score, 5 out of 15 which indicated severe cognitive impairment. Record review of the facility resident tracking log, dated 9/24/24 on 10/9/24, titled COVID+ Residents, reflected Resident #24 was COVID-19 tested on [DATE], and positive test results were received on 9/24/24. Indicating the first resident to test positive in the facility. 25. Record review Resident #25's face sheet, dated 9/30/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia, schizoaffective disorder, and anxiety disorder. Record review of Resident #25's quarterly MDS assessment, dated 6/22/24, reflected he had a BIMS score 7 out of 15, which indicated severe cognitive impairment. 26. Record review Resident #26's face sheet, dated 9/30/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia, anxiety disorder and type 2 diabetes mellitus. Record review of Resident #26's quarterly MDS assessment, dated 6/19/24, reflected he had a BIMS score 9 out of 15, which indicated moderate cognitive impairment. Record review of the facility's COVID testing log, on 10/9/24, indicated on 9/30/24 the facility conducted COVID-19 testing on 17 residents who were on the facility's male memory care unit. Upon receiving the results, the facility moved Resident #1 identified as positive to the hot zone for isolation. During observation on 10/10/24 at 10:45 AM to 12:15PM, CNA A and CNA B working on the memory unit wore the same PPE while working with all 16 residents regardless of Covid status. During an observation on 10/10/24 at 11:20 AM, CNA A wore a gown and mask, no face shield, goggles, or gloves were worn. CNA A wiped Resident #3's (COVID Positive) nose with a tissue and did not use hand sanitizer or change PPE. CNA A then tried to stop Resident #4 (COVID negative) from trying to get items out of the community refrigerator located in the dining room. Resident #4 touched multiple juice cups and other cups. At 11:30 AM items from the refrigerator were then served to residents in the dining room for lunch. During an observation on 10/10/24 at 10:55 AM, Resident #5 (COVID positive) was sitting in his room and was on the B side of the room. Resident #4 was (COVID negative) in the same room on the A side of the room. Neither resident was wearing a face mask. During an observation on 10/10/24 at 11:20 AM, Resident #4 (COVID negative) was sitting at the lunch table with Resident #5 (COVID positive) to eat lunch. The residents shared the table together for approximately 10 minutes before staff moved Resident #4 to be at a table with another table. Both residents were within arm's reach of each other. During an interview on 10/11/24 at 2:15 PM, the DON stated the facility had the means to keep the Covid positive residents separated from exposed residents. She stated the facility chose not to separate the residents on the locked memory care unit. She stated the exposed residents on the locked memory care unity would eventually become COVID positive regardless. During an interview on 10/10/24 at 1:55 PM, CNA A stated the unit was much a hot unit (unit housing COVID positive residents). She stated all the residents hang out the same and we treat them all the same. She stated that all the residents were exposed. During a follow-up interview on 10/10/2024 at 2:15 PM, the DON stated there were 16 total residents on the hot COVID unit. She stated there were 12 COVID positive residents (#1, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15) and 4 COVID negative residents (#4, #6, #16, and #17). She stated the COVID-19 infection prevention policy was the policy they used for much everything COVID related. She stated there was no quarantine or isolation separate policy this was the policy they used regarding both isolation and quarantine. She stated they were following all CDC guidelines they could, but regarding the male locked unit it was more difficult to keep the residents quarantined. During an interview on 10/10/24 at 2:55 PM, CNA B stated she wore all her PPE the entire time she was on the unit, which included mask, face shield/goggles, gown, and gloves. She stated all the residents were exposed, so they were all getting treated the same. She stated she had not removed her PPE since getting to work. She stated Resident #2 normally used his walker. She stated she noticed after being diagnosed with COVID, Resident #2 seemed a little unstable on his walker and to prevent Resident #2 from falling she would put him in a wheelchair. During an interview on 10/10/24 at 8:20 PM, CNA B stated everyone on the unit was much COVID positive. He stated he was not sure why the facility did not move the positive residents over to the other locked unit when Resident #1 first tested positive. He stated the facility had a locked unit and the staffing, to him, was enough to cover a second locked unit. He stated each night he got to the facility, it's a hot zone. He stated he went to work and treated every resident the same. He stated some of the residents did have symptoms and he only knew of one that went to the hospital. During an interview on 10/10/24 at 8:30 PM, CNA D stated she had been working the unit the past few nights, maybe a week. She stated the unit was treated like a hot zone. She stated she never saw PPE boxes outside of each room, PPE was only located at the entrance of the unit not really for each individual resident. She stated she kept the same PPE on while on the unit the entire time and treated every resident the same because they were either hot or exposed. She stated she was not sure why the facility did not move the covid positive residents. She stated there was a locked unit with no one on it and the facility was using agency staff to help cover shifts, so the facility could have covered the shifts if they needed to. During an interview on 10/10/24 at 9:00 PM, RN E stated she was not sure why the facility did not move the first positive resident. She stated she was told by the DON it was how the corporate company worked and it was in the facility policy to work the unit that way. She stated she was not sure why Resident #4 and Resident #5, one negative and one positive were roomed together. She stated she guessed the facility could have moved Resident #5 to another room, but she was not sure how that would have affected him. She stated all the residents got COVID. She stated she believed the facility had another locked unit and had the staff to move the residents. During an interview on 9/28/24 at 10:15 AM, LVN B stated it was her first day back in a week. She stated she needed to get an updated COVID list for Side A of the building. She stated she knew a few of the residents were good to be removed from isolation and were allowed to be out of their rooms. She stated all the COVID room doors should be closed. She stated she was not sure why all the doors were not closed. She stated she was not sure how COVID got in the building, but it spread very quickly. She stated the PPE required to go into any hot or warm room was, gloves, gown, N95 and face shield/goggles. During a follow-up interview on 9/27/24 at 1:57 PM, the DON stated the facility required PPE for hot zone or warm zone was mask, gown, and gloves. She stated that was what every employee should put on if they entered a resident's room who was COVID positive or suspected of COVID. She stated, oh yeah, face shield and or goggles should be worn, I forgot about that. She stated she did not know her staff were not wearing goggles. She stated CNA F should have been wearing goggles or a face shield while in Resident #19's room. She stated she did not know Resident #18 was leaving his room to go use the restroom in his old room. She stated she was going to fix his toilet seat immediately, so he did not leave his room anymore because he was exposing other residents. Record review of Covid-19 testing from 09/30/24 through 10/09/24 for the male memory care unit reflected: 09/30/24-1 Covid-19 positive of 17 residents 10/02/24- 1 additional Covid-19 positive residents 10/03/24 -4 additional Covid-19 positive residents 10/04/24 - 2 additional Covid-19 positive residents 10/07/24- 4 additional Covid-19 positive residents 10/09/24- 1 additional Covid-19 positive resident. Record review of the facility's, undated, COVID-19 Infection Prevention policy reflected, 7. Placement and Response to Newly Identified COVID-19 Infected residents. A. Residents with signs or symptoms consistent with COVID-19 who have had close contact of those who test positive should be placed (isolated) in a single-person room, if possible, and the door should be kept closed (if safe to do so). Record review of the facility's, undated, Use Personal Protective Equipment (PPE) When Care for Patients with Confirmed or Suspected COVID-19 reflected: Before caring for patients with confirmed or suspected COVID-19 Healthcare Personnel (HCP) must wear: Face Shield or Goggles, N95 or higher respirator, one pair of clean non-sterile gloves, and isolation gown. Record review of the facility's Infection Control Policy, Before moving a positive resident to a COVID19 unit, consider if the COVID19 unit staff can manage the secure unit resident safely. If not, then the resident must remain on the secure unit for his/her protection as a higher priority. This was determined to be an Immediate Jeopardy (IJ) was identified on 10/11/24. The DON and Administrator were notified. The Administrator was provided with the IJ template on 10/11/24 at 5:44 PM The following Plan of Removal submitted by the facility was accepted on 10/12/24 at 6:20 PM: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on October 12th, 2024. Plan of Removal: F880: Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Immediate Actions Taken for Those Residents Identified: Action: COVID negative residents will be temporarily moved to another hall (off the secured unit). Residents will continue to be tested per policy. As residents of the secure unit recover, they will be relocated to the negative cohort secure unit. Residents will be moved back into the secured unit if they test positive or there are no longer COVID+ residents on the male secured unit. The negative residents, who have not tested positive within the last 30-days, are separated on their own hall, residents are residing in separate rooms, staff was wearing masks and eye protection. Testing Policy: Testing will occur every three days, until the facility had been COVID free for 14-days. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 10/12/2024 2. How the Facility Identified Other Possibly Effected Residents: Action: Residents in the secured unit were tested on [DATE]. Four (4) residents were identified as COVID negative (Residents #4, #6, #16, and #17). Person(s) Responsible: Director of Nursing and Assistant Director of Nursing Date: 10/12/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Administrator and Director of Nursing educated by Clinical Resource Nurse over COVID policy as it related to isolation protocol (COVID positive residents will not cohort with negative residents.) The facility policy was developed based on the CDC's recommendation & guidance. PPE must be donned correctly before entering the patient area (e.g., isolation rooms or isolation unit if cohorting). PPE should be doffed when leaving an individual patient room or isolation unit if cohorting. PPE must remain in place and be worn correctly for the duration of work in contaminated areas and should not be adjusted during patient care. If cohorting, positive residents' gown and gloves should be changed following patient care. PPE includes NIOSH approved respirator, well-fitting face masks, gowns, gloves, eye protection (goggles or face shields). N95 masks may be worn for the duration of the shift when used solely for source control but should be changed when soiled or compromised. Other PPE should be changed when it becomes soiled. https://www.cdc.gov/infection-control/hcp/core-practices/index.html and https://www.cdc.gov/covid/hcp/infection-control/index.html#cdc_infection_control_background_1_recommended_routine_infection_prevention_and_control_ipc_practices_during_the_covid_19_pandemic (section 1) Person(s) Responsible: Clinical Resource Nurse Date: 10/12/2024 Action: Administrator and Director of Nursing educated by Clinical Resource Nurse over COVID policy as it related to isolation protocol (COVID positive residents will not cohort with negative residents.) The facility policy was developed based on the CDC's recommendation & guidance. PPE must be donned correctly before entering the patient area (e.g., isolation rooms or isolation unit if cohorting). PPE should be doffed when leaving an individual patient room or isolation unit if cohorting. PPE must remain in place and be worn correctly for the duration of work in contaminated areas and should not be adjusted during patient care. If cohorting positive residents' gown and gloves should be changed following patient care. PPE includes NIOSH approved respirator, well-fitting face masks, gowns, gloves, eye protection (goggles or face shields). N95 masks may be worn for the duration of the shift when used solely for source control but should be changed when soiled or compromised. Other PPE should be changed when it becomes soiled. https://www.cdc.gov/infection-control/hcp/core-practices/index.html and https://www.cdc.gov/covid/hcp/infection-control/index.html#cdc_infection_control_background_1_recommended_routine_infection_prevention_and_control_ipc_practices_during_the_covid_19_pandemic (section 1) All staff will be educated prior to working their next shift. Any new or temporary staff (agency) will be educated prior to working their first shift. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 10/12/2024 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will observe the secured unit x2 daily, until COVID resolves to monitor for correct PPE usage (staff should wear gown, eye protection, and N95 mask when caring for COVID positive residents) and proper hand hygiene. Director of Nursing, Assistant Director of Nursing, and/or Designee will continue to test per protocol and will follow isolation guidelines per the facility policy. Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 10/12/2024 Action: Ad hoc QAPI performed with Medical Director informing him of the IJ template for F880 and the facility's plan to remove immediacy. Person(s) Responsible: Administrator Date: 10/12/2024 Monitoring of the Plan of Removal included the following: During an observation on 10/13/24 at 4:30 AM walked facility, two sides to the building. Side A where most of the residents were and no locked units. There were 6 total covid positive residents on this side. Most residents were out of bed, walking around or sitting in the dining room. Side B had the male locked units and some residents who were removed from the hot unit that were on that side of the building for their covid outbreak. Both sides, all staff were wearing facemasks. During an interview on 10/13/24 at 4:50 AM DON stated that the facility had been organized by: Side A was no hot or warm unit, individual rooms with individual residents on quarantine. Side B was broken down into two units: Unit 1, locked unit with 4 negative residents currently. One CNA required only to wear mask and face shield. Unit 2, male locked unit with currently 12 positives that always have a CNA and a Nurse on the unit in full PPE. During an interview on 10/13/24 at 4:45 AM, CNA G stated yes she did get in-serviced before she started her shift on 10/12/24. She stated she stays on the unit 1 all the time. She stated there were only 4 negative residents on this unit at this time. She stated the DON's education included all the PPE required to wear while in the facility, were on unit 1, and what to wear on unit 2. She stated a mask must be always worn while in th[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 12 (Resident #1) residents reviewed for elopement. The facility failed to provide supervision for Resident #1, who was care planed for wandering in unsafe places, to prevent him from eloping from the facility on 04/18/2024. The facility was unaware Resident #1 had exited the facility, the last time he was seen by an employee was 2:00 PM, and as a result, the resident was missing for approximately 6 and half hours and was located by assistance from law enforcement. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was lowered on 04/27/2024 at 3:30 PM, the facility remained out of compliance at a severity level of no actual harm with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could affect residents who were identified as elopement risks and placed them at risk of serious bodily harm, physical impairment, or death. Findings include: Record review of Resident #1's face sheet dated 04/24/2024 revealed [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease, type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), hypertension (high blood pressure), and Major Depressive Disorder. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns indicated Resident #1 had a BIMS score of 7 meaning severe cognitive impairment. Section E- Behavior revealed Resident #1 had not exhibited and wandering. Section GG- Functional Abilities and Goals revealed Resident #1 required supervision or touching assistance for eating, hygiene, dressing, transferring and walking. Section M- Skin Conditions revealed Resident #1 had no skin conditions. Record review of Resident #1's Care plan dated 04/18/2024 revealed: Problem Start Date 12/19/2023: Behavioral Symptoms Goal: Resident will have fewer episodes of Depression and wandering in unsafe places Approach: Start Date 12/19/2023 Approach Start Date: 12/19/2023 Always ask for help if resident becomes abusive/resistive; Start Date: 12/19/2023 Convey acceptance of resident during periods of inappropriate behavior; Start Date: 12/19/2023 Encourage diversional activities; Start Date: 12/19/2023 Keep environment calm and relaxed; Start Date: 12/19/2023 Redirect resident as needed; Start Date: 12/19/2023 Remove from public area when behavior is unacceptable Problem Start Date: 12/19/2023: Falls/Safety Risk/Elopement Risk Goal: Resident will remain free of injuries related to falls and will remain in a safe environment Approach: Start Date- 12/19/2023 Assess resident's footwear for proper fit and non skid soles; Start Date: 12/19/2023 Encourage use of call light; Start Date: 12/19/2023 Instruct resident on safety measures; Start Date: 12/19/2023 Keep call light in reach: Start Date: 12/19/2023 Orthostatic hypotension precautions; Start Date: 12/19/2023 PT referral; Problem Start Date: 12/19/2023: Delirium Goal: Resident will be as alert and oriented as possible. Approach: Start Date: 12/19/2023 Assess for constipation; Start Date: 12/19/2023 Assess for Pain; Start Date: 12/19/2023 Minimize distraction; Start Date: 12/19/2023 Orient PRN; Start Date: 12/19/2023 Rule out acute illnesses Problem Start Date: 12/19/2023 Category: Cognitive Loss/ Dementia Cognitive Loss-related Alzheimer disease. Goal: Resident will be as alert and oriented as possible Approach: Approach Start Date: 12/19/2023 Anticipate needs and observe for nonverbal cues; Start Date: 12/19/2023 Approach in calm manner; Start Date: 12/19/2023 Explain what you intend to do while providing care; Introduce self-Created; Start Date: 12/19/2023 Orient PRN to person, place and time. Record review of the facility's document titled Accidents/Incidents dated 04/23/2024 revealed Resident #1 had an elopement on 04/18/2024. During an interview on 04/25/2024 at 4:55 PM CNA F stated she remembered seeing Resident #1 in the dining area around 1:30 PM on 04/18/2024. During an interview on 04/25/2024 at 2:15 PM, OT L stated she had visited with Resident #1 on 04/18/2024 around 2:00 PM. She stated he had come into the therapy area and was happy and talkative. OT L stated she could not believe that Resident #1 left the building. During an interview on 04/25/2024 at 5:45 PM CNA I stated she was working Hall 1 and placed Resident #1's tray in his room approximately 4:45pm. CNA I stated she assumed he was in the dining room watching television, playing games or reading books. CNA I stated she got distracted with another resident and did not go look for Resident #1. CNA I stated she later went back into Resident #1's room and his tray had not been touched. CNA I stated she figured the resident was still reading or playing games, so she left his tray for it to be re-heated when he was ready to eat. CNA I stated she should have gone and looked for the resident, but she did not. Record review of Resident #1's progress notes revealed: Date & Time: 04/18/2024 at 8:00 PM, Documented by LVN B [Recorded as Late Entry on 0411912024 12:36AM] nurse went into resident room to give him his medication. resident wasn't in his. nurse and staff went to all rooms and living area looking for him. nurse notified ADMN and DON that resident couldn't be found. administrator notified police. police came to facility and look in all rooms. nurse notified resident [family member] to report resident left the facility without telling anyone. resident was found at salvation army and bring back to facility. resident was wearing shorts, gray shirt and black shoes and his glasses. resident stated he got upset and took off walking and went a crunch (sic) that took him to the [local homeless shelter] resident was taking to hospital for eval and treatment. resident [family member] notified he has returned and sent to hospital to get check out and will be moved to room [resident room] in station 2 unit. nurse in unit aware of the transfer and has his medications. waiting for resident return. Date & Time: 04/19/2024 at 3:06 AM Documented by LVN U: Resident returned via facility transport staff to secured unit. Assessed resident upon return, no open wounds, lesions, or immediate bruising observed. Resident range of motion WNL. Hand grasps strong, able to push and pull with hands and feet. States nothing happened to him during his departure. Resident denies pain, weakness, or feelings of sickness. Does not appear to be in distress. Resident made comfortable in their new room and offered a tray of food. Resident states that he's going to rest. Plan of care continues. During an interview on 04/24/2024 at 12:20 PM, LVN B stated she worked the night of 04/18/2024. LVN B stated when she started her shift at 6:00 PM and she would pass medications on Hall 2 and then would pass medications on Hall 1. LVN B stated she went into Resident # 1's room about 7:30 PM to give him his evening medications and discovered he was not in his room and his meal tray had not been touched. LVN B stated she immediately went to search for Resident #1. LVN B stated she asked staff if they had seen Resident #1 and asked them to look for him. LVN B stated when he was not in his usual places, she then called a CODE PINK, which was the code for missing resident. LVN B stated she then contacted the DON and ADMN around 8:00 PM and contacted law enforcement after speaking with DON. LVN B stated she was not aware of how long resident had been gone. During an interview on 04/24/2024 at 1:20 PM LVN D stated there were a handful of residents who were assessed as being safe to sign themselves out of the facility, and Resident #1 was not one of those residents. LVN D stated Resident #1 was not appropriate to be out of facility unsupervised. LVN D stated that Resident # 1 likes to wander around the building. LVN D stated the facility had two dining areas, but the facility was only using one dining area. LVN D stated Resident #1 called the dining area that was not being used his library and would go read books in there because it was quiet. LVN D stated if he was not in that dining area reading books, he would be in the other dining area playing video games. LVN D stated it was common for staff to leave Resident #1's meal trays in his room because he would come back to his room when he saw meals were being delivered. LVN D stated she had worked the day shift on 04/18/2024, she remembered seeing Resident #1 around lunch time but did not remembering him after that. During an interview on 04/24/2024 at 1:58 PM the SW stated some residents were able to sign themselves out of the facility on a pass, if deemed safe to be out of facility on their own. The SW stated nursing assessed residents on their fall risk, BIMS, and cognitive ability. The SW stated Resident #1 was not safe to be out of facility on his own. The SW stated she was not aware of how Resident #1 got out of the facility or the time frame he was gone. The SW stated Resident #1 should not have been able to exit the building because the staff at the nurse's station and the AD should have been monitoring the doors. The SW stated Resident #1 had sunburn on his nose related to the elopement. The SW stated resident could have fallen, gotten hurt or killed. During an interview on 04/24/2024 at 2:25 PM, the DON stated she was notified, around 8:30PM on 04/18/2024, that Resident #1 was missing and arrived at facility a little before 9:00 PM. The DON stated she helped with getting a head count to verify all residents were in building. The DON stated law enforcement officers were going from room to room conducting searches. The DON stated law enforcement located Resident #1 at the local homeless shelter about 9:00pm. The DON stated Resident #1 was sent to Emergency Department to be assessed. The DON stated she talked with the Medical Director, and he gave an order for Resident #1 to be admitted to the secure unit when he returned from the Emergency Room. The DON stated Resident # 1 returned from the Emergency Department around 2:30 AM and was placed in the secure unit for safety. The DON stated that no other interventions were attempted prior to placing him in the secure unit. The DON stated she had talked with Resident #1's family representative, and they were on board for placing Resident #1 in the secure unit. The DON stated they were not sure what time Resident #1 had exited the building. The DON stated OT L stated they had seen Resident #1 about 2:00 PM, and a resident stated they saw him walk out the front door with someone around 2:30 PM. The DON stated the effect on Resident #1 could have been an injury from being out of the building on his own. The DON stated she did not know if Resident #1 would be safe out of the facility on his own. The DON stated all staff were responsible for monitoring the doors to ensure residents were not getting out of the building. The DON stated what led to failure of Resident #1 getting out of the building was that he was sneakier than anticipated. During an observation and interview on 04/24/2024 at 3:30PM, Resident # 1 was sitting in his room on his bed in the secure unit. Resident #1 stated he was not sure how he got out of the building, or which door he walked out. Resident #1 stated he saw an open door and just walked out. Resident # 1 stated he did not remember if he walked out with anyone. During an interview on 04/24/2024 at 4:50 PM, the Medical Director stated Resident #1 was placed in secure unit due to concerns for his safety when he returned from the emergency department after his elopement. The Medical Director stated Resident #1 was not safe to be out of the facility without having supervision. Review of google maps https://www.google.com/maps, accessed on 04/25/2024, revealed the distance between the facility to the local homeless shelter was 3 to 4 miles (depend on route taken). The resident would have had to walk down highly traffic streets with speed limits of 35 to 55 mph, cross busy intersections, and cross railroad tracks. During an interview on 04/26/2024at 11:35 AM, Deputy Fire Chief stated there were eleven trains that traveled thru the city between the hours of 6:00 AM and 6 PM per day and there were ten trains that traveled thru the city between 6:00 PM and 6:00 AM per day. During an interview on 04/26/2024 at 12:15 PM, the AD stated prior to Resident #1's elopement some residents and visitors had the door code. The AD stated that some of their residents appear to be visitors so they could walk out with vendors or visitors, and no one would know they were a resident. The AD stated prior to the elopement the facility did not have a process for monitoring the doors. Record review of the facility policy titled Wandering and Elopements, dated September 1, 2023, revealed: The facility will ensure that residents who exhibit wandering behavior and or/or are at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Definitions 'Wandering' is random or repetitive locomotion that may be goal-directed (e.g., The person appears to be searching for something such as an exit or person), non-goal directed, or animals. 'Elopement' occurs when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so . Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. Resident will be assessed by the IDT for risk of Elopement and unsafe wandering on admission, readmission, quarterly, and//or with a change of condition (e.g., increased agitation, changes in mobility, wandering). A person-centered care plan will be developed. Based on the risk factors that identified in the risk assessment. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, and minimize risk associated with hazards will be added to the residents' care planning. Appropriate staff. Provided to help prevent accidents or elements. Nursing staff. Response interventions, and document accordingly. Changes we made. Indicated changes of condition. Any changes are new interventions, so we communicated to relevant staff. Record review of the facility policy titled Emergency Procedure-Missing Resident, dated September 1, 2023, revealed: Resident elopement resulting in a missing resident is considered a center emergency. This was determined to be an Immediate Jeopardy (IJ) on 04/26/2024 at 1:45 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 04/26/2024 at 3:45 PM. Record review of Plan of Removal accepted on 04/27/2024 at 12:08 PM reflected the following: 689: Accidents, Hazards, Supervision & Devices The facility failed to ensure Resident #1 received adequate supervision to prevent resident elopement. Residents at risk for elopement can be affected by this deficiency. Immediate Action: Action: Resident #1 was sent to the hospital for evaluation when he arrived back to the nursing facility 4/18/2024, no new orders received. Resident was assessed upon returning from the hospital on 4/19/2024. Resident was reassessed for being an elopement risk on 4/18/2024 and placed in the secured unit for safety. Medical Director notified of the incident. Person(s) Responsible: Charge Nurse and Director of Nursing Date: 4/18/2024-4/19/2024 Action: Resident head count performed throughout the center to ensure no other residents were identified as missing. No other residents noted missing. Person(s) Responsible: Director of Nursing Date: 4/18/2024 Action: All doors verified in working order. No issues noted with the door functions. Additionally, 4/15/2024, 4/16/2024, & 4/17/2024 the doors were checked for functionality with no concerns. Gates checked for functionality: 4/26/2024; No concerns, all gates are functioning properly. Person(s) Responsible: Maintenance Director & Designee Date: 4/18/2024; 4/26/2024 Action: Mock elopement drills performed each shift in 24 hours. Person(s) Responsible: Director of Nursing Date: 4/19/2024, 4/21/2024, & 4/23/2024 Steps to Ensure Compliance: Action: Signage present on doors that state, Attention visitors please do not allow anyone to exit the building with you that did not come in with you, help us keep our residents safe, any questions please contact a staff member, thank you. Person(s) Responsible: Director of Nursing Date: 4/26/2024 Action: All residents in house received an updated elopement assessment. Ensured all care plans match the updated elopement assessment and are person-centered. Person(s) Responsible: Director of Nursing and/or Designee Date: 4/18/2024 Action: All staff educated: Wandering & Elopement/Missing Resident Policy (to include adequate supervision to prevent accidents or elopements and when delivering meal trays in either dining area or in residents rooms staff should ensure residents are located and aware of meal. Any meal tray picked up that is not eaten staff need to verify resident is located and aware meal tray is ready. Charge nurse will be notified immediately if resident is not observed and informed. All staff educated prior to working their next shift. All new and temporary staff educated prior to working their first shift. Person(s) Responsible: Director of Nursing, Administrator, and/or Designee Date: 4/19/2024 Action: Certified Nurses Aides, Certified Medication Aides, and Charge Nurses educated on the resident profile to inform them of the level of supervision, elopement risk, and educated over accuracy of documentation. The type and frequency of resident supervision may vary among residents as determined by the residents' assessed needs and the identified hazards in the environment. All Certified Nurses Aides, Certified Medication Aides, and Charge Nurses will be educated prior to working their next shift. All new and temporary staff educated prior to working their first shift. Person(s) Responsible: Director of Nursing and/or Designee Date: 4/26/2024 Action: If resident is not observed during medication pass, meal times, and/or routine resident care rounds the charge nurse will be notified and the center will initiate a search for the resident immediately. The clinical staff will know to perform this action through education. All Certified Nurses Aides, Certified Medication Aides, and Charge Nurses will be educated prior to working their next shift. All new and temporary staff educated prior to working their first shift. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 4/26/2024 Action: Action items in the above plan of removal will be monitored for effectiveness daily, x7 days a week, for 1 month and until deemed by QAPI committee that the facility is in substantial compliance. If any changes are needed, they will be brought to the QAPI committee and discussed for a plan action. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 4/27/2024 Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy template and the facility's plan to lower the Immediate Jeopardy. Person(s) Responsible: Administrator Date: 4/26/20 Surveyors monitored the facility's Plan of Removal ad confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 04/27/2024 at 12:08 PM. to 04/27/2024 at 3:18 PM as follows: Action: Resident #1 was sent to hospital on [DATE] -Record review of Resident #1's progress note dated 04/18/24 at 8:00 pm signed by LVN B revealed 'resident was taking to [a local] hospital for eval and treatment. resident [family member] notified he has returned and sent to hospital to get check out and will be moved to room [ROOM NUMBER] in station 2 unit. -Reviewed Discharge Instruction from hospital dated 04/18/2024 at 10:17 pm Action: Resident #1 elopement risk assessment on 04/18/2024 -Record review of elopement risk assessment completed on 04/18/2024 at 09:40 am indicating resident was an elopement risk. Action: Resident #1 placed in secured unit on 04/18/2024 oRecord review of Orders- 04/18/2024 order stating admit to secure unit due to high elopement risk and poor safety awareness. oObservation- 04/27/24 at 1:10 pm observed resident #1 resting in bed on the secure unit with no issue noted. Action: doors in working orders on oRecord review on 04/15/2024- verified check off sheets for all doors and gates checked my maintenance man. 04/27/24 at 1:30 pm. Interview with Maintenance stated he had performed the checks daily since 04/15/24. oRecord review on 04/16/2024- verified check off sheets for all doors and gates oRecord review on 04/17/2024- verified check off sheets for all doors and gates oRecord review on 04/18/2024- verified check off sheets for all doors and gates oRecord review on 04/26/2024- verified check off sheets for all doors and gates Action: gates functioning properly oObservation on 04/27/2024 at 1:35 pm all doors were locked, and gates functioned properly. Action: Mock Elopement drills on each shift oRecord review on 04/19/2024- verified sign in sheet performed at 11:00 am oRecord review on 04/21/2024- verified sign in sheet performed at 1:00 pm and verified sign in sheet performed at 8:00 pm oRecord review on 04/23-/2024 verified sign in sheet performed at 8:00 pm oDuring an interview on 04/27/24 at 12:25 pm CNA C confirmed he had participated in a Mock elopement drill. CNA works day shift on station1 Verified Mock drill sign sheet he participated on 04/21/24. oDuring an interview on 04/27/24 at 1:30 pm LVN M confirmed he had participated in a Mock elopement drill. Verified Mock drill sign sheet she participated in on 04/23/24. LVN works day shift on station 1. oDuring an interview on 04/27/24 at 1:35 pm LVN N confirmed he had participated in a Mock elopement drill. Verified Mock drill sign sheet she participated in on 04/23/24. LVN works day shift on station 2. oDuring an interview on 04/27/24 at 2:00 pm LVN P confirmed she had participated in a Mock elopement drill on 04/21/24. Verified Mock drill sign sheet she participated in on 04/21/24. LVN works day shift on station 1. Action: of signage on ALL doors oObservation on 04/27/24 at 12:00 pm Observed sign on main entrance when entered facility. oObservation on 04/27/24 at 1:35 pm Observed sign on back entrance. Action: no elopements since 04/18 oDuring an interview no residents have eloped since 04/18 stated by Administrator & Clinical Resource Nurse List of all residents that required change in elopement assessment oRecord review of random sample of residents at risk for elopement that care plans were person-centered (specifically residents not in locked unit) 12 outside secure unit and 17 inside total of 29 residents who are elopement risk; 10 of those 12 residents not on the locked were, previously, no elopement risk Review: oRecord review of Resident #16- verified elopement risk assessment completed 04/19/24 and care plan was initiated 04/24/2024 o Record review of Resident #17- verified elopement risk assessment completed 04/19/24 and care plan was already in place. oRecord review of Resident #18- verified elopement risk assessment completed 04/19/24 and care plan was initiated 04/19/2024 Copy of inservice & signature sheet oRecord review of Wandering & Elopement/Missing Resident Policy oRecord review Resident profiles regarding level of supervision, Type/frequency of supervision, elopement risk, accuracy of documentation, Types of identified hazards in the environment, Verify inservice o1 nurse on each station & on each shift = total of 4 nurses oDuring an interview on 4/27/24 at 1:30 pm via phone interview LVN M confirmed he had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. LVN works night shift on station 1 oDuring an interview on 04/27/24 at 1:35 pm via phone interview LVN N confirmed he had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. LVN works night shift on station 2 oDuring an interview on 04/27/24 at 2:00 pm LVN P demonstrated how to pull up a resident's profile and identified if a resident was an elopement risk. LVN confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. LVN works day shift on station 2 oDuring an interview on 04/27/24 at 2:40 pm LVN E demonstrated how to pull up a resident's profile and identified if a resident is an elopement risk. LVN confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. LVN works day shift on station 1 o2 nurse aides on each station & on each shift Total of 8 aides if 12H shift oDuring an interview on 04/27/24 at 12:20 pm CNA R demonstrated how to pull up a resident's profile and identified if a resident is an elopement risk. CNA confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works day shift on station 1 oDuring an interview on 04/27/24 at 12:25 pm CNA C demonstrated how to pull up a resident's profile and identified if a resident is an elopement risk. CNA confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works day shift on station 1 oDuring an interview on 04/27/24 at 1:00 pm CNA H demonstrated how to pull up a resident's profile and identified if a resident is an elopement risk. CNA confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works day shift on station 2 oDuring an interview on 04/27/24 at 1:10 pm CNA T confirmed she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works night shift on station 2 oDuring an interview on 04/27/24 at 2:45 pm CNA S confirmed during a phone interview that she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works night shift on station 1 oDuring an interview on 04/27/24 at 2:50 pm A CNA confirmed during a phone interview that she had received in-services on Wandering & Elopement/Missing Resident Policy and Resident profiles. CNA works night shift on station 1 Interview charge nurses if any residents not observed during Medication pass, Mealtimes, Routine resident care rounds, and Ask what these are & how to document the rounds oDuring an interview on 04/27/24 at 1:30 pm via phone interview LVN M confirmed he understands what to do If resident is not observed during medication pass, mealtimes, and/or routine resident care rounds. LVN works night shift on station 1 oDuring an interview on 04/27/24 at 1:35 pm via phone interview LVN N confirmed she understands what to do If resident is not observed during medication pass, mealtimes, and/or routine resident care rounds. LVN works night shift on station 2 oDuring an interview on 04/27/24 at 2:00 pm LVN P confirmed she understands what to do If resident is not observed during medication pass, mealtimes, and/or routine resident care rounds. LVN works day shift on station 2 oDuring an interview on 04/27/24 at 2:40 pm LVN E confirmed she understands what to do If resident is not observed during medication pass, mealtimes, and/or routine resident care rounds. LVN works night shift on station 1 Action: adhoc QAPI & Medical Director notified of IJ oRecord reviewed sign is QAPI sheet where medical Director was informed o04/27/24 at 12:26 observed Administrator give in-service to dietary staff regarding Wandering & Elopement/Missing Resident Policy and Abuse and Neglect. The Immediate Jeopardy was removed on 04/27/2024 at 3:30 PM, the facility remained out of compliance at a level of no actual harm and a scope of isolated, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN was informed of this at 3:30PM.

**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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and complications associated with an indwelling catheter for number 1 of 2 (Resident #1) reviewed for catheters. The facility failed to empty Resident #1's urinary catheter bag for two days, allowing the bag to fill overflowing up into the tubing that was inserted in the resident's bladder. The facility also failed to change the catheter when sediment was observed. Resident #1 was sent to a local hospital and diagnosed with sepsis (life threatening medical emergency related to the body's response to an infection) and a UTI. An IJ was identified on 02/22/2023. The IJ template was provided to the facility on [DATE] at 4:55pm. While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facilities need to complete in service training and evaluate their effectiveness of their plan of removal. This failure placed residents at risk of not receiving care and services to prevent urinary tract infections or other issues related to bladder Functioning. Findings included: Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnoses: Unspecified fracture of left shaft/femur (bone in the thigh), Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Record review of Resident #1 Discharge Minimum Data Set (MDS) Section C dated 09/19/2022 revealed in Section H (bladder and bowel) that she was frequently incontinent, 7 or more times episodes of incontinent, but 1 episode of continent). Record review of Resident #1 Quarterly Minimum Data Set (MDS) Section C dated 11/15/2022 revealed in Section H (bladder and bowel) that resident had an indwelling catheter. Observation and interview on 02/18/2023 at 10:15 AM, Resident #1's catheter bag was overflowing, urine in the tubing backing up. The catheter bag was leaking on the floor. Resident reported that it had not been drained in 2 days. The resident's urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. The DON was present with observation and visualized the catheter tubing and bag. When asked she said what she thought it was, she said that it appeared to be a puss like substance. She said that she was going to have it changed immediately. Interview on 02/18/2023 at 1:20pm, the DON stated that indwelling catheter bags should always be covered. She also stated that catheter bags that are full of urine backflowing in the catheter tubing place the resident at risk for infections. She stated she did not know reason for overflow catheter bag with urine backflowing into the catheter . She said it was the nurses responsibility to change it. Observation on 02/18/2023 at 3:58pm, revealed Resident #1 continued to have an indwelling catheter with an overfilled catheter bag with urine backflowing in the catheter tubing. The bag continued to be leaking urine onto the floor. The urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. This observation was reported to the Corporate Regional Resource Nurse-J Observation and interview on 02/19/2023 at 8:35 am, revealed Resident #1's catheter bag had been emptied; however, the catheter had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. There was a trash bag on the floor under the uncovered catheter bag. Resident #1 stated that the trash bag was placed to catch the leaking urine from the catheter bag . Interview on 02/19/2023 at 9:45 am, RN-V stated she had not gone to check Resident #1's catheter bag to check see if it had been drained or changed during previous day's shift. She reported it was delegated to her, but she was busy and had not had a chance to do it. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician . She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, the DON stated she asked LVN-O and RN-V to change Resident #1's catheter bag yesterday afternoon. She could not remember the exact time, but it was after lunch. She said she went back to Resident #1's rooms yesterday afternoon and it continued to not be completed. She then asked them again to complete the task. She stated this failure placed the residents at risk for an infection. Interview on 02/19/2023 at 3:10pm, RN-V said she did not change Resident #1's catheter tubing but only changed the bag. She said she obtained a urine sample for an ordered UA from the catheter tubing that continued to have sediment and puss like substance but not from the bag. Interview and observation on 02/19/23 03:15 PM, Corporate Regional Resource Nurse-J-J stated she instructed RN-V to change Resident #1's entire catheter on 02/18/2023. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, Resident #1 was observed unresponsiveness with emesis (vomiting) on chest by surveyors and Corporate Clinical Company Leader RN-I. Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said that she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to community hospital via EMS. Interview on 02/19/2023 at 4:34pm, the DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. The DON stated that she discovered that the Resident #1 left the facility (to the hospital) without a changed catheter tubing but only changed catheter bag. It was her expectation that it was changed yesterday. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she presses the call light frequently and it takes a while to answer. She said that the lady that came to answer the call light after two hours of pressing it. She had long dark hair and was part of administration but did not work the floor. Resident #56 said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 said that the staff stated she couldn't help Resident #1 and left the room. Resident #56 said she thought the staff was coming back but never did. Resident #56 said that she could hear Resident #1 throwing up and gurgling. Resident #56 said no one changed their catheters. She said that yesterday (02/19/2023) the staff just changed the bag. Resident #56 said that the regional Hispanic nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 said it was the same nurse that told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff on 02/19/2023 and behind. She said that when the regional nurse came, she told her to change the catheter bag only. She said that she is often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. Interview on 02/21/2023 at 4:46 PM, interview with Resident #1 family members A and B revealed that when they would come to see her, she would look malnourished , and her catheter bag was always full. Review of Resident #1 physician orders dated 10/13/2022 revealed Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) and Foley Catheter: Provide catheter care every shift. Record review of Resident #1 electronic orders accessed on 02/20/2023 revealed there were orders to address her indwelling catheter. Resident #1 did have orders to change foley catheter and drainage bag as needed for indications of blockage, increased sediment, infection and displaced, as needed. Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine. Initiated date of 10/15/2022 and revised date of 01/31/2023. Record review of Resident #1 most recent significant change Minimum Data Set (MDS) Section C dated 01/30/2023 revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a Brief Interview for Mental Status (BIMS) of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision. Record review of Resident #1 significant change MDS on 01/30/2023 revealed Resident #1 had an indwelling catheter reported in section H: Bladder and Bowel. Record review of Resident #1's vital reports, dated 02/21/2023, provided by Corporate Clinical Leader RN-H revealed the following documentation concerning Resident #1's catheter being drained, and the amount of urine noted, between 01/18/2023 until 02/19/2023, was not documented or done on- o 01/20/2023 on day or night shift o 01/21/2023 on day or night shift o 01/22/2023 on day or night shift o 01/23/2023 on day shift o 01/24/2023 on day or night shift o 01/25/2023 on day or night shift o 01/26/2023 on day or night shift o 01/27/2023 on day shift o 01/28/2023 on day or night shift o 01/29/2023 on day or night shift o 01/30/2023 on day or night shift o 01/31/2023 on day or night shift o 02/01/2023 on day or night shift o 02/02/2023 on day shift o 02/03/2023 on day shift o 02/04/2023 on day or night shift o 02/05/2023 on day shift o 02/06/2023 on day or night shift o 02/07/2023 on day or night shift o 02/08/2023 on day shift o 02/09/2023 on day or night shift o 02/10/2023 on day or night shift o 02/11/2023 on day or night shift o 02/12/2023 on day shift o 02/13/2023 on day or night shift o 02/14/2023 on day or night shift o 02/15/2023 on day or night shift o 02/16/2023 on day shift Record review of hospital record dated 02/19/2023 at 8:48pm History and Physical, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's community hospital records revealed dated 02/19/2023, Resident #1 was admitted into community hospital ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's community hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of hospital records dated 02/21/2023 revealed that Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of hospital records dated 02/21/2023 Resident #1's Assessment and Plan revealed: 1. UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin (antibiotics). 2. Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic). Record review of the facilitates policy titled Catheter Care, Urinary; dated September 2014 revealed: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparations: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: 1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 2. If it breaks in aseptic technique, disconnection or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Input/Output: 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Maintaining Unobstructed Urine Flow: 1. Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks. 2. Unless specifically ordered, do not apply a clamp to the catheter. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine tubing and drainage from flowing back into the urinary bladder. Infection Control: 1. Use standard precautions when handling manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. a. Do not clean the periurethral area with antiseptics to prevent catheter associated UTI's while the catheter is in place. Routine hygiene. b. Be sure the catheter tubing and drainage are kept off the floor. c. Empty the drainage bag regularly using a separate, clean collection container for each resident. d. Empty the collection bag at least every 8 hours. Changing Catheters: 1. Changing indwelling catheters or drainage bags as routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstructions, or when the closed system is compromised. Complication: 1. Observe the resident for complications associated with urinary catheters. a. If the resident indicates that his/her bladder is full or that he/she needs to void, notify the physician. b. Check the urine for unusual appearance (color, blood). c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed, d. Report any complications that the resident may have of burning, tenderness, or pain in the urinary area. e. Observe for signs or symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. Specimen Collection: 1. If a small volume of urine is needed for a urinalysis or culture, cleanse the port with a disinfectant and aspirate from the needless port using a sterile syringe ir cannula adapter. Documentation: The following information should be recorded in the resident's medical record. 1. The date and time the catheter care was given. 2. The name and title of the individual giving the care 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw colored, dark, or red) clarity (cloudy, solid particles, or blood, and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reasons why the interventions taken. 9. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the procedure. 2. Report the information in accordance with the facility policy and professional standards of practice. Record review of U.S. National Library of Medicine Medline Plus (https://medlineplus.gov/ency/article/003981.htm) electronically accessed on 03/01/2023 revealed the following: Indwelling catheter care. When to Call the Doctor. A urinary tract infection is the most common problem for people with an indwelling urinary catheter. Call your health care provider if you have signs of an infection, such as: Pain around your sides or lower back. Urine smells bad, or it is cloudy or a different color. Fever or chills. A burning sensation or pain in your bladder or pelvis. Discharge or drainage from around the catheter where it is inserted into your body. You do not feel like yourself. Feeling tired, achy, and have a hard time focusing. Also call your provider if: Your urine bag is filling up quickly, and you have an increase in urine. Urine is leaking around the catheter. You notice blood in your urine. Your catheter seems blocked and not draining. You notice grit or stones in your urine. You have pain near the catheter. You have any concerns about your catheter. Changing Your Catheter, you will need to change the catheter about every 4 to 6 weeks. Always wash your hands with soap and water before changing it. When to Call the Doctor. Your catheter seems blocked. You notice grit or stones in your urine. Your supplies do not seem to be working (balloon is not inflating or other problems). You notice a smell or change in color in your urine, or your urine is cloudy. You have signs of infection (a burning sensation when you urinate, fever, or chills). This was determined to be an Immediate Jeopardy (IJ) on 02/22/2023 at 4:55 pm. The Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs were notified. The Interim Administrator was provided with the IJ template on 02/22/2023 at 4:55 pm. The following Plan of Removal was accepted on 02/23/2023 at 7:58pm and included: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 2/22/2023. Action 1: Resident #1 discharged to an acute care hospital for further evaluation on 2/19/2023. Action 2: The Director of Nursing and or/designee will in-service all nurses regarding resident assessment and charting/documentation. The Director of Nursing and/or designee will in-service all nurses regarding foley catheter care. The Director of Nursing and/or designee will in-service all CNAs, TNAs, Hospitality Aides regarding reporting foley catheters holding sediment/being foggy to the charge nurse and ensuring that they are emptying the bag as needed. If the CNAs, TNAs, Hospitality Aides feel as if their concerns are not being followed through, they are to report immediately to the Director of Nursing this will be made evident through communication with the CNAs, TNAs, Hospitality Aides and their Director of Nursing. If the CNAs, TNAs, Hospitality Aides feel as if the charge nurse and nursing administration is not following up they should immediately report to their administrator. How will the facility ensure that care needs are being communicated up the chain? The facility will ensure care needs are communicated up the chain through open communication, rounding and speaking with staff/listening to their concerns, and facility's communication with their corporate support team. How will missed treatments be communicated from shift to shift? Nurses will be in-serviced to communicate, this communication can be verbal, 72-hour report/facility activity report (72-hour report/facility activity report contains new orders, progress notes written, discontinued orders, event reports, vitals outside of normal range, opened or created observations), and/or via telephone, to their nursing administration regarding missed treatments, as well as, communicating shift to shift on missed treatments. Who will be monitoring that the nurses have an understanding of the importance to communicate identified issues with other shifts and administration? The Director of Nursing, Administrative Nurses, and Administrator will monitor that the nurses have the understanding of the importance to communicate via writing on the 72-hour report/facility activity report, verbally, and/or via telephone identified issues with other shifts and administration by education, morning clinical meetings/review of the 72-hour report/activity report with nurses, nursing administration, and administration, and nursing-to-nurse report. How will the facility ensure that Nurses and CNA's have a good understanding of individual resident care needs and who is monitoring their competency? Nurses and Nurse Aides will have a good understanding of individual care needs by understanding on how to pull the residents' care plans from the electronic medical record. This action will be in-serviced. The Director of Nursing and/or designee will ensure competency through requesting staff to demonstrate understanding, at random, 3 times weekly, for 4 weeks. All indicated staff will be in-service immediately prior to working their next shift. All new and temporary (internal/external agency) staff will be in-serviced over the above information, the administrator and/or Director of Nursing will ensure this by checking the schedule and ensuring a designee will in-service the material for anyone on the schedule that has yet to be in-serviced. Date: 2/23/2023 Person(s) Responsible: Administrator and Director of Nursing Action 3: On 2/20/2023 the Clinical Company Leaders, Regional Resource Nurse-J, and/or designee completed foley catheter rounds to ensure all foley catheters are in good condition and changed those that were needed. All residents' orders with indwelling catheters were reviewed by Clinical Company Leaders, Regional Resource Nurse-J, and/or designee. Clinical Company Leaders, Regional Resource Nurse-J, and/or designee validated the foley/suprapubic catheter order set was entered in the resident's chart. No additional identified areas of concern on 2/20/2023. Date: 2/22/2023 Person(s) Responsible: Clinical Company Leaders, Regional Resource Nurse-J, and/or designee Action 4: Three times a week Director of Nursing will complete random audits on foley catheters and foley catheter documentation for 4 weeks. Director of Nursing will share findings with administrator and educate staff/perform a skills check off as needed. Date: 2/22/2023 Person(s) Responsible: Director of Nursing and Administrator Action 5: Ad Hoc QAPI meeting performed with administrator, DON, corporate team and Medical Director. Date: 2/22/2023 Person(s) Responsible: Administrator Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm revealed: Resident #1 was transferred to local acute care hospital for further evaluation on 02/19/2023. Facility provided documentation of completion of foley catheter rounds ; and Ad Hoc QAPI meeting performed. Interviews on from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm with 5 CNAs, 2 TNAs, and 1 Hospitality aide revealed they had been educated on foley catheters and communication. Interviews on from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm with 7 nurses revealed they had been educated foley catheter care and communication The Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs were informed the Immediate Jeopardy was removed on 02/24/2023 at 6:48pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 4 of 4 residents (Resident #1, Resident #79, Resident #53, Resident #57) reviewed for abuse and neglect. 1. The facility failed to follow physician's orders to prevent Resident #1 who had an indwelling catheter received appropriate treatment and services to prevent a urinary tract infection and complications associated with an indwelling catheter. 2. The facility failed to follow physician's orders to prevent Resident #79's stage 4 pressure ulcer to his sacrum from developing osteomyelitis, and his right heel pressure ulcer to deteriorate from a stage 3 to a stage 4. 3. The facility failed to have sufficient staff with necessary competencies and failed to have interventions in place to provide resident care with aggressive with physical behaviors. R53 assaulted residents on multiple occasions on Station 2/Hall 6 (women secured locked unit), that led to resident injuries that required medical treatment. 4. The facility failed to have interventions in place to prevent Resident #57 from being abused by other residents on Station 2/Hall 2 (men secured locked unit), due to lack of staff with competencies to provide care with resident with aggressive behaviors int he locked unit. An Immediate Jeopardy (IJ) was identified on 02/22/23. While the IJ was removed on 02/24/23, the facility remained out of compliance at a pattern of actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death. Findings include: 1. Resident #1 Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: Unspecified fracture of left shaft/femur, Non-ST elevation myocardial infarction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1 physician orders dated 10/13/2022 revealed Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: Provide catheter care every shift. Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: Change catheter and drainage bag as needed for indications of blockage, increased sediment, infection, displacement as needed. Record review of Resident #1 Discharge MDS Section C dated 09/19/2022 revealed in Section H (bladder and bowel) that she was frequently incontinent, 7 or more times episodes of incontinent, but 1 episode of continent). Record review of Resident #1 Quarterly MDS dated [DATE] revealed in Section C (Cognitive Patterns) a BIMS Score of 15 indicating no cognitive impairment and in Section H (bladder and bowel) that resident had an indwelling catheter. Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine). Initiated date of 10/15/2022 and revised date of 01/31/2023. Record review of Resident #1 most recent significant change MDS Section C dated 01/30/2023 revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a BIMS of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision. Record review of Resident #1 significant change MDS on 01/30/2023 revealed Resident #1 had an indwelling catheter reported in section H: Bladder and Bowel. Observation and interview on 02/18/2023 at 10:15 AM, Resident #1's catheter bag was full and overflowing with urine and backflowing up the tubing. The catheter bag was leaking on the floor. Resident reported that it had not been drained in 2 days. The resident's urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. Observation and interview on 02/18/2023 at 10:16 AM, with the DON present Resident #1's catheter tubing and bag was visualized. The DON said that the thick cloudy substance in the resident's catheter bag and tubing appeared to be a puss like substance. She said that she was going to have it changed immediately. Interview on 02/18/2023 at 1:20pm, DON stated indwelling catheter bags should always be covered. She also stated catheter bags that are full of urine backflowing in the catheter tubing placed the resident at risk for infections. She stated she did not know the reason for Resident #1's overflowing catheter bag with urine backflowing into the catheter tubing. Observation on 02/18/2023 at 3:58pm, Resident #1 continued to have an indwelling catheter with an overfilled catheter bag with urine backflowing in the catheter tubing. The bag continued to be leaking urine onto the floor. The urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. This observation was reported to the Corporate Regional Resource Nurse-J. Observation and interview on 02/19/2023 at 8:35 am, Resident #1's catheter bag had been emptied; however, the Foley catheter and tubing had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. There was a trash bag on the floor under the uncovered catheter bag. Resident #1 stated that the trash bag was placed to catch leaking urine from the catheter bag. Interview on 02/19/2023 at 9:45 am, RN-V stated she had not gone to Resident #1's catheter bag to check if it had been drained or changed during previous day's shift. She reported it was delegated to her, but she was busy and had not had a chance to do it. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician. She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, DON stated she asked LVN-O and RN-V to change Resident #1's catheter, tubing and bag yesterday afternoon. She could not remember the exact time, but it was after lunch. She said she went back to Resident #1's rooms yesterday afternoon and it continue to not be completed. She then asked them again to complete the task. She stated this failure placed the residents at risk for an infection. Interview on 02/19/2023 at 3:10pm, RN-V said she did not change Resident #1's catheter tubing but only changed the bag. She said she obtained a urine sample for an ordered UA from the catheter tubing that continued to have sediment and puss like substance but not from the bag. Interview and observation on 02/19/23 03:15 PM, Corporate Regional Resource Nurse-J-J stated she instructed RN-V to change Resident #1's entire catheter on 02/18/2023. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, with Corporate Clinical Company Leader RN-I present, Resident #1 was observed unresponsiveness with emesis on chest . Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Review of Resident #56's quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS Score of 15 indicating no cognitive impairment. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to a local hospital via EMS. Interview on 02/19/2023 at 4:34pm, the DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. DON stated she discovered Resident #1 left the facility (to the hospital) without a changed catheter tubing but only a changed catheter bag. It was her expectation that it was changed yesterday. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she pressed the call light frequently and it takes a while to answer. She said the lady who came to answer the call light after two hours had long dark hair and was part of administration but did not work the floor. Resident #56 (Resident #1's roommate) said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 (Resident #1's roommate) said that the staff stated she could not help Resident #1 and left the room. Resident #56 (Resident #1's roommate) said she thought the staff was coming back but never did. Resident #56 (Resident #1's roommate) said she could hear Resident #1 throwing up and gurgling. Resident #56 (Resident #1's roommate) said no one changed their catheters. She said yesterday (02/19/2023) the staff just changed the bag. Resident #56 (Resident #1's roommate) said the regional nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 (Resident #1's roommate) said it was the same nurse who told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff 02/19/2023 and behind. She said when the regional nurse came, she told her to change the catheter bag only. She said she was often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. Interview on 02/21/2023 at 4:46 PM, with Resident #1's Family Members A and B revealed when they would come to see her, she would look malnourished, and her catheter bag was always full. Record review of Resident #1's vital reports, dated 02/21/2023, provided by Corporate Clinical Leader RN-H revealed no evidence of catheter care, drainage of catheter bag and amount of urine obtained during drainage on 48 occasions between 01/18/23 and 02/19/23. Record review of Resident #1's hospital record History and Physical dated 02/19/2023 at 8:48pm, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's hospital records dated 02/19/2023 revealed Resident #1 was admitted into the hospital's ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of Resident #1's hospital records dated 02/21/2023 revealed Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of Resident #1's hospital records dated 02/21/2023 Assessment and Plan revealed: 1. UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin for empiric treatment. 2. Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic) for empiric treatment. 2. Resident #79 Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis (infection of the bone caused by bacteria), pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues causing fatigue and pain), major depressive disorder, dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), dependence on supplemental oxygen, chronic atrial fibrillation (irregular heart beat), Methicillin resistant Staphylococcus aureus (certain type of bacteria resistant to treatment by many common antibiotics), and Type 2 diabetes mellitus . Review of Resident #79's admission MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage 3 pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed: Section M: Skin Conditions indicated two Stage 4 pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment ; Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN; Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment . Review of Resident #79's electronic orders revealed: Multivitamin plus Minerals 1 tablet by mouth daily (start date 11/15/22) Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative (start date 11/25/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved (start date 11/25/22) Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative (start date 11/25/22) Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily (start date 11/29/22) Pro-Stat AWC (amino acids-protein hydrolys) 17-100 gram-kcal/30ml give 30ml by mouth twice a day (start date 11/29/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved (twice a day - PRN, morning, bedtime) (start date 11/29/22) Cleanse right heel with normal saline or wound cleanser apply anasept to wound and secure with a bordered dressing daily (start date 12/29/22) Use cushioned boots while in bed as tolerated (start date 1/3/23) Ertapenem 1 gram intravenously daily for 42 days r/t osteomyelitis (start date 1/13/23 end date 2/24/23) Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2cm in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Review of Resident #79's physicians orders dated 11/25/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved. Review of Resident #79's physicians orders dated 11/29/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved. Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage 3 pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) of the Right Heel measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage 4 Pressure Wound of the Right Heel. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage 4 Pressure Ulcer to right heel measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. During an observation on 02/20/23 at 3:25 PM of Resident #79's wound care revealed RN-V completed wound care with the assistance of MDS-RN and LVN Q. RN-V failed to change gloves after removing sacrum dirty wound dressing and beginning to apply treatment and clean dressing to sacrum. RN-V also failed to perform hand hygiene before applying new gloves to begin treatment to right heel. Following the treatment, RN-V was unable to be located for an interview. Interview on 2/24/23 at 4:48 PM, LVN-Q stated wound care with Resident #79 on 2/20/23 performed by RN-V went badly. She stated she did not see RN-V wash hands or use sanitizer at any time before or during the dressing changes, but she did see her change her gloves in between each wound. LVN-Q stated that was not the correct procedure for hand hygiene during wound care and could lead to recontamination of the wound. She stated that RN-V was feeling overwhelmed but that was not an excuse. She stated that it was just overall not good. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated Resident #79 was admitted to facility on 11/15/22 with stage 3 to sacrum and stage 3 to right heel and that both wounds were documented on admission. Corporate Clinical Company Leader RN-H stated that in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed it went one month without treatment or observation leading to it decline to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had declined to a stage 4. She stated the documentation stating the wound was improving even with the presence of osteomyelitis was strictly referring to the wound bed appearance from her understanding. Corporate Clinical Company Leader RN-H stated the resident was diagnosed with osteomyelitis at the site of the sacral wound by the wound care physician. She stated the staff was supposed to do skin sweeps weekly to check wounds and get measurements and the wound care doctor saw residents weekly as well. The staff did their checks on the residents that the doctor did not see. The measurements were documented in the wound management section of the chart. Corporate Clinical Company Leader RN-H stated wound care was documented on the treatment administration record only unless something was wrong or there were changes. If there was something different with a wound, she stated a prudent nurse would document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated the wound care physician's progress notes were uploaded into the resident's EMR electronically and that he was able to put his own orders in remotely. She stated if someone did transcribe orders for him it would be the nurse who did rounds with him while he was in the building seeing residents, normally the wound care/treatment nurse when the facility had one or the DON. If the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. Corporate Clinical Company Leader RN-H stated when an order was put into the facility's charting program it went directly onto the MAR. She stated during the morning meeting, the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. Corporate Clinical Company Leader RN-H stated all information regarding wounds had been provided or would be found in focused observation notes. In an interview on 02/22/23 at 09:57 AM , LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. When LVN-AE would ask RN-V why it was not being done, RN-V would say it was because she would be frustrated and that she was one person and could not get them (treatments) done. LVN-AE did not understand why because RN-V always had a med aide, so that would have left her free to do the treatments. LVN-AE stated that the wounds would have the same dressing on them on Monday that she put on the residents on Friday. LVN-AE stated she worked Monday through Friday as the treatment/wound care nurse. LVN-AE reported RN-V to the DON and the former Administrator, then later reported it to Regional Nurse Consultant and others who no longer work for the company. She was told by all of them that they would talk to RN-V. LVN-AE stated it never got corrected. LVN-AW felt the residents did not receive wound care as ordered by the physician when she was not in building. LVN-AE stated that every Thursday the wound care physician would see residents but by the time he arrived, she had a week to make them look better, so he did not make comments that the residents' wounds were worse. LVN-AE stated she got conflicting information from DON's regarding skin assessments. LVN-AE stated at first, she would do skin assessments on wound care residents, then was told the nurses were supposed to do skin assessments and she was only supposed to do the wound management (measurements, wound descriptions). LVN-AE said she left the facility because the facility was not willing to change and hold RN-V accountable for wound care, and she was afraid of losing her license due to the wounds in the facility. In an interview on 2/22/23 at 10:25 AM, LVN-P stated since the wound care nurse quit whoever was working the floor was responsible for wound care for the residents. She stated typically, there was a charge nurse and a med nurse on the day shift, and they helped each other out with the residents. LVN-P stated Station 1 had 6 residents getting wound care at that time. When wound care was done, she stated she only signed off on the TAR and she never put a progress note in just to state the wound care had been done. She stated if there were changes to the wound it was documented in a progress note, the doctor was notified, she would notify the family and continue the treatment or write orders if any new orders were given. She stated a nurse always rounded with the wound care doctor when he saw the residents. She stated he was in the facility weekly, and she rounded with him last week because there was no one else to do it. LVN-P stated until the facility hired a new wound care nurse, she believed the DON was going to take over rounding with him. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. She stated the facility was currently in the process of revising their wound care program to address wound care management, assessments, treatments, and care planning issues the facility had been experiencing. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. Wound Care Physician stated that if a resident's wound care was not done as ordered over the weekend that when he came to the facility on Thursday, the wounds would have time for improvement by the time he saw them again if the treatments were started back up on Monday. He stated he did rounds with the floor nurses when he saw the residents. 3. Resident #53 Record review of Resident #53's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She resided on Station 1 Hall 6 which was a Woman's secured unit (the average age of the women residents on Station 1 Hall 6 was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank indicating inability to obtain a Brief Interview for Mental Status; Section E: Behavior indicated no psychosis, presence of physician behavior symptoms directed toward others, significant risk for physical illness or injury on self and others, rejection of care, wandering that places resident at significant risk of getting to a potentially dangerous place and intrusion on privacy of activity of others. Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night, Problem: Falls. Approach. Ordered an oversize bean bag for positioning. Review of Resident #53's electronic record from April 2022 to February 2023 revealed no evidence of documented 15-minute checks and no evidence of physician's order for 1:1 level of supervision. Record review of Resident #53's transfer documentation packet, faxed on 04/19/2022 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others. Record review of Nurse Practitioner progress not[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents (Resident # 1, Resident #79) reviewed for pressure ulcers. The facility failed to prevent Resident #1 from developing 5 new pressure ulcers (Stage IV to right ischium, Stage IV to left Ischium, Stage IV to Left Heel, Stage IV to right heel, and Not Stage to sacrum) while she resided in the facility. The facility failed to promote healing and prevent Resident #79's Stage IV pressure ulcer to his sacrum from developing osteomyelitis (an infection in the bone caused by bacteria) The facility failed to promote healing and prevent Resident #79's right heel pressure ulcer from deteriorating from Stage III to Stage IV. An Immediate Jeopardy (IJ) was identified on 2/22/2023 at 4:58 PM. While the IJ was removed on 2/24/2023 at 6:48 PM, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its plan of removal. These failures placed residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death. The findings were: Review of The National Pressure Injury Advisory Panel (NPIAP) accessed on 03/14/2023 https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed: Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident #1 Review of Resident #1's electronic face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: Unspecified fracture of left shaft of the femur (long, straight portion of the upper leg bone), Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1's admission MDS, dated [DATE], revealed: Section C: Cognitive Patterns BIMS Score of 9 indicating moderate cognitive impairment; Section G: Functional Status limited/one-person assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions of no pressure ulcers. Review of Resident #1's Significant Change MDS dated [DATE], revealed: Section C: Cognitive Patterns BIMS Score of 14 indicating cognitively intact; Section G: Functional Status: extensive/two + persons assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage III pressure ulcers, one Stage IV pressure ulcer, and two Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Site 1: Right buttock/ischium Review of Resident #1's Wound Management Detail Report dated 07/28/2022 at 4:08pm by LVN-AD revealed: Pressure Ulcer to Right Buttock, not present on admission. Unstageable measured 2.8cm in length by 2.8cm in width with unmeasurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:44pm by LVN-Q revealed: Stage IV measured 4cm in length by 6cm in width with 2.5 measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 7/28/22 Initial exam of Right Ischium: Unstageable Pressure Ulcer 2.8cm x 2.8cm x unmeasurable depth; surgical debridement performed 11/24/22 Change of staging Right Ischium: Stage IV 4.6cm x 6.0cm x 2.0cm; surgical debridement performed 2/16/23 Last available progress note Right Ischium: 4cm x 6cm x 2.5cm; surgical debridement performed Site 2: Left buttock/ischium Review of Resident #1's Wound Management Detail Report dated 08/04/22 at 3:24pm by LVN-AD revealed: Unstageable Pressure Ulcer to Left Buttock, not present on admission. Measured 4.5cm in length by 4cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:50pm by LVN-Q revealed: Stage III measured 1.7cm in length by 4.2cm in width with 0.5cm measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 8/04/22 Initial exam of Left Ischium: Stage II Pressure Ulcer 4.5cm x 4.0cm x unmeasurable depth; no debridement done 8/11/22 Change of Staging of Left Ischium: Unstageable Pressure Ulcer: 3.2cm x 1.5cm x 0.2cm; surgical debridement performed 11/10/22 Change of Staging of Left Ischium: Stage III 4.5cm x 2.5cm x 1cm; surgical debridement performed 2/16/23 Change of Staging of Left Ischium: Stage IV 1.7cm x 4.2cm x 0.5cm; surgical debridement performed Site 3: Left heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:17am by LVN-AE revealed: Unstageable - Deep Tissue Pressure Ulcer left heel not present on admission measured 5.5cm in length by 5cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:54pm by LVN-Q revealed: Stage IV measured 3cm in length by 4cm in width with no measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 11/17/22 Initial exam of Left Heel: Unstageable DTI Pressure Injury 5.5cm x 5.0cm x unmeasurable depth; no debridement done 12/8/22 Change in Staging of Left Heel: Unstageable Pressure Ulcer 5.5cm x 5.0cm x unmeasurable depth; no debridement done 2/16/23 last available progress note for Left Heel: Unstageable Pressure Ulcer 3cm x 4cm x unmeasurable depth; no debridement done Site 4: Right heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:15am by LVN-AE revealed: Pressure Ulcer Right Heel not present on admission measured 5cm in length by 7cm in width and no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:52pm by LVN-Q revealed: Stage IV measured 2.7cm in length by 3.8cm in width and no measurable depth. Review of Resident #1's wound care physician progress notes revealed the following: 11/17/22 Initial exam of Right Heel: Unstageable DTI Pressure Injury 5cm x 7cm x unmeasurable depth; no debridement done 12/8/22 Change in Staging of Right Heel: Unstageable Pressure Ulcer 5cm x 7cm x unmeasurable depth; no debridement done 12/29/22 Change in Staging of Right Heel: Stage IV Pressure Ulcer 5.5cm x 5cm x unmeasurable depth; surgical debridement performed 2/16/23 last available progress note for Right Heel: Stage IV 2.7cm x 3.8cm x unmeasurable depth; no debridement done Site 5: Sacrum Review of Resident #1's Wound Management Detail Report dated 11/09/22 at 12:50 PM by LVN-AE revealed: Pressure Ulcer Sacrum not present on admission measured 10cm in length by 8cm in width and no measurable depth Review of Resident #1's Wound Management Detail Report dated 2/09/23 at 2:36 PM by LVN-AE revealed: Pressure Ulcer Sacrum not present on admission measured 1.5cm in length by 1cm in width and no measurable depth Review of Resident #1's electronic orders revealed: Ascorbic acid (vitamin c) tablet; 500mg 1 tab oral once a day (start date 10/08/22) Wound Treatment Order: Location: Pressure Wound of the Left Ischium Partial Thickness. Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day (start date 10/20/22) Wound Treatment Order: Location: Unstageable of the Right Ischium Full Thickness. Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. Once a Day. (start date 10/20/22) Wound Treatment Order: Location: Pressure Wound of the Left Ischium Partial Thickness. Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Twice a Day-PRN (start date 11/29/22) Wound Treatment Order: Location: Unstageable of the Right Ischium Full Thickness. Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. Twice A Day - PRN (start date 11/29/22) Cleanse sacrum with normal saline or wound cleanser apply thin layer of triad, yellow tube, to wound two times a day. Every Shift (start date 12/29/22) Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Every Shift (start date 2/10/23) Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg daily. Once A Day. Morning 06:00 AM - 06:00 PM (start date 2/10/23) Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed and secure with bordered dsg as needed. Every Shift - PRN (start date 2/10/23) Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed and secure with bordered dsg daily. Once A Day. Morning 06:00 AM - 06:00 PM (start date 2/10/23) Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.; Problem: Resident has a pressure ulcer to left heel related to immobility. Goal: Resident's ulcer will not increase in size. Approach: Conduct a systematic skin inspection during daily treatment . Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels.; Problem: Resident has a pressure ulcer to right buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.; Problem: pressure Ulcer Sacrum Stage III. Goal: Area will show improvement in the next 14 days. Approach: Turn every 2 hours and prn. In an interview on 02/19/2023 at 2:38 PM, Corporate Clinical Company Leader RN-I stated the facility would accept responsibility for Resident #1's pressure ulcers and that they were facility acquired. She stated that she could not find any documentation that they were not acquired in the facility. Corporate Clinical Company Leader RN-I stated that the failure of the facility to prevent Resident #1 from developing new pressure ulcers could result in an infection and that the failure was due to ongoing staffing issues. In an interview on 02/22/23 at 09:57 AM, LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. LVN-AE stated that Resident #1's wound got worse because RN-V would have the wrong dressings on the resident. LVN-AE stated that Resident #1's sacrum was to be left open to air per physician orders, but she would come back on Monday and there would be a dressing (silicone border dressing) covering the wound and when she would remove the dressing, it would take the new healing skin off. She stated Resident #1 did not show pain, just that her wounds would be worse. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. He stated that all of Resident #1's wounds were facility acquired. Review of Resident #1's electronic record from 05/20/2022 to 02/23/2023 revealed no evidence of physician's progress note demonstratiting the resident's pressure ulcers were clinically unavoidable. Resident #79 Review of Resident #79's electronic Face Sheet revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis (an infection in the bone caused by bacteria), pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues causing fatigue and pain), major depressive disorder, dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), dependence on supplemental oxygen, chronic atrial fibrillation (irregular heart beat), Methicillin resistant Staphylococcus aureus (certain type of bacteria resistant to treatment by many common antibiotics), and Type 2 diabetes mellitus. Review of Resident #79's admission MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage III pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed: Section C: Cognitive Patterns BIMS Score of 11 indicating moderate cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage IV pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2c in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage III pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage IV Pressure Ulcer to right heal measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) of the Right Heel Full Thickness measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage IV Pressure Wound of the Right Heel. Review of Resident #79's electronic orders revealed: Multivitamin plus Minerals 1 tablet by mouth daily (start date 11/15/22) Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative (start date 11/25/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved (start date 11/25/22) Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative (start date 11/25/22) Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily (start date 11/29/22) Pro-Stat AWC (amino acids-protein hydrolys) 17-100 gram-kcal/30ml give 30ml by mouth twice a day (start date 11/29/22) Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved (twice a day - PRN, morning, bedtime) (start date 11/29/22) Cleanse right heel with normal saline or wound cleanser apply anasept to wound and secure with a bordered dressing daily (start date 12/29/22) Use cushioned boots while in bed as tolerated (start date 1/3/23) Ertapenem 1 gram IV daily for 42 days r/t osteomyelitis (start date 1/13/23 end date 2/24/23) Review of Resident #79's Treatment Administration Records from November 2022 to February 2023 revealed no evidence of wound treatments completed on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023. Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN; Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment .; Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment . Observation on 2/18/23 at 3:30 PM Resident #79 was lying in bed, turned slightly onto his left side with heels floated on pillows and heel protectors to bilateral feet. Observation on 2/19/23 at 10:30 AM Resident #79 was lying in bed flat on his back with heels floated on pillows, bilateral heel protectors were in place. Observation on 2/20/23 at 9:40 AM Resident #79 was sitting in Geri-chair in dialysis suite with pillows elevating feet. Resident #79 had 2 blankets covering his legs because he stated that room was always cold, surveyor unable to verify if heel protectors were in place. Observation on 02/20/23 3:25 PM: RN-V gathered supplies as ordered from treatment cart and placed in resealable plastic bag with resident #79's name written on it and carried bag to resident's room. MDS-RN and LVN-Q entered room and donned gloves. LVN-Q used hand sanitizer prior to entering resident room. MDS-RN was not observed to use hand sanitizer after entering Resident #79's room. RN-V used hand sanitizer, cleaned tray table with sanitizer wipes and placed wax paper on cleaned tabletop without donning gloves. RN-V removed 2 6inx6in foam border dressing from package and dropped on wax paper, removed 3 saline ampules, 1 can of wound spray, 1 tube of barrier cream, 4inx4in gauze, calcium alginate packing, and cotton tipped applicators from resealable plastic bag and placed on wax paper without donning gloves. RN-V saturated 4x4 gauze with saline without donning gloves. RN-V donned clean gloves. Resident #79 assisted onto his left side by MDS-RN. Dirty dressing and soiled packing removed by MDS-RN; soiled dressing was dated 2/18/23. Wound appeared beefy red inside, wound edges well-defined and healthy looking, area surrounding wound was bright red and irritated in appearance, area appeared larger than size of foam border dressing (6x6in) but no measurements were taken during this dressing change. Without changing soiled gloves, RN-V cleaned wound with saline soaked gauze, patted area dry with dry gauze, opened calcium alginate package and used cotton tipped applicator to pack calcium alginate packing into wound. Clean 6inx6in foam border dressing placed over wound. Resident rolled onto his back then LVN-Q stated, don't forget you have to date time and initial the dressing. RN-V assisted resident back onto his left side and RN-V dated and initialed the clean dressing. RN-V did not change gloves in between dirty and clean dressing. RN-V removed her gloves and donned a clean pair. LVN-Q held Resident #79's leg by the calf while RN-V removed Resident #79's right heel dressing, soiled dressing did not appear to have a date and initial on it. RN-V sprayed wound cleanser on right heel wound, applied wound cleanser to wound with cotton tipped applicator, and applied a clean 6inx6in foam bordered dressing. RN-V dated and initialed the clean dressing to Resident #79's right heel. RN-V removed her gloves. RN-V donned clean gloves and removed dressing to left heel, wound cleanser and gauze used to clean left heel. MDS-RN stated that there were no orders for the treatment or dressing to the left heel, but the staff do them as a preventative measure. RN-V removed her gloves, collected trash, and left the room. Surveyor attempted to find RN-V for an interview regarding the wound care, but she was unable to be located. Interview on 2/24/23 at 4:48 PM, LVN-Q stated wound care with Resident #79 on 2/20/23 performed by RN-V went badly. She stated she did not see RN-V wash hands or use sanitizer at any time before or during the dressing changes, but she did see her change her gloves in between each wound. LVN-Q stated that was not the correct procedure for hand hygiene during wound care and could lead to recontamination of the wound. She stated that RN-V was feeling overwhelmed but that was not an excuse. She stated that it was just overall not good. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated Resident #79 was admitted to facility on 11/15/22 with stage 3 to sacrum and stage 3 to right heel and that both wounds were documented on admission. Corporate Clinical Company Leader RN-H stated that in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed it went one month without treatment or observation leading to it progress to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had worsened to a stage 4. She stated the documentation stating the wound was improving even with the presence of osteomyelitis was strictly referring to the wound bed appearance from her understanding. Corporate Clinical Company Leader RN-H stated the resident was diagnosed with osteomyelitis at the site of the sacral wound by the wound care physician. She stated the staff was supposed to do skin sweeps weekly to check wounds and get measurements and the wound care doctor saw residents weekly as well. The staff did their checks on the residents that the doctor did not see. The measurements were documented in the wound management section of the chart. Corporate Clinical Company Leader RN-H stated wound care was documented on the treatment administration record only unless something was wrong or there were changes. If there was something different with a wound, she stated a prudent nurse would document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated the wound care physician's progress notes were uploaded into the resident's EMR electronically and that he was able to put his own orders in remotely. She stated if someone did transcribe orders for him it would be the nurse who did rounds with him while he was in the building seeing residents, normally the wound care/treatment nurse when the facility had one or the DON. If the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. Corporate Clinical Company Leader RN-H stated when an order was put into the facility's charting program it went directly onto the MAR. She stated during the morning meeting, the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. Corporate Clinical Company Leader RN-H stated all information regarding wounds had been provided or would be found in focused observation notes. In an interview on 02/22/23 at 09:57 AM, LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. When LVN-AE would ask RN-V why it was not being done, RN-V would say it was because she would be frustrated and that she was one person and could not get them (treatments) done. LVN-AE did not understand why because RN-V always had a med aide, so that would have left her free to do the treatments. LVN-AE stated that the wounds would have the same dressing on them on Monday that she put on the residents on Friday. LVN-AE stated she worked Monday through Friday as the treatment/wound care nurse. LVN-AE reported RN-V to the DON and the former Administrator, then later reported it to Regional Nurse Consultant and others who no longer work for the company. She was told by all of them that they would talk to RN-V. LVN-AE stated it never got corrected. LVN-AW felt the residents did not receive wound care as ordered by the physician when she was not in building. LVN-AE stated that every Thursday the wound care physician would see residents but by the time he came, she had a week to make them look better, so he did not make comments that the residents' wounds were worse. LVN-AE stated she got conflicting information from DON's regarding skin assessments. LVN-AE stated at first, she would do skin assessments on wound care residents, then was told the nurses were supposed to do skin assessments and she was only supposed to do the wound management (measurements, wound descriptions). LVN-AE said she left the facility because the facility was not willing to change and hold RN-V accountable for wound care, and she was afraid of losing her license due to the wounds in the facility. In an interview on 2/22/23 at 10:25 AM, LVN-P stated since the wound care nurse quit whoever was working the floor was responsible for wound care for the residents. She stated typically, there was a charge nurse and a med nurse on the day shift, and they helped each other out with the residents. LVN-P stated Station 1 had 6 residents getting wound care at that time. When wound care was done, she stated she only signed off on the TAR and she never put a progress note in just to state the wound care had been done. She stated if there were changes to the wound it was documented in a progress note, the doctor was notified, she would notify the family and continue the treatment or write orders if any new orders were given. She stated a nurse always rounded with the wound care doctor when he saw the residents. She stated he was in the facility weekly, and she rounded with him last week because there was no one else to do it. LVN-P stated until the facility hired a new wound care nurse, she believed the DON was going to take over rounding with him. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. She stated the facility was currently in the process of revising their wound care program to address wound care management, assessments, treatments, and care planning issues the facility had been experiencing. In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. Wound Care Physician stated that if a resident's wound care was not done as ordered over the weekend that when he came to the facility on Thursday, the wounds would have time for improvement by the time he saw them again if the treatments were started back up on Monday. He stated he did rounds with the floor nurses when he saw the residents. Review of facility policy Prevention of Pressure Injuries revised May 2022 revealed: Purpose: The purpose of this protocol is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Prevention: Skin Care 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence. 3. Avoid alkaline soaps and cleansers. 4. Use a barrier product to protect skin from moisture. 5. Use incontinence products with high absorbency. 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. 7. Use facility-approved protective dressings for at risk individuals. Nutrition 1. Conduct nutritional screenings for residents at risk. 2. Conduct a comprehensive nutritional assessment for any res[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have enough qualified staff to provide adequate care for residents with mental and psychosocial disorders for 13 of 13 residents (Resident #6, Resident #9, Resident #15, Resident #36, Resident #38, Resident #40, Resident #43, Resident #53, Resident #57, Resident #74, Resident #83, Resident #88, and Resident #199) reviewed for staffing behavioral health needs. 1. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #43, Resident #53 and Resident #74 to prevent a resident-to-resident physical altercation that led to injuries that required treatment of Resident #43 and Resident #53 on 12/03/22. 2. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40 and Resident #53 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #40 on 12/21/22. 3. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #9 and Resident #53 to prevent a resident-to-resident physical altercation that led that required treatment to an injury of Resident #9 on 12/21/22. 4. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #6 and Resident #40 to prevent a resident-to-resident physical altercation that led to an injury that required medical treatment of Resident #40 on 01/01/23. 5. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residentson Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40, Resident #53 and Resident #74 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #53 on 01/26/23. 6. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #57 and Resident #83 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #57 on 01/06/23. 7. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #57 and Resident #88 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #57 on 02/04/23. 8. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #38 and Resident #199 to prevent a resident-to-resident physical altercation that led that required treatment to an injury of Resident #38 on 01/22/23. 9. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #15 and Resident #53 to prevent a resident-to-resident physical altercation on 11/26/22. 10. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #36 and Resident #40 to prevent a resident-to-resident physical altercation on 12/04/22. 11. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40 and Resident #74 to prevent a resident-to-resident physical altercation on 12/06/22. 12. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station /Hall 6 (women secured locked unit) to meet the needs of Resident #6 and Resident #53 to prevent a resident-to-resident physical altercation on 12/20/22. 13. The facility failed to ensure there was sufficient staffingwith necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on . on Hall 200/Unit 2 (women secured locked unit) to meet the needs of Resident #6 to prevent her from eating Styrofoam during lunch on 02/18/23. Resident #6 had a history of ingesting inedible objects. An IJ was identified on 02/22/2023. The IJ template was provided to the facility on [DATE] at 4:56pm While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because the facility needed to continue to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for being provided care by staff who are not trained to care for resident with identified behavioral issues. Findings include: Record review of Facility assessment dated [DATE], Part 3, titled Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: Staff: Licensed nurses: Station 2 (Station 2 has 6 halls): LVN/RN Days: 2 and Nights: 2 (12hour shifts). Direct Care Staff/CNAs: Station 2: Days 6, Nights 4 (12-hour shifts). Station 2 Hall 6 (Women's Secured Unit) In an observation on 02/14/23 at 11:00 am, Station 2 Hall 6 had 6 residents with known behaviors including 1 resident who required 1:1 supervision. One CNA was observed on the hall. Station 2 Hall 1 (Men's Secured Unit) In an observation on 02/14/23 at 11:47 am, Station 2 Hall 1 had 14 residents with known behaviors. 1 agency CNA, ADON, and LVN-T were observed on the hall. In an interview on 02/14/23 at 11:00 am, CNA-E said she worked 6am to 6pm and worked 12 hours by herself on the women's secured unit, with 1 resident requiring 1:1 supervision. A staff member would come in every 2 hours to check on her. She said she did not feel safe working alone and was unable to prevent resident to resident altercations. CNA-E stated she had received training in the past for Alzheimer's/dementia but not for residents with aggressive behaviors. In an interview on 02/14/23 at 11:47 am, LVN-T said the facility usually had 2 staff on the men's secured unit and 1 staff on the women's secured unit during the day shift. She floated between the 2 units but spent the majority of her time on the men's unit as that was where her desk as. She said 1 staff on the women's secured unit as not enough to protect the residents. She said staff was cut back from 2 staff to 1 staff on the women's unit about a month ago. Resident #53 Record review of Resident #53's electronic face sheet, dated 02/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. She was being housed on the women's secured unit (the average age of the residents was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior of this type occurred 1 to 3 days, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - behavior of this type occurred 1 to 3 days. E0900: Wandering - 1 (Behavior of this type occurred 1 to 3 days). Section G: Functional Status. G0110. Activities of Daily Living Assistance: H. Eating: 3 (extensive assistance). G0120 Bathing: Self-Performance: 4 (Total dependence) G0300: Balance during transitions and walking: A. Moving from seated to standing position - 1 (not steady, but able to stabilize without human assistance). B. Walking (with assistive device is used) - 1 (Not steady, but able to stabilize without human assistance). Section P0100: Physical Restraints: Not used. Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night, Problem: Falls. Approach. Ordered an oversize bean bag for positioning. Record review of Resident #53's transfer documentation packet, faxed on 04/19/2023 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others. Record review of Nurse Practitioner progress note, dated 06/10/22, revealed Resident #53 was transferred from other facility due to not being able to continually provide the 1:1 care and attention that she requires. Record review of Social Worker progress note, dated 09/12/22 at 5:27 pm, revealed: SW expressed to Family Member J, facility is not able to meet resident needs and SW will need to talk with Family Member J regarding plans to transition resident to another facility. Record review of Social Worker progress note, dated 10/01/22 at 10:33 am, revealed: SW expressed to Family Member J, facility is not able to meet resident needs. 1. Review of facility investigation on 12/03/22 at 3:53 pm, Resident #53 slapped the face of Resident #43, and Resident #74 retaliated. A record review of the Provider Investigation Report revealed Resident #43 was sitting in the recliner minding her own business and for no reason Resident #53 slapped Resident #43 in the face. This in turn upset Resident #74 who scratched Resident #53 on the arm. Resident #42 had slight redness noted to the left side of her face. Resident #53 had several scratch marks to her upper right arm. Resident #53 was placed on increased supervision with staff. Record review of Resident #53's progress note dated 12/03/22 at 4:39 am, revealed Resident #53 had multiple behaviors throughout the evening and night. Grabbing at residents. Attempting to remove snacks from other residents. Walking on knees and crawling on the floor. Attempting to hit and kick staff during care. Removing clothes and brief and walking down hall. Walks to exit door of secured unit 1 and slaps and then tries to open locked door. No documentation resident was on 1:1 supervision. Record review of Resident #53's progress note dated 12/03/22 at 3:53 pm, revealed Resident #53 hit another resident across the face. (Resident was not identified.) Record review of Resident #53's progress note dated 12/03/22 at 5:46pm, revealed another resident was yelling get away, get away. Resident #53 hit another resident in the face and the other resident scratched at Resident #53's upper arm. Residents were separated. Resident #53 then went toward another resident and attempted to hit her, but the LVN intervened. (Other residents were not identified.) Record review of Resident #53's progress note dated 12/03/22 at 6:05 pm, revealed Resident #53 was on 1:1 supervision. Record review of Resident #53's progress note dated 12/03/22 at 6:43pm, LVN-T documented in Resident #53's progress notes per DON, resident to be 1:1. If no staff available to be 1:1 then resident can be on Q (every) 15-minute checks. Record Review of Resident #53's progress note dated 12/03/22 at 10:15 pm, revealed Resident #53 was on 15-minute checks. During an interview on 02/17/23 at 9:45 am, the Interim Administrator stated she could not provide documentation of who or how may staff were working on the women's secured unit at that time of the incident or documentation of 15-minute checks. 2. Review of facility investigation on 12/21/22 at 11:25 am, Resident #53 scratched Resident #9 on the forehead. A record review of the Provider Investigation Report revealed, Resident #9 was sitting in a chair when Resident #53 approached her and brushed Resident #9 on her forehead, causing a small 2cm X 1cm scratch. The facility stated Resident #53 did not intend to hurt Resident #9 as both residents were acting per their norm. Record review of Resident #53's progress note, dated 12/21/22 at 5:35 am, revealed resident #53 had multiple behaviors throughout the shift, including crawling on the floor, pulling and trying to remove the keypad cover, attempting to open doors, removing pants and brief and walking naked in the hallway, pulling a sign off the door, grabbing at residents and attempting to take their snacks, refusing evening medications, and attempting to climb in bed with another resident. Resident received Diazepam 15mg and it was documented it was not effective. Record review of Resident #53's progress notes, dated 12/21/22 at 12:09 pm, revealed Resident #53 scratched another resident in the face. Resident also attempted to grab and hit the nurse. 3. Review of facility investigation on 12/21/22 at 1:52 pm, Resident #53 reached out her arm causing a skin tear to Resident #9. A record review of the Provider Investigation Report revealed, Resident #53 was ambulating in the hallway and reached out grabbing Resident #9's arm causing a small 1cm X 2cm skin tear to her forearm. The facility stated it is normal for Resident #53 to reach out and grab objects and people within reach. Record review of progress notes, dated 12/21/22 at 9:40 pm, revealed Resident #53 was non-stop agitated and should have been on 1:1 observation. Resident #53 scratched and pulled the hair of the LVN on duty. Upon discussion with the ADON, Resident #53 was to be monitored until further notice. Record review of progress notes revealed no documentation of resident being placed on 1:1 observation. 5. Review of facility investigation on 01/26/23 at 7:00 pm, Resident #53 made contact with Resident #40's face and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #40 walked to close to Resident #53 who flailed her hands making contact with Resident #40's face. Resident #74 intervened and scratched Resident #53 on her elbow. The scratch was visible. Resident #53 was placed on 1:1 observation until she went to sleep. Record review of Resident #53's progress note dated 01/26/23 at 7:00 pm revealed, an unknown resident was sitting in a chair watching TV when Resident #53 walked past the unknown resident and hit her on the jaw with a closed fist. Record review of Resident #53's progress note dated 01/26/23 at 7:10 pm revealed, Resident #53 walked past resident #40 and attempted to slap her. Resident #74 grabbed Resident #53's right elbow causing a 1.5cm X 0.5cm superficial scratch. Resident #53 was already currently on 1:1 monitoring. 9. Review of facility investigation on 11/26/22 at 4:00 pm, Resident #53 pulled the hair of Resident #15 and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #74 was in the hallway when Resident #53 attempted to hit her, Resident #74 hit Resident #53 on the arm. Resident #15 was sitting at the dining room table and Resident #53 came up and pulled Resident #15's hair. Resident #53 was placed on 15-minute checks. Record review of Resident #53's progress note dated 11/26/22 at 3:50 pm, revealed Resident #53 was walking in the dining room and pulled Resident #15's hair. Resident #74 hit Resident #53 on the right arm after she pull Resident #15's hair. No documentation that Resident #53 was placed on 15-minute checks. 12. Review of facility investigation on 12/20/22 at 1:15 pm, Resident #53 reached out towards Resident #6 and Resident #6 reached out toward #53 swiping her in the face. A record review of the Provider Investigation Report revealed, Resident #53 unknowingly/unintentionally reached out (per her norm) toward Resident #6 brushing her face, in return Resident #6 swatted at Resident #53 in reaction and was instructed to not do that anymore. No injury noted. Record review of Resident #53's progress note dated 12/20/22 at 3:07 pm, revealed Resident #53 was in the dining room reaching out towards Resident #6. Resident #6 slapped Resident #53 in the face on the right cheek. No injury. Residents were separated. Resident #6 Record review of Resident #6's electronic face sheet accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 12/20/21 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, macular degeneration (deterioration of the retina of the eye that causes vision loss), and hypertension (high blood pressure). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. Other behavioral symptoms not directed toward others - behavior not exhibited. E0800 Rejection of care - behavior did not occur, E0900 Wandering - behavior occurred 1-3 days. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - Supervision. 2. Support: set up help only. Record review of Resident's #6's Care Plan dated 11/02/22 revealed the following problems and approaches: At risk for elopement - (problem start date 01/12/23) Requires secure unit placement. Attempted to take out of the secure unit. She started to wander aimlessly throughout all halls and rooms placing her at risk for other residents becoming aggressive towards her. Goal: Resident will be safe throughout her surroundings for 90 days. Approaches: Secure unit placement evaluation quarterly and prn. Elopement assessment quarterly and prn, Problem: (start date 01/05/23) Resident has physically abusive behavioral symptoms. Resident was hit by another resident and in return hit the other resident several times in defense. Goal resident will not harm self or others secondary to physically abusive behavior. Approach: avoid over stimulation, noise, crowding, and other physically aggressive residents), Avoid power struggles with resident, divert resident's behavior by encouraging resident to move to another common area away from distraction and other potentially aggressive residents who might provoke an unwanted response from resident #6 such as aggression, maintain a calm environment and approach, Problem: (start date 12/16/2019) I have impaired vision related to macular degeneration. Goal: I will not have accidents as a result of eye disease. Approaches: Assist as needed with ADL's and toileting Problem: At risk for falls, Goal: I will be free of falls Approaches included: increase staff supervision with intensity based on resident needs. 13. In an observation and interview on 02/18/23 at 12:43 pm during lunch on the Women's Secured Unit, the Assistant Administrator in Training was assisting Resident #53, she was attempting to spoon feed her, while the resident was constantly standing up and down, attempting to leave the table, and grabbing at her and other residents. The Director of Rehab was watching the rest of the residents, attempting to assist Resident #6 who was eating Styrofoam. Resident #40 was attempting to eat a piece of uncut chicken fried steak with the plastic fork sticking through the middle of it. There was no nurse present in the dining room during this time. The Director of Rehab attempted to get the Styrofoam from Resident #6 but never succeeded. The Assistant Administrator in Training and DOR said Resident #40 was supposed to eat finger foods due to the resident not allowing them to assist her with eating. A record review of Resident #6's Get to Know Me information, not dated, prepared by the Social Worker, revealed For all meals take everything off her tray; just leave the plate and just a spoon - if not, she will hoard everything in sight and chew on napkin and plastics. Resident #40 Record review of Resident #40's electronic face sheet accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder. Record review of Resident #40's Annual MDS dated , dated 01/11/23, revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. Section E 0900 Wandering - behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance. 2. Self-performance - Set up help only. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of resident #40's Care Plan revealed the following problems and approaches: Problem: Mood state - start date 01/06/23 resident exhibits socially inappropriately disruptive behavioral symptoms. Resident wanders about without direction and becomes physically aggressive (hitting, kicking etc.) when she gets near other residents or staff in her path as well as being hit by resident's she provokes with her unwanted behavior. Goal: Resident will not harm self or others secondary to socially inappropriate, disruptive behavior of opportunistically hitting or kicking residents who get in her pathway or reach while she wanders. Approach: Assess whether the behavior endangers the resident or others. Intervene, if necessary, by moving resident to a safe area, to wander, avoid over stimulation (noise, crowding and other physically aggressive residents, when resident begins to reach for, hit, kick, or grab others, provide for basic needs pain, hunger toileting, too hot/cold etc. Problem: behavioral symptoms: (start date 09/09/22) I pace up and down the halls frequently with no regards to others in my path. 08/01/22 I walked up behind another resident and got hit in the stomach. 08/17/22 I pushed another resident in the hallway while I was pacing up and down the hall. 08/26/22 I hit another resident in the face while walking in the hallway. 12/04/22 Hit by another resident. Goal: I will have less than 3 episodes of physical aggression with other people in my path over the next 90 days. Approaches: I will be redirected to least crowded areas when pacing. I will have increased monitoring and a referral to a behavioral center. 4. Review of facility investigation on 01/01/23 at 4:50 pm, Resident #40 hit Resident #6, and Resident #6 hit Resident #40 back. A record review of the Provider Investigation Report revealed, Resident #40 approached Resident #6's wheelchair and bumped the wheelchair with her foot making contact with the back of Resident #6's head. Resident #6 turned around in reaction and made contact with Resident #40's face. No injury noted per report. Record review of Resident #40's progress notes, dated 01/01/23 at 6:32pm, revealed Resident #40 kicked another resident's wheelchair and tapped her lightly on the head. That resident turned around and hit Resident #40 on the left eye and on her back several times. Resident #40 had redness under her left eye and redness to her upper back. 11. Review of facility investigation on 12/06/22, Resident #40 kicked Resident #74 and Resident #74 retaliated hitting Resident #40's back. A record review of the Provider Investigation Report revealed, Resident #74 was unintentionally kicked in the leg by Resident #40. Resident #74 then hit Resident #40 in the right shoulder. No injury reported. Record review of Resident #40's progress notes dated 12/06/22 at 5:40 pm, revealed Resident #40 kicked Resident #74 in the right leg. Resident #74 hit Resident #40 in the back. No injury reported. Resident #43 Record review of Resident #43's face sheet in the electronic medical record, accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 10/14/22 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, schizoaffective Disorder (a mental health condition), and hypertension (high blood pressure). Record review of Resident #43's Significant Change in Status MDS dated [DATE], revealed her BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering - behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - set up help. 2. Support: 1-person physical assist. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of Resident #43's Care Plan revealed the following problems and approaches: Problem: (start date 08/23/21) I have a history of aimless wandering increasing safety concerns. 12/03/22 Behavior from another resident. Goal: I will have less than 2 episodes of wandering into others space over the next 90 days. Approaches: I will be redirected if I walk up to someone and invade their personal space, I will be redirected as needed when wandering to prevent me from going into an unsafe area, I will reside in the secured unit. Problem Start Date: 08/10/2021 Category: Falls. I am at risk for falls related to unsteadiness. Approaches: I will be encouraged to wear footwear that fit properly and have non-skid soles. I will be redirected from areas I don't need to be in. Problem: for elopement- (start date 01/11/23). Goal - Resident will not wander out of designated secure area over the next 90 days. Approach: Secure Unit Placement. Secure unit evaluation quarterly and PRN, elopement assessment quarterly and PRN Risk related to Alzheimer's /dementia. Resident #74 Record review of Resident #74's Face Sheet document in the electronic medical record accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: dementia with behavioral disturbance, major depressive disorder, and delusional disorder. Record review of Resident #74's Annual MDS dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering -behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - supervision. 2. Support: set up help only. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. Record review of Resident #74's Care Plan revealed the following problems and approaches: Problem: At risk for elopement - (start date 01/11/23). Goal: Resident will be kept safe in surroundings. Approaches: continuous placement in secure unit, elopement assessment quarterly and nail care weekly. Problem: Behavioral symptoms - resident exhibits verbal and physical aggression when other residents invade her space and surroundings. Goal: Resident will not show behaviors of aggression. Approaches: Remove and provide a quiet place, staff will encourage rapport with other residents, staff will encourage redirection when resident exhibiting bouts of verbal/ physical aggression, I will have increased supervision until reviewed by psych services., I will be assisted to a quiet place when things become too loud for me, Keep environment calm and relaxed. Resident #9 Record review of Resident #9's Annual Assessment MDS, dated [DATE], revealed Resident #9 was admitted to the facility on [DATE]. Diagnosis include [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 4 Residents (Resident #1, Resident #79, Resident #53, Resident #57) reviewed for administration quality of care, in that: 1. Resident #1 had an indwelling urinary catheter that had not been drained for 2 days causing backflow of urine due to nursing staff not following physician's orders and the facility's lack fo administrative monitoring an ensuring resient care. The catheter tubing had sediment and puss like substance in tubing. Resident #1 became unresponsive, sent to hospital, initial diagnosis of UTI, and admitted to ICU due to nursing staff neglecting to follow physician's orders. 2. Resident #1 had five facility acquired pressure ulcers that progressed to Stage III and Stage IV due to nursing staff neglecting to follow physician's orders. Facility administrative personnel did not monitor and ensure nursing staff followed physician orders and provided residents care to attain highest practicable well-being. 3. Resident #79 had one Stage III pressure ulcer upon admit that worsened to have osteomyelitis due to nursing staff neglecting to follow physician's orders. The facility's administration did not ensure it's resident skin assessments and wound treatments were completed by nursing staff and monitored by administrative personnel for effectiveness and completeness 4. The facility's administrative personnel did not ensure nursing staff were sufficiently staffed in the women's secured locked hall for resident safety. Station 2 Hall 6 was a women's secured locked hall with six (6) female residents with known behaviors with one (Resident #53) of the six (6) women required 1:1 level of supervision. The facility failed to staff the Hall with more than one trained staff consistently. The staff utilized a gait belt around Resident #53 to redirect, restraint her movement, and prevent altercations from other residents. 5. The facility's administrative personnel did not ensure nursing staff were sufficiently staffed in the men's secured locked hall for resident safety. Station 2 Hall 2 was a men's secured locked hall with fourteen (14) male residents with known behaviors. On 01/06/2023, there was a resident/resident altercation and no staff were located on the hall. An Immediate Jeopardy (IJ) was identified on 02/23/2023. The IJ template was provided to the facility on [DATE] at 10:28am. While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of pattern and a severity of actual harm because the facility's need to evaluate the effectiveness of their corrective actions. These failures placed residents at risk of physical and psychological harm due to lack of oversight by facility administration. The findings included: 1. Record review of Resident #1 face sheet revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnoses: Unspecified fracture of left shaft/femur, Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). Review of Resident #1's Significant Change in Status MDS dated [DATE] revealed: Section C Cognitive Patterns BIMS Summary Score of 14 indicating no cognitive impairment; Section H Bladder and Bowel indicated indwelling catheter Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine. Initiated date of 10/15/2022 and revised date of 01/31/2023. Review of Resident #1 physician orders dated 10/13/2022 to 10/21/2022 revealed -Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems). -May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) -Provide catheter care every shift. -Change catheter and drainage bag as needed for indications of blockage, increased sediment, infection, displacement as needed. Record review of Resident #1's vital reports revealed no evidence of catheter care, drainage of catheter bag and amount of urine obtained during drainage on 48 occasions between 01/18/23 and 02/19/23. During observations between 02/18/2023 at 10:15 am to 02/18/2023 at 3:58, Resident #1 was observed to have an indwelling catheter bag that was full and overflowing with urine that was backflowing in the catheter tubing as well as urine leaking onto the floor on three (3) occasions. The catheter bag was dated 01/12. The urine was cloudy, with sediment (matter that settles to the bottom of a liquid) visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. Interview on 02/18/2023 at 10:16 AM, the DON stated Resident #1's catheter tubing and bag appeared to be a puss like substance and required to be changed immediately. The DON stated Resident #1's catheter bag should always been covered and that the bag being completely full to where it is overflowing places resident at risk for infection. She stated she did not know the rationale for the catheter bag to be overflowing with urine and backflowing in the catheter tubing. During an observation 02/19/2023 at 8:35 am, Resident #1's catheter bag had been emptied; however, the foley catheter tubing had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. During an interview on 02/19/2023 at 8:40 am, the DON stated she delegated the task for changing Resident #1's catheter but did not know rationale for the task to not have been completed. Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician. She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. During an interview on 02/19/2023 at 10:02 am, Corporate Clinical Company Leader RN-I stated Resident #1's catheter should have been changed due to the sediment alone. She said that she could see where there was an issue for concern. Interview on 02/19/2023 at 11:04 am, the DON stated she went back to Resident #1's rooms on 02/18/2023 in the afternoon and the task to change the catheter continues to not be completed. She then asked nursing staff again to complete the task. She stated this failure placed the residents at risk for an infection. Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. Observation on 02/19/2023 at 2:57 pm, Resident #1 was observed unresponsiveness with emesis (the action or process of vomiting) on chest by surveyors and Corporate Clinical Company Leader RN-I. Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said that she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. Review of Resident #56's quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS Score of 15 indicating no cognitive impairment. During an interview on 02/19/2023 at 3:10pm, RN-V stated she did not change Resident #1's catheter tubing but just changed the bag. She stated she obtained a urine sample from the catheter tubing that was observed to be crusted with sediment and puss like substance visible in the tubing. During an interview on 02/19/2023 at 3:15pm, Corporate Regional Resource Nurse-J-J stated that she instructed RN-V to change Resident #1's entire catheter and not just the bag. She stated she did not verify the task was completed. Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to community hospital via EMS. Interview on 02/19/2023 at 4:34pm, DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. The DON stated that she discovered that the Resident #1 left the facility (to the hospital) without a changed catheter tubing but only changed catheter bag. It was her expectation that it was changed yesterday. During an interview on 02/19/2023 at 4:34 pm, the DON stated that Resident #1's catheter appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She stated it was her expectation that catheter to be changed 02/18/2023. She stated Resident #1 left the facility to the community hospital without the catheter being changed. Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she pressed the call light frequently and it takes a while to answer. She said that the lady that came to answer the call light after two hours. She had long dark hair and was part of administration but did not work the floor. Resident #56 said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 said that the staff stated she couldn't help Resident #1 and left the room. Resident #56 said she thought the staff was coming back but never did. Resident #56 said that she could hear Resident #1 throwing up and gurgling. Resident #56 said no one changed their catheters. She said that yesterday (02/19/2023) the staff just changed the bag. Resident #56 said that the regional Hispanic nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 said it was the same nurse that told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff 02/19/2023 and behind. She said that when the regional nurse came, she told her to change the catheter bag only. She said that she is often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. During an interview on 02/21/2023 at 1:24 pm, Corporate Clinical Leader RN-SB stated that not changing a catheter could place a resident at risk for an infection. She stated that Resident #1's entire catheter system should have been changed and not just the bag. She stated the failure was due to the RN not using appropriate nursing judgement. During an interview on 02/21/2023 at 1:30 pm, Corporate Regional Resource Nurse-J stated she directed RN-V to change Resident #1's bag at the beginning of the shift and then later told RN-V to change the entire catheter. She stated that it appeared to be changed. She stated that the catheter should be changed any time there is puss or sediment in the tubing or bag. She stated that the catheter had not been changed prior to Resident #1 found unresponsiveness. She stated that the failure could result in infection, sepsis, and pain. During an interview on 02/21/2023 at 2:50 pm, Corporate Clinical Leader RN-VR stated that Resident #1's record had inaccurate documentation due to days of no documentation of Resident #1's catheter care including urine output. Record review of hospital record dated 02/19/2023 at 8:48pm History and Physical, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. Record review of Resident #1's community hospital records revealed dated 02/19/2023, Resident #1 was admitted into community hospital ICU with diagnosis of UTI & rule out stroke. Record reviewed on Resident #1's community hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) Record review of hospital records dated 02/21/2023 revealed that Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). Records review of hospital records dated 02/21/2023 Resident #1's Assessment and Plan revealed: 1.UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin for empiric (preventative and protective) treatment. 2.Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic) for empiric treatment 2. Review of Resident #1's admission MDS, dated [DATE], revealed Section C: Cognitive Patterns BIMS Score of 9 indicating moderate cognitive impairment; Section G: Functional Status limited/one-person assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions of no pressure ulcers. Review of Resident #1's Significant Change MDS dated [DATE], revealed Section C: Cognitive Patterns BIMS Score of 14 indicating cognitively intact; Section G: Functional Status: extensive/two + persons assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage III pressure ulcers, one Stage IV pressure ulcer, and two Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Site 1: Right buttock/ischium Review of Resident #1's Wound Management Detail Report dated 07/28/2022 at 4:08pm by LVN-AD revealed: Pressure Ulcer to Right Buttock, not present on admission. Unstageable measured 2.8cm in length by 2.8cm in width with unmeasurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:44pm by LVN-Q revealed: Stage IV measured 4cm in length by 6cm in width with 2.5 measurable depth. Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of right ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of right ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. As needed twice a day Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to right buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change. Site 2: Left buttock/ischium Review of Resident #1's Wound Management Detail Report dated 08/04/22 at 3:24pm by LVN-AD revealed: Pressure Ulcer to Left Buttock, not present on admission. Measured 4.5cm in length by 4cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:50pm by LVN-Q revealed: Stage III measured 1.7cm in length by 4.2cm in width with 0.5cm measurable depth. Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of left ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day Review of Resident #1's physicians orders dated 11/29/2022 for pressure wound of left ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. As Needed twice a day. Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change. Site 3: Left heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:17am by LVN-AE revealed: Unstageable - Deep Tissue Pressure Ulcer left heel not present on admission measured 5.5cm in length by 5cm in width with no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:54pm by LVN-Q revealed: Stage IV measured 3cm in length by 4cm in width with no measurable depth. Review of Resident #1's physician orders dated 02/10/2023 revealed: Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Once a day in the morning and as needed every shift Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left heel related to immobility. Goal: Resident's ulcer will not increase in size. Approach: Conduct a systematic skin inspection during daily treatment . Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels. Site 4: Right heel Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:15am by LVN-AE revealed: Pressure Ulcer Right Heel not present on admission measured 5cm in length by 7cm in width and no measurable depth. Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:52pm by LVN-Q revealed: Stage IV measured 2.7cm in length by 3.8cm in width and no measurable depth. Review of Resident #1's physician orders dated 02/10/2023 revealed: Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Once a day in the morning and as needed every shift Review of Resident #1's physician orders dated 10/08/22 revealed: Ascorbic acid (vitamin c) tablet; 500mg 1 tab oral once a day Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to right heel related to immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection Approach: .Conduct a systematic skin inspection during daily treatment Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels. Site 5: Sacrum 12/29/22 Cleanse sacrum with normal saline or wound cleanser apply thin layer of triad, yellow tube, to wound two times a day. Every Shift Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: pressure Ulcer Sacrum Stage III. Goal: Area will show improvement in the next 14 days. Approach: Turn every 2 hours and prn. 3. Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis, pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus, major depressive disorder, dependence on renal dialysis, dependence on supplemental oxygen, chronic atrial fibrillation, Methicillin resistant Staphylococcus aureus, and Type 2 diabetes mellitus. Review of Resident #79's admission MDS dated [DATE] revealed Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage III pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission. Review of Resident #79's Quarterly MDS dated [DATE] revealed Section M: Skin Conditions indicated two Stage IV pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission. Site 1: Sacrum Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2c in depth. Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis. Review of Resident #79's physicians orders dated 11/25/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved. Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative. Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative Review of Resident #79's physicians orders dated 11/29/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved. Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment . Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022. Site 2: Right Heel Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage III pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth. Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed. Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) measured 1cm in length by 1.1cm in width with no measurable depth. Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage IV Pressure Wound of the Right Heel. Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission. Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage IV Pressure Ulcer to right heal measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type. Review of Resident #79's physician orders dated 12/29/2022 revealed: Cleanse right heel with normal saline or wound cleanser apply anasept (antibiotic) to wound and secure with a bordered dressing daily. Review of Resident #79's physician orders dated 01/03/2023 revealed: Use cushioned boots while in bed as tolerated Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/03/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023 Review of Resident #79's Care Plan last revised 1/30/23 revealed: Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment . Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022. Review of Resident #79's physicians orders dated 11/29/2022 revealed: Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily. Pro-Stat AWC (high-calorie, complete protein liquid for Advance Wound Care) 17-100 gram-kcal/30ml give 30ml by mouth twice a day. Review of Resident #79's physician orders dated from 01/13/2023 to 02/24/2023 revealed: Ertapenem (strong antibiotic to treat serious infections) 1 gram IV daily for 42 days related to osteomyelitis In an interview on 02/19/2023 at 2:38 PM, Corporate Clinical Company Leader RN-I stated the facility owned Resident #1's pressure ulcers and that they were facility acquired. She stated that she could not find any documentation that they were not acquired in the facility. Corporate Clinical Company Leader RN-I stated that the failure of the facility to prevent Resident #1 from developing new pressure ulcers could result in an infection and that the failure was due to ongoing staffing issues. During an interview on 02/20/2023 at 2:30pm, Corporate Clinical Company Leader RN-I stated her expectations were for skin assessments to be completed weekly and the nursing staff were not consistence with documenting the treatments with the interim and acting DON monitoring. She stated these failures were due to communications between staff members. She stated that the lack of communication negative impacts the continuity of care. During an observation on 02/20/23 at 3:25 PM of Resident #79's wound care revealed RN-V completed wound care with the assistance of MDS-RN and LVN Q. RN-V failed to change gloves after removing sacrum dirty wound dressing and beginning to apply treatment and clean dressing to sacrum. RN-V had to be reminded by LVN-Q to date and initial new dressing to the sacrum. RN-V also failed to perform hand hygiene before applying new gloves to begin treatment to right heel. Following the treatment, RN-V was unable to be located for an interview. In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed that it went one month without treatment or observation leading to it progress to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had progressed to a stage 4. She stated If there was something different with a wound that a prudent nurse should have document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated it was her expectation that if someone did transcribe orders for Wound Care Doctor that it would be the nurse who did rounds with him or if the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. She stated that during the morning meeting, it was her expectation that the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. During an interview on 02/22/2023 at 9:57am, WC LVN-MB stated that she reported to Corporate Regional Resource Nurse-J, previous administrator, and previous DON the concerns of lack of wound care during the days WC LVN-MB was not scheduled. In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware that skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. 4. Record review of Resident #53's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She resided on Station 1 Hall 6 which was a Woman's secured unit (the average age of the women residents on Station 1 Hall 6 was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness