**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for two residents (Resident #111, #113 and #114) out of seven reviewed for abuse. The facility failed to protect Resident #113 and #114 from a physical altercation on 3/23/25. Resident #114 sustained redness and pain to the left eye and sent to the ER. The facility failed to address Resident # 114's continued threatening and aggressive behavior towards residents and staff. The facility failed to address Resident #113's inappropriate sexual behavior on 5/03/2024 towards an unknown female resident as documented in the medical records. An Immediate Jeopardy (IJ) was identified on 05/03/2025. The IJ template was provided to the facility on [DATE] at 1:58 PM. While the immediacy was removed on 05/08/2025 at 1:24 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. Failures outside IJ -The facility failed to ensure CNA A properly repositioned Resident #111 CNA A shuffling and adjusting his head on the pillow. these failures could place residents at risk of physical or psychosocial harm as a result of the abuse. Findings included: 1. Record review of Resident #113's face sheet dated 04/22/25 reflected a [AGE] year-old male first admitted to the facility on [DATE] and discharged on 03/28/25 to another facility. His diagnoses included dementia, persistent mood disorders, hypertension, chronic pain syndrome and muscle weakness. Record review of Resident #113's quarterly MDS dated [DATE] reflected he had a BIMS score of 6 out of 15 indicating severe impaired cognition. Section E revealed he had no behaviors or refusals of care. He used a wheelchair for mobility. He required supervision to moderate assistance with all ADLs. Record review of Resident #113's care plan with the closed date of 03/31/25 included: Focus - resident had moods that were not easily altered by staff intervention as evidenced by persistent mood disorder, symptoms and signs involving appearance and behavior. Date initiated as 05/06/24. Interventions included - document staff interventions, notify physician, psych referrals. Focus - Resident was taking psychotropic medications and at risk for adverse reactions and behaviors. Date initiated was 05/06/24. Interventions included - monitor for anxiety driven behaviors and report to physician. Monitor for psychosis driven behaviors such as aggressiveness, combativeness, and report to physician. Focus - he was resistant to care and at risk of injury as evidenced by refusal of baths at times. Date initiated was 09/06/24. Focus - He had episodes of inappropriate behaviors and at risk for future episodes and injuries as evidenced by not allowing housekeeping to clean room, refusing care (becoming aggressive at times). Date initiated was 11/27/24. Interventions included - give medications as ordered, monitor and chart behaviors every shift and report progress to physician. Provide psych consult per order. Focus - Resident reportedly hit his roommate in the eye. Date initiated was 03/23/25. Interventions included - refer to Medical Behavioral Hospital for inpatient geri psych placement. Immediately inform resident to stop and separate from others when resident becomes aggressive. Further review of Resident #113's care plan revealed sexually inappropriate behavior was not addressed. Record review of Resident #113's progress note on 5/3/24 at 2:26 PM written by LVN U read in part: Resident #113 was observed by the nurse inappropriately touching on a female resident while she was on her bed resting. The female resident had long pants and a top on. The resident was redirected back to his room .and stated, I will not do it again. The RP was notified .NP notified; orders received for psych consult. Record review of Resident #113's progress note on 5/04/24 at 3:20 AM written by LVN V indicated the resident was verbally and physically abusive to anyone in his path while trying to go into another residents room. The only intervention was to let his aggression run its course and keep other residents safe. Resident #113 proceeded to constantly hit/bang/kick the window and door of the secure door. The activity continued for 2 hours. Resident #113 was going room to room waking other residents by banging on doors and opening or closing doors. Interventions were attempted to redirect Resident #113 failed. At 3:20 AM Resident #113 finally went to bed and slept. Record review of Resident #113's Psychological Services progress note dated 5/12/24 at 10:24 AM indicated the focus of the session was emotional withdrawal, communication, and physical decline. Further review revealed sexually inappropriate behavior, or aggressive behavior was not addressed. Record review of Resident #113's Psychological Services progress note dated 8/21/24 at 11:32 AM written by the LCSW indicated the resident was agitated when another resident wandered into his room. Further review indicated the resident did not like shared space and liked his privacy. Record review of a progress note on 11/24/24 at 6:05 PM written by LVN T indicated Resident #113 was following and yelling at his roommate calling him names as well as yelling at staff. Resident #113 would be upset when staff entered his room. He was redirected, told to calm down then continued to yell. Record review of Resident #113's progress note on 11/26/24 at 9:42 AM written by the Social Services Assistant indicated a care plan meeting with the RP was scheduled for 11/26/24 at 11:00 AM. Further review revealed there were no details regarding the outcome of the meeting. Record review of Resident #113's Psychological Services progress note dated 11/27/24 at 6:43 AM written by LCSW indicated he was agitated, frustrated with staff and another resident. Record review of Resident #113's Psychiatric progress note dated 2/6/25 written by the Psychiatric NP indicated the resident was improving but remained isolated and unable to tolerate a new roommate. Record review of progress note on 3/18/25 at 5:02 PM written by the ADON indicated Resident #113 was yelling, screaming and vocally aggressive to the nursing staff as he refused a shower. The ADON de-escalated the situation, and the resident later continued to refuse. The RP was notified. Record review of Resident #113's progress note on 3/23/25 at 12:07 PM written by RN F indicated at 12:45 PM the resident was observed threatening, grasping roommate in his wheelchair, telling roommate to leave the room. Record review of a progress note on 3/23/25 at 12:58 PM written by RN F indicated Resident #113 refused shower care and was reported to be hitting the staff. The resident was reoriented. Record review of Resident #113's progress note on 3/23/25 at 5:22 PM written by the SW indicated the SW left messages for the RP to report resident's increasingly aggressive behaviors. Further review indicated Resident #113 hit his roommate in the eye and they were immediately separated. Resident #113 remained in the office with SW while reaching out to a behavioral hospital for evaluation. Record review of Resident #113's progress note on 3/23/25 at 6:32 PM written by RN F indicated Resident #113 was reported by a CNA to be physically aggressive towards the roommate, verbally threatening and pushing the other resident's wheelchair. Record review of Resident #113's progress note on 3/23/25 at 7:47 PM written by RN F indicated the resident was kept separated from the roommate while waiting for transportation to behavioral center. Record review Resident #113's progress note on 3/23/25 at 9:44 PM written by LVN L indicated the resident was transported to the hospital at 9:00 PM accompanied by the RP. Record review of Resident #113's progress note on 3/23/25 at 11:40 PM written by the SW indicated the resident returned from the hospital. He was alert and calm and placed in a room alone. The resident was referred to Mental Health. Record review of Resident #113's progress note on 3/28/25 at 8:33 AM written by LVN L indicated the resident was transferred to another nursing facility. Record review of Resident #113's order summary report dated 04/22/25 indicated an order for behavior monitoring which included agitation, hitting, increasing complaints, kicking, cussing, aggression and refusing care every shift for use of Depakote starting 06/04/24. An order for Depakote 125mg tablet every 8 hours for mood disorder was started on 05/03/24. The last order change was on 02/26/25 for Depakote 250mg TID. An order for Memantine 5mg tablet twice a day for dementia was started on 5/16/24. An order for Melatonin 5mg at bedtime for insomnia was started on 5/20/24. In a telephone interview on 4/22/25 at 1:45 PM, LVN U stated the incident on 5/3/2024 when Resident #113 was inappropriately touching a female resident was reported to the Administrator at the time. LVN U did not recall the name of the female resident nor the details of what happened when asked about the inappropriate touching. In an interview on 4/22/25 at 2:25 PM the interim Administrator stated if a resident inappropriately touched another resident, they would be placed on 1:1 monitoring until sent out for evaluation, and that they did not need to be at the facility. In an interview on 4/23/25 at 9:20 AM, the Psychiatric NP stated it was concerning that Resident #113 even left his room. Had she known of Resident #113's sexual interaction with another resident, she would have assessed him and adjusted meds, have a talk with him and involve social services. He knew what he was doing, he was agitated and aggressive. The Psychiatric NP stated, he would have gotten away with it if he wasn't caught. If there were further events, he would have been discharged . Psychiatric NP stated she was not at the facility on 5/3/24 and did not start covering the facility until October 2024. The risks of having no interventions for behaviors would be residents could walk up to other residents, repeating the aggressive behavior and no one seeing it, and there would be risk of sexual abuse as well. She stated in the secure unit, every resident was supposed to be monitored, and there should not be residents with low BIMS scores wandering around. In an interview on 4/23/25 at 12:25 PM The DON stated sexual behavior should have been in the care plan for Resident #113. The MD should have been notified and the resident should have been transferred out for evaluation. The DON stated she was not at employee of the facility at the time of sexually inappropriate incident on 5/3/24. In a telephone interview on 4/23/25 at 3:20 PM, the SW revealed she was unaware of Resident #113 inappropriately touching a female resident on 5/3/2024. SW stated had she been notified, she would have talked to both residents involved. In an interview on 5/1/25 at 12:58PM, the Social Service Assistant stated she was not aware of Resident #113's sexual inappropriate behavior on 5/3/24. The Social Service Assistant stated if she had been aware then she would have immediately separated the residents, refer to psychologist and psychiatric services, and he would have to be removed from the facility. 2. Record review of Resident #114's face sheet dated 05/06/24 reflected a [AGE] year-old male first admitted to the facility on [DATE] and discharged on 03/26/25 to acute care hospital. His diagnoses included depression, personal history of suicidal behavior, dementia, tension headaches, hypertension, and hemiplegia (one sided paralysis). Record review of Resident #114's quarterly MDS dated [DATE] indicated he had a BIMS score of 9 out of 15 indicating moderate impaired cognition. Section E indicated he had no behaviors or refusals of care. He had impairment to one side of the upper body. He used a wheelchair for mobility. He required substantial assistance with most ADLs. Record review of Resident #114's undated care plan included: Focus - Resident had moods not easily altered by staff as evidenced by - history of suicidal behavior. Interventions included - notify physician if mood interferes with physical functioning, psych referral as needed. Focus - resident at risk for increased confusion and decline in ADLs as dementia progresses. Date initiated was 08/05/24. Interventions included - administer medications as ordered. Reorient resident daily as needed. Further review revealed verbal and physical aggressive behavior was not addressed nor was the physical altercation with the roommate Resident #113 on 03/23/25 addressed. Record review of Resident #114's chart revealed a progress note on 8/04/24 at 2:52 PM written by the SW indicated the Resident #114 reported a verbal altercation with another male resident resulting in an exchange of curse words. A referral to Psychiatry (Medication Management) was made on 8/4/24 by SW for anger outburst. Record review of Resident #114's Psychological Services progress note dated 8/27/24 at 4:55 PM written by the LCSW indicated a diagnosis of adjustment disorder with anxiety. Further review revealed anger outburst was not addressed. Record review of Resident #114's progress note on 11/12/24 at 2:07 PM written by The Social Service Assistant indicated he had agitation and verbal aggression towards his roommate. Resident #114 was then moved to a different room. Record review of Resident #114's Psychological Services progress note dated 11/21/24 at 5:12 PM written by the LCSW revealed verbal aggressive behavior was not addressed. Record review of Resident #114's progress note on 3/13/25 at 5:51 PM written by RN F indicated the resident was physically aggressive towards roommate and staff, threatening to kill the roommate. The resident refused collection of urine for test. The NP, DON and ADON were notified. Record review of Resident #114's progress note on 3/13/25 at 6:35 PM written by the DON indicated the resident was throwing drink containers out the door and at passing residents, yelling, cursing, and threatening staff. The resident was transferred to the ER for evaluation and the RP was notified. The resident returned to facility on 3/14/25. Record review of Resident #114's facility Behavioral Health note on 3/14/25 written by the Psychiatric NP for Medication follow up for dementia indicated Resident #114's medications were not adjusted at the ER visit, and he was tolerating medications with no problems. Further review indicated the resident expressed frustration regarding recent medical experiences including visit to the hospital. Further review indicated Resident #114 had psychiatric history of: combative, physical aggression, and confusion. Record review of Resident #114's progress note on 3/23/25 at 6:02 PM written by RN F indicated the resident told the nurse he was hit in his eyes by the roommate. Further review indicated he had discoloration to the left eye and the NP, RP, Administrator, DON and SW was notified. Record review of Resident #114's progress note on 3/23/25 at 7:35 PM written by SW indicated that Resident #114 verbally reported that his roommate hit him in the eye. Record review of the facility PIR (Provider Investigation Report) dated on 03/31/25 and signed by the acting Administrator at the time, indicated the incident of abuse by resident-to-resident altercation occurred on 03/23/25 at 4:30 PM involving Resident #113 and #114. The PIR indicated the incident was reported to the State on 3/24/25 at 5:00 PM. The report indicated Resident #114 alleged that the roommate, Resident #113 hit him in the eye and that it was not witnessed by any staff member. Resident #114 had redness to the left eye lid, denied pain and Resident #113 was unable to be interviewed to recall the incident. Each resident was sent out to the ER for evaluation. There were no delayed injuries for Resident #114 and Resident #113 was returned from psych hospital. The PIR indicated the incident occurred in the secure unit and that Resident #114 did not have capacity to make informed decisions and had the history of verbal and physical aggression as well as wandering. The PIR indicated that Resident #113 had a history of verbal and physical aggression as well as wandering. The PIR indicated the investigation findings were unconfirmed and the facility planned to find alternate placement for Resident #113 due to increasing behaviors. Further review indicated an emailed progress note dated 03/24/25 at 10:39 PM indicating Resident #114 was evaluated by the facility's LMSW and LCSW Therapists on 3/24/25. The progress note indicated Resident #114 reported that the roommate would sometimes become confused and agitated. Further review of the progress note indicated Resident #114 was calm and in no distress during the session. The PIR included the facility incident report dated 3/23/25 at 12:58 PM written by RN F. The incident report indicated RN F was notified by the CNA of Resident #113's physical aggression towards his roommate and that RN F observed Resident #113 verbally threatening and pushing the other resident's wheelchair in the hallway. The immediate actions taken residents were separated, kept away from each other by RN F and the attending staff in the unit. The DON and SW were notified. Further review of the PIR revealed no indication as to whether or not the Ombudsman and Law Enforcement were notified. The PIR did not include any statements by staff members. Record review of Resident #114's Order Summary Report dated 04/22/25 indicated an order for Venlafaxine extended release 37.5mg capsule daily for depression was started on 11/27/24. The most recent dose change was Venlafaxine extended release 75mg on 03/01/25. An order for Memantine 5mg tablet daily for dementia was started on 08/13/24. An order to monitor for side effects of antidepressant medication use every shift started on 11/27/24. Resident #113 had bronchitis and was treated with an antibiotic Azithromycin 500mg tablet every 8 hours beginning on 03/14/25 and ending on 3/19/25. In an interview on 4/20/25 at 9:30 AM, MA D said she recalled the incident between Resident #113 and #114. MA D stated Resident #113 originally was in the room by himself, and Resident #114 had a roommate that was discharged . MA D stated both residents resided in the same room on the secure unit. MA D stated the main cause of the incident was that Resident #113 would not allow Resident #114 to get into the room. MA D stated she knew they were not a good match because they would have arguments. MA D stated room changes do not work well with residents in the secure unit. Interview on 4/20/25 at 10:00 AM, CNA T stated that on 3/23/25 the altercation between Residents #113 and #114 took place in the secure unit hallway just outside the dining room. Resident #113 said to Resident #114 why are you going into my room!. Resident #113 grabbed Resident #114, there was a scuffle between the two men. CNA T stated they were swinging at each other, and she was in the middle trying to separate them. She stated she could not see if Resident #113 struck Resident #114 in the eye but that Resident #114's eye was red, and it was not red prior to that. CNA T stated Resident #114 had a pair of fingernail clippers in his hand. He was not supposed to have it; she did not know how he got hold of one. CNA T stated Resident #114 was afraid of Resident #113 because he would call him names; CNA T stated she reported to the nurse on duty. CNA T stated Resident #113 had taken swings at her in the past due to refusal of care. CNA T stated she would document and report to nursing but did not provide dates or names of staff. CNA T A stated Resident #113 and #114 should not have been put together as roommates due to their aggressive behavior towards one another which included arguing with one another. CNA T stated Resident #113 would get upset thinking the roommate was taking his stuff. CNA T stated she did not get a chance to write a witness statement regarding the altercation on 3/23/25. In an interview on 4/21/25 at 11:20 AM, the Social Service Assistant stated since Resident #114 did not want to get out of bed, he was a good roommate for Resident #113 and facility census increased so the two had to become roommates. The Social Service Assistant stated Resident #113 would be aggressive to other roommates in the past but never physical prior to the incident with Resident #114. Resident #113 had 2-3 roommates prior, and it always ended up not working because he would block roommates from getting into the room. The Social Service Assistant stated it was all documented in his chart and had multiple care plans with the family; he just did not want a roommate. In an interview on 04/22/25 at 10:06 AM, RN F stated MA D notified her about the incident between Resident #113 and #114. RN F stated she immediately notified the SW, ADON, DON she then walked into the secure unit and in the hallway, she saw both residents. RN F stated Resident #113 was upset, he pushed Resident #114's wheelchair and Resident #113 said to Resident #114, you cannot do that! RN F stated Resident #113 would often talk loudly when upset. RN F stated she heard about Resident #113 going into Resident #114's things but she did not witness that. RN F stated before they were roommates, they were friends talking and visiting with each other. RN F stated this was why they thought they would be compatible. Interview on 4/22/25 at 11:50 AM, MA D stated she heard the commotion in the hallway and saw CNA T separating the Residents #113 and #114. She heard Resident #113 say Trash, trash! and usually when he says these things she knows he was very agitated. She did see Resident #114 with fingernail clippers and heard Resident #114 say he was going to use it as he waved it in his hand. A nurse took the clippers away but she did not have the name of the nurse. She did provide a statement to Administrator for the incident. MA D stated there were other incidents where Resident #113 would block the door with his bed and not allow his roommates to enter, saying it was his room. Resident #113 would curse out the staff as well. Incidents like that were reported to administration. MA D could not recall dates or who it was reported to. In an interview on 4/22/25 at 2:25 PM with the interim Administrator and the DON, the interim Administrator stated that combative residents should not be put together and that they would agitate and possibly beat each other up. The interim Administrator stated nail clippers would not be allowed as they could cut themselves, or someone could wander into room, pick it up and use it as a weapon. The interim Administrator stated families may not always comply and if aware then the rooms would be searched. The DON stated she was not notified of the nail clippers. The DON stated she was aware Resident #114 was threatening to kill his previous roommate (before Resident #113 was roommate) and he was then transferred to hospital for observations and returned to the facility. The interim Administrator stated she would not have accepted him back if she were the Administrator at the time. The interim Administrator stated she was unable to locate the completed facility investigation for the resident-to-resident altercation on 3/23/25. In a telephone interview on 4/23/25 at 7:25 AM, the previous Administrator stated an internal investigation was completed for the resident-to-resident altercation incident on 3/23/25 and that she did conduct staff interviews. She stated the incident was unwitnessed and did not report to law enforcement because it was a verbal altercation, and the residents had dementia and were confused. She stated later that day, it was reported that Resident #114 had been struck by Resident #113 in the eye and that was when she sent Resident #114 out to hospital for evaluation. In an interview on 4/23/25 at 9:20 AM, the Psychiatric NP stated Resident #113 did not want to have roommates and would block the door. The Psychiatric NP stated she also followed Resident #114 and was not notified of Resident #114 threatening to kill the roommate. She learned about it much later. Resident #114 had an increase in antidepressant medication Venlafaxine on 2/27/25, and probably was not appropriate to be in the same room as Resident #113 due to behaviors. The risk would be that one day they would get on each other's nerves, and someone could get hurt especially if they were physical. In a telephone interview on 4/23/25 at 9:21 AM, The Psychiatric NP stated that she was the Psychiatric NP for both Resident #113 and #114. The Psychiatric NP stated Resident #114 was not aggressive, didn't bother anybody, and stayed in bed depressed. Resident #114 was more with it and that he did not have anything in common with anyone in the secure unit. She stated, at one time in January 2025, Resident #113 had a roommate and had witnessed he was annoyed with the roommate who was in bed and nonverbal. Resident #113 would accuse that roommate of taking his belongings. This behavior was discussed with her by the SW and DON. Prior to that, Resident #113 was fine with the curtain between his bed and the roommate's bed. Resident #113 would remain on his side. By February 2025, Resident #113 was in a room by himself. Resident #113 and Resident #114 seemed like they got along well and would be fine as roommates. In an interview on 4/23/25 at 12:25 PM the DON stated after altercation on 3/23/25, Residents #113 and #114 were placed in separate rooms and no increase in staff were made, when asked how the other residents were protected. The DON stated there were no further incidents. In a telephone interview on 4/23/25 at 3:20 PM the SW stated she was notified of the resident-to-resident altercation between Resident #113 and #114 on 3/23/25. The SW stated they were immediately separated and then she worked on trying to find a different place for Resident #113. The SW stated Resident #113 did not do well with roommates. In an interview on 4/24/25 at 9:05 AM, the DON stated Resident #114 would be verbal with staff and refuse care and that Resident #113 would stay in his room, and she did not know much about him but knew he refused care. The DON stated behaviors, whether verbal or physical, should be in care plan and MDS, so everybody knows about the behaviors. DON stated they should not have been roommates. The DON stated Resident #113 and Resident #114 had never been roommates in the past and that the decision to put them together was made by a previous Administrator. DON stated she was not notified of verbal or physical behaviors from either resident prior to the incident on 3/23/25. She stated Resident #113 was placed on 1:1 until transport to hospital and upon return was back to a room by himself. The DON stated Resident #113 had no behaviors while in hospital but should have been placed on 1:1 monitoring until he was transferred out for good. In an interview on 5/1/25 at 12:58PM the Social Service Assistant stated Resident #113 did not like it when staff would come into the room to clean up the roommate and would then be pretty aggressive towards staff. The Social Service Assistant stated after any incidents Resident #113 would have, the Social Service Assistant would call family every day for family to try and calm down Resident #113. It would work for a few days and then aggression would repeat. The Social Service Assistant stated other interventions were psych services, adjustment to meds and emergency visits. It was discussed with the family about transferring him out, but he needed a secure unit. There was never a concern about other residents' safety around Resident #113 as he didn't come out of his room. The Social Service Assistant stated having a roommate would be a risk because Resident #113 could cause chaos, agitation, and this would be more harmful to other residents. The Social Service Assistant stated, in reality the facility could not meet his needs, he needed his own room because anyone put into his room would be a disaster. This was shared with previous management but there was a time the facility was bed locked except for his room and the Administrator or Owner placed Resident #113 with another resident. The Social Service Assistant stated Resident #113 had three different roommates on different occasions. The Social Service Assistant stated the concerns about Resident #113 having a roommate to the Administrator/Owner and was told it was not a private room. The Social Service Assistant stated it was unsafe to have another resident room with him because the roommate would not get the needed care when Resident #113 would deny staff from entering. The Social Service Assistant stated after the first roommate, Resident #113 was by himself for about 6 months before he had roommates. Resident #114 was his last roommate. All staff were responsible for non-allowable items and cannot search a resident room without cause and consent. Record review of the facility policy for Abuse and Neglect, effective date of October 2022 read in part: .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations Types of abuse: 1. Physical, 2. Verbal . Record review of the facility policy for Behavioral Assessment, Intervention and Monitoring, dated in 2001, read in part: .Policy Statement .5. Residents will have minimal complications associated with the management of altered or impaired behavior .Management 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm 11. The director of nursing, or designee, will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care. Additional staff and/or staff training will be provided if it is determined that the needs of the residents cannot be met with the current level of staff or staff training . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/03/25. The Administrator was informed and was provided the IJ template on 05/03/25 at 1:58 PM. Plan of Removal (POR) was requested. The following Plan of Removal was submitted by the facility and was accepted on 5/06/25 at 7:19 PM: F600 Introduction: On 5/3/2025 at 01:58PM, the surveyor issued an Immediate Jeopardy F600 (IJ) template notification stating Regulatory Services had determined that the facility failed to protect the resident's right for Resident #113 and Resident #114 to be free from abuse. The facility failed to protect Resident #114 from a physical altercation on 3/23/25 where Resident #114 was sent to the ER for a red eye. The facility failed to address sexual behaviors in the care plan for Resident #113. All current residents could be at risk because of the failure to provide supervision. At the Time of the IJ it was noted that: 1. Both residents #113 and #114 were discharged prior to the change in ownership of the facility. Access to resident records that were closed prior to the change are not accessible by the current provider. 2. Resident #113 has been discharged safely from the facility on 3/26/2025. 3. Resident #114 has been discharged safely from the facility on 3/28/2025 . 4. Neither resident has returned to the facility. As a result of the IJ

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (Resident #18 and Resident #33 ) of 7 residents reviewed for enteral nutrition. - The facility failed to provide treatment and services, which included an abdominal binder, to prevent complications of enteral feeding due to Resident #18's behaviors of pulling on and pulling out her G-tube which resulted in: the resident pulling out her G-tube on 2 occasions (11/12/24 and 04/15/25) which required hospitalization to place a new tube; and on 1 occasion (03/27/25) the resident pulling on her G-tube and an IV pole falling on her head on. - The facility failed to provide treatment and services, which included an abdominal binder, to prevent complications of enteral feeding due to Resident #33's behaviors of pulling out his G-tube which resulted in the resident pulling out his G-tube on 3 occasions (02/04/25, 02/12/25, 02/23/25 and 04/15/25) which required hospitalization to place a new tube. An IJ was Identified on 04/17/25. The template was provided to the facility on [DATE] at 12:33 PM. While the IJ was removed on 04/22/25 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of injuries, hospitalization, and death. Findings Include: Resident #18 Record review of Resident #18's Face Sheet dated 04/15/25 revealed, a [AGE] year-old female who admitted to the facility 01/14/21 with diagnoses which included: dysphagia (difficulty swallowing), high blood pressure, contracture of the right hand/ left hand and left foot, Dementia with other behavioral disturbance and anxiety disorder. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, upper and lower extremity functional limitations in range of motion, dependent on staff for all aspects of self-care (eating, oral hygiene, toileting hygiene, shower/bathing, dressing), dependent on staff for all aspects of mobility, no physical/verbal behavioral symptoms directed towards others and no behavioral symptoms not directed towards others. Record review of Resident #18's Care Plan printed 04/15/25 revealed, focus- requires the use of feeding tube and is at risk of aspiration (accidental inhalation of food/fluids into the airway), weight loss and dehydration. Feeding tube is related to dysphagia; intervention- administer tube feeding and water flushes as ordered, monitor/document/report to the physician as needed for the following complications related to tube feedings . tube dislodged. Focus initiated 12/29/22- inappropriate behaviors: resident has episodes of inappropriate behaviors of an causing her oxygen tubing from constantly falling off her face onto the floor. Interventions- monitor and chart behaviors every shift and report progress to MD. Focus- history of spitting and crying out at times according to staff and chary review; intervention- referred to mental health services as needed. Focus initiated 02/07/21- resident has impaired communication,[family]reports he is the only one that can get resident to verbally communicate; intervention-[family]will assist with translation when needed, staff will monitor for facial grimaces and body language. , focus- signs and symptoms of anxiety like hypersensitivity, paranoid, nervousness and is at risk for further episodes of anxiety and injury; intervention- medication as ordered, redirect resident from source of anxiety. Resident #18's care plan did not include the resident pulling on or pulling out her G-tube. Record review of Resident #18's Order Summary dated 04/15/25 revealed, she did not have an order for an abdominal binder, or orders for monitoring of increased movement, restlessness, or agitation. Record review of Resident #18's Progress Notes from to 04/15/25 revealed: *11/12/24 at 11:56 PM- CNA informed nurse during care that resident had pulled her G Tube from her abdomen. Nurse went to assess resident and she was found with tube laying on her abdomen without any s/s of pain or distress. DON and Attending notified *11/13/24 at 01:03 AM- EMS arrived to transport resident to hospital *03/27/25 at 05:32 PM- Resident #18 pulled her feeding tube and IV pole fell on her head. The resident had no bumps and bruises, and the NP was notified *03/28/25 at 09:40 AM- From incident yesterday evening pole fell on resident head right eye and forehead bruises was noted this morning, resident is already on neuro checks. NP was notified A.DON as well resident medication was administered. *04/15/25 at 05:47 PM- Patient pulled her G-tube out. Nurse sent patient to hospital for replacement . Record review of Resident #18's EMR revealed, no orders for monitoring of behaviors associated with Resident #18 pulling on and pulling out her G-tube. An observation and interview on 04/15/25 at 09:50 AM revealed, Resident #18 in bed with contracted feet and hands. The resident had a bruise with a scab and dry blood on her forehead, with her bed low to the ground and fall mat on the left side of the bed. The resident had a firm grip on her G-tube tubing, pulling it tightly and her abdomen was observed to rise as she tugged on the tubing. The surveyor immediately exited the room to notify facility staff. When the surveyor returned to the room with MA A the resident was no longer pulling on her tube but continued to pull her legs up and move her hands. MA A said the resident returned to the facility that morning from the hospital. The resident had large tan bandage strips loosely placed on top of the site where her G-tube entered her abdomen, there was no abdominal binder or other assistive device preventing Resident #18 from pulling out her G-tube. An observation and interview with LVN J on 04/15/25 at 11:15 AM revealed, Resident #18 squirming/fidgety/restless in bed, with her legs pulled up. There was tube feeding residue, not previously seen, on the resident's sheets and incontinent brief. LVN J said Resident #18 readmitted to the facility in the morning she pulled out her G-tube. She said the resident did not have an order for an abdominal binder, and a binder was not used to protect Resident #30 from dislodging her G-tube. LVN J said, she can have an abdominal binder. In an interview on 04/15/25 at 11:23 AM, the NP said she started following Resident #18, 6 weeks ago. She said the residents restless, fidgety, and squirming behavior is what she considered her baseline. The NP said she originally thought the resident's behaviors were due to a UTI so Resident #18 was treated with a course of antibiotics, but the behaviors remained when the medication was completed so she now believed she needed psych services. The NP said residents with excessive restlessness and continuous activity were at risk of pulling out their G-tube, so they should have an abdominal binder covering the tube which would prevent them from easily pulling out the tube. The NP said the resident did not have an order for an abdominal binder because she had not received any reports that the resident consistently pulled on her G-tube. She said the failure to have an abdominal binder on a G-tube resident with excessive movement and restlessness placed the resident at risk for the G-tube dislodgement, danger if the IV pole holding the feed falls leading to injuries. In an interview on 04/15/25 at 12:27 PM, MA B said Resident #18 always moved around and was restless. She said the resident had never had an abdominal binder, but she probably could use it. In an interview on 04/15/25 at 12:30 PM, MA A said he had worked at the facility for 8 years and Resident #18's normal behaviors included: agitation and trying to pull out her G-tube. He said the resident did not have an abdominal binder, so he put a sheet on top her G-tube to prevent her from pulling on it. In an interview on 04/15/25 at 12:35 PM, the DON said Resident #18 was non-verbal. She said the resident had always been grabby and fidgety and received psych services. In an interview on 04/15/25 at 12:38 PM, LVN J said Resident #18 just returned from the facility after she pulled out her G-tube and the IV pole fell and hit her head. She said she received an order for an abdominal binder from the NP and was waiting for central supply to deliver the binder. An observation on 04/16/25 at 07:47 AM revealed, Resident #18 in bed, with no abdominal binder in place. The resident was restless and taking off her clothing. In an interview on 04/16/25 at 07:48 AM, MA A said there was an order for an abdominal binder for Resident #18, but she did not have one on because it had not arrived at the facility. In an interview on 4/16/25 at 07:50 AM, LVN J said Resident #18 did not have an abdominal binder on. She put in an order for an abdominal binder for Resident #18 yesterday, but it had not arrived. In an interview on 04/16/25 at 11:27 AM, LVN H said Resident #18 was one of her residents. She said even though the resident is bedbound she did not stay in one place, moved her arms and legs around a lot and is very fidgety. LVN H said she worked with Resident #2 for the past two years and off-course she pulls out her G-tube but the staff could not restrict her. She said she had previously notified nursing management of the resident pulling on and out her g-tube, but no changes were made. She said on 04/15/25 at around 4 AM when she checked on the resident, she saw that Resident #18's G-tube was dislodged and the IV pole was on the floor. In an interview on 04/16/25 at 02:18 PM, RN A said Resident #18 was always fidgety and liked to play and pull on her G-tube. She said Resident #18 did not have an abdominal binder on the night 04/15/25, and she was never educated or informed about any interventions that should be in place to protect Resident #18. RN A said due to resident's movement and preference to pull on her G-tube she had communicated her concerns with nursing management and thought the resident needed an abdominal binder, but nothing was done. In an interview on 04/16/25 at 08:27 AM, the DON said she started her position in February 2025 and Resident #18 always had behaviors that included pulling on her G-tube. She said in March 2025 the resident pulled on her tubing which caused the IV pole holding her feeding to fall and hit her in the head leading to an injury. After the incident, the resident had neuro checks in place to confirm she did not have a change in condition and the IV pole was moved to the other side of the bed. The DON said Resident #18's behaviors were discussed in an IDT meeting, and it was decided a GDR was contraindicated and the only intervention in place after the incident in March was the NP ordering labs. In an interview on 4/16/25 at 03:48 PM, the DON said an abdominal binder was ordered from their vendor, but it had not arrived yet, so the staff were monitoring Resident #18's behaviors. She said Resident #18's abdominal binder was expected to arrive on 04/17/25 . Resident #33 Record review of Resident #33's Face Sheet dated 04/17/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: chronic respiratory failure, asthma. Bipolar disorder, severe with psychotic features, paraplegia(paralysis of legs and lower injury), Gastrostomy and Tracheostomy (opening in neck to access the windpipe). Record review of Resident #33's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The resident had no behavioral symptoms present including physical or verbal behavioral symptoms towards others and no other behavioral symptoms towards others (hitting or scratching self, pacing, rummaging or disruptive sounds) Record review of Resident #33's undated Care Plan printed 04/17/25 revealed, Focus- risk of aspiration r/t feeding tube in place; intervention- report N/V, absent bowel sounds to MD and RP. Focus- history of depression and is at risk of episodes of depression, adverse reactions and depression driven behaviors; intervention- monitor for impeding episodes of depression- document any noted in clinical record, prove psych consult per order. Record review of Resident #33's Order Summary dated 04/17/25 revealed, she did not have an order for an abdominal binder prior to 04/15/25. Record review of Resident #33's Progress Notes from 01/16/25 to 04/17/25 revealed, Resident #33 pulled out or pulled on his G-tube on the following days: 02/04/25- Residents G-tube was dislodged 02/12/25- Residents G-tube was dislodged and he was sent out to the Hospital 02/23/25- Resident pulled out his G-tube and was sent out to the hospital ER for G-tube placement. 02/25/25- Resident was found pulling on G-tube around 9 am. Resident was cleaned up and abdominal binder was applied. 04/15/25- Residents G-tube became dislodged and he was sent out to the hospital ER of G-tube placement. In an interview on 04/16/25 at 09:18 AM, the MDS Nurse said she had been in her current position for 8 to 9 years but worked in the facility for 19 years. In an interview on 04/17/25 at 11:31 AM, the DON said Resident #18's abdominal binder had not arrived at the facility yet. In an interview on 04/16/25 at 11:40 AM, the MDS Nurse said she was responsible for completing resident care plans. She said the care plan functioned as a plan of how to care for a resident. The MDS nurse said everything needed to care for a resident should be included, day to day tasks/care, wound status, behaviors, diagnosis, code status, and weight management. She said if a resident had behaviors, those behaviors should be included in their care plan with specific details that include the type of behaviors and should include goals and interventions. The MDS Nurse said incorrect care plans posed no risks to residents because nobody looks at the care plan except state. She said staff do not look at resident care plans to determine how to care for residents but received care information from reports, documentation, and verbal communications. The MDS nurse said she did not know about Resident #18's continuous behaviors of pulling at and on her G-tube and she only knew that the resident had once pulled on her IV pole causing it to fall and injury her. She said based on the behaviors she now knows Resident #18 displayed, the resident's care plan should have had a focus area addressing them. In an interview on 04/17/25 at 12:50 PM, the DON said she took the role at the facility in February. She said the purpose of the care plan is to provide guidance for patient care and resident needs. The DON said she was responsible for the accuracy and completion of the care plan, but the MDS nurse is the person who actually completes the care plan. She said each resident's care plan should address their: diet, code status, diagnoses, treatments received and behaviors. The DON said the care plan triggers everything the nurses do for the residents and lets them know what interventions they need to implement. She said inaccuracies in the care plan can result in missed treatments or interventions and in Resident #18's case it led to the resident pulling out her G-tube, injury, and hospitalization to replace her G-tube. The DON said she was not aware of Resident #18's behaviors of pulling on and out her G-tube, she was not aware those behaviors were not in the resident's care plan, but it should have been. Record review of the facility policy Assistive Devices and Equipment with no revision date revealed, our facility provides, maintains, train s and supervises the use of assistive devices and equipment for residents. 1- devices and equipment that assist with resident mobility, safety and independence are provided for residents. 2- recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's record. An IJ was Identified on 04/17/2025. The template was provided to the facility on [DATE] at 12:33 PM. The following Plan of Removal submitted by the facility was accepted on 04/18/2025 at 07:52 PM and the Administrator was notified on 04/18/25 at 08:01 PM. {Facility Name] 4/18/2025 Plan of Removal F689 On 4/17/2025 at 12:33 PM, the surveyor provided an Immediate Jeopardy (IJ) template notification stating Regulatory Services had determined the facility failed to provide adequate supervision and assistance devices to prevent accidents. The facility failed to provide supervision and/or devices to prevent Resident #18 from pulling her G-tube which resulted in: an injury after the IV pole fell and hit her in the head and her G-tube being dislodged on 2 occasions. 1. Immediate Action: o The Director of Nursing immediately reassessed Resident #18 to validate the resident's G-tube was in place, patent, and medication/nutrition was being administered per provider orders. An abdominal binder ordered on 4/15/2025 after displacement was received 4/17/2025 and applied per provider orders. No other concerns were identified. Resident #18 tolerated the application of device well and exhibits no distress . o The MDS Coordinator updated and revised Resident #18 care plan to include provider orders for G-tube, any current/historical behaviors including agitation, fidgeting, and attempts to remove or dislodge the G-tube. Care plan revisions include interventions to prevent/reduce displacement of G-tube and requirement of documenting provider notification of any changes in behavior specifically related risk of G-tube displacement. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Immediate Action: o The Director of Nursing/Designee immediately conducted a review of all facility residents and determined 13 residents were currently receiving nutritional feeding through a G-Tube/Peg Tube. All 13 residents were immediately assessed to validate tubes were secure and patent. Further assessment included a 7 day look back record review to determine that there are no new changes in behavior, increased agitation, or fidgeting related to potential risk of G-Tube/Peg Tube displacement. o The Director of Nursing determined that 4 of the 13 residents receiving nutritional supplements via G-Tubes/Peg Tubes, including Resident #18, would potentially benefit from the use of an abdominal binder. The abdominal binders were previously ordered from the supply vendor and received, provider orders were obtained, and all abdominal binders have been applied to applicable residents and applicable residents are tolerating well with reduced risk of displacement. o It was identified in the expanded sample that 1 of the 13 residents [Resident #33] receiving nutrition via G-tube/Peg Tube had also displaced feeding tube on 2/4/25, 2/12/25, 2/23/25, and 4/15/25. After interview with staff, it was determined that residents is restless, and fidgets and these behaviors have been noted in a progress note dated 4/18/25. The MDS was opened with an ARD (Assessment Review Date) of 4/21/25 to capture these behaviors. The care plan has been revised. The resident is currently receiving physical therapy for range of motion and bed mobility. An occupational therapy eval has been requested. o The MDS Coordinator completed updates/revisions for the 13 resident care plans that included noting any current or historical behaviors (7 day look back) related to potential displacement of G-Tube/Peg tube and validated that if behaviors were identified, interventions included actions to take to reduce risk of displacement and documentation of provider notification. New orders for abdominal binders and monitoring for 4 of the 13 residents have been added to care plan interventions to assist in reducing the potential displacement of G-Tubes/Peg Tubes as applicable. Start Date: 4/17/2025 Completion Date: 4/18/2025 Responsible: Administrator Immediate Actions: o The QAPI Committee reviewed the policies and procedures regarding enteral feeding, safety precautions to validate accuracy. Added to the policy were recommendations to assist nursing staff when residents exhibit behaviors of attempts to remove tube i.e.: pulling, fidgeting, restlessness. o The Director of Nursing/Designee provided training to nursing staff who provide care to residents who receive nutritional feeding via a tube. Staff will not be allowed to provide direct resident care until training has been provided. o Training included validating G-Tube/Peg Tube is secure, patent, and provider orders for med/nutrition are administered per orders. o If resident is exhibiting restlessness, agitation, or changes in behaviors related to obstruction/removal of a G-tube will be documented in the resident record which pulls to the 24 hour report and the Provider/Director of Nursing are to be promptly notified and increased supervision is implemented to maintain tube replacement and patency until root cause of increased restlessness, agitation, changes in behavior are determined. o Completed a return determination with nursing staff on proper placement of G-tube and securing abdominal binder to validate competency. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Immediate Actions: o The Director of Nursing/Designee will monitor residents with G-Tubes/Peg Tubes including those that require supportive devices such as abdominal binders that reduce the risk of tube displacement q shift and as needed to validate correct placement and patency of tubes for residents who currently have provider orders. If concerns are identified, immediate corrective action will be implemented, provider notified, and applicable staff re-educated. o The Director of Nursing/Designee will monitor changes in behavior including increased agitation and restlessness daily to promptly determine a root cause and ensure appropriate interventions have been implemented timely on the care plan to reduce potential negative outcomes, including displacement of G-Tube/Peg Tube. o An ad-hoc QAPI meeting was held, and the facility medical director was notified of the deficient practice and plan of removal. The Plan of Correction will be reviewed monthly during the QAPI meeting for the next 3 months and as needed until a lesser frequency is deemed appropriate. Meeting minutes will be taken and maintained for 12 months. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Monitoring of the POR. An observation on 04/19/25 at 12:25 PM revealed, Resident #18 in bed with an abdominal binder on. An observation on 04/19/25 at 12:29 PM revealed, Resident #33 with an abdominal binder on. In an interview on 04/19/25 at 01:01 PM, MA B said she received training on G-tube safety on 04/16/25. She said the training addressed how to address active/agitated residents with G-tube, ensuring interventions like abdominal binders are in place, ensuring the resident is safe and administering medications as ordered if necessary. MA B said the training reinforced that G-tube residents with increased agitation could be at risk of dislodgement and the IV pole falling on them. In an interview on 04/20/25 at 06:45 AM, LVN H said she was trained on 04/17/25 about G-tube safety. She said Resident #18 moved around a lot and had a tendency to pull on and out her G-tube, . In an interview on 04/20/25 at 08:55 AM, MA A said he had not received any training on G-tubes, Care Plans or Accidents/Supervision. An observation on 04/20/25 at 08:57 AM revealed, Resident #22 in bed with an abdominal binder in place. An observation on 04/20/25 at 09:05 AM, revealed Resident #18 in bed with an abdominal binder in place. The resident was calm, in no immediate distress and did not have concerning body movement. In an interview on 04/20/25 at 09:00 AM, CNA K said she received training on G-tube safety in the previous week. She said if a resident with a G-tube was agitated they were expected to report it to the nurse and ensure an abdominal binder was on if there was an order. In an interview on 04/20/25 at 09:05 AM, LVN J could not answer what in-services she received and had to be prompted by the surveyor. She said she received training on G-tubes and care plans on 04/17/25 and 04/20/25. LVN J said when a resident on a G-tube has behaviors nurses are expected to document the incident in the chart and report it to management, while CNAs document behaviors in the POC and report it to their nurse. She said when residents with G-tubes become agitated they are at risk of dislodgment so nursing staff should initiate interventions like an abdominal binder if there is an order for one and notifications should be sent out. In an interview on 04/20/25 at 09:07 AM, the ADON said she completed training with staff on 04/17/25 regarding G-tube Placement, Behaviors and Abdominal binders. She said staff were educated that residents who are agitated, fidgety, constantly moving/irritated should be documents on having behaviors in the POC or the progress notes. The ADON said staff were trained that these residents are at risk of dislodgement and can also pull-down equipment. She said the training addressed reporting and documenting behaviors that increase risk of G-tube dislodgement, sending notifications and interventions that should be in place. The ADON said she also did training on resident care plans and how documentations played into the development of care plans, where to find a resident's care plan and how to review the interventions in place. She said this training was provided to CNAs, CMAs, Nurses, RTs, and anyone who provided care to residents., In an interview on 04/20/25 at 10:21 AM, LVN B said he had not received any training about G-tube safety and his knowledge was based on basic nursing. In an interview on 04/20/25 at 01:10 PM, the MDS Nurse said she received a 1-on-1 training from the Interim Administrator regarding care plan timing & accidents, incidents on 04/17/25 and training regarding G-tubes on 04/18/25. She said the training reinforced that she should know about resident behaviors such as pulling on and pulling out their G-tube and make sure there is the appropriate documentation. The MDS Nurse said behaviors should be tracked, orders should be in place for a binder, the binder must actually be used/in place on the resident and such orders must be in the resident's plan of care. The MDS nurse said even though the MDS is only a 7 day look back the behaviors should be documented in the resident's plan of care. The MDS nurse said she was educated that all behaviors should be documented in the care plan even if it were the resident's baseline behaviors because agitated residents are at risk of pulling out their G-tube which could result in rupture, injury, trauma, infection, and hospitalization. In an interview on 04/22/25 at 04:56 AM, RN A said she received training on G-tube safety the previous week and on 04/21/25. She said the training focused on preventing G-tube dislodgement with the use of a binder. RN A said when a resident with a g-tube is agitated or has increased movement nursing staff are expected assess the resident and if needed apply an abdominal binder or get an order for an abdominal binder. She said resident behaviors are to be documented in the resident's chart and interventions such as repositioning, medications administered as ordered, and notification sent to the MD/NP because increased behaviors/movement can place residents at risk of dislodgement, bleeding, bloating and infection. RN A said documenting any incidents that occur is important because it plays into the resident's care plan. In an interview on 04/22/25 at 05:01 PM, RN E said he received training on G-tube safety on 04/21/25. He said if a resident with a G-tube had behaviors such as fidgeting and pulling on the tube they should not be ignored, they should be assessed and interventions such as abdominal binders or PRN meds should be in place. RN E said if a resident even if these behaviors are continuous staff should document it whenever they see it because it plays into the care plan. In an interview on 04/22/25 at 05:05 AM, CNA X said he did not receive any training on G-tubes, care plans or behaviors in residents with behaviors but if a resident was observed pulling on their G-tube staff should ensure interventions like abdominal binders are in place, notification should be sent to their nurse and document the behaviors in the POC to prevent dislodgement. In an interview on 04/22/25 at 05:09, RT A said he had not received in-person training on G-tube safety but had received a text message on some trainings and asked if he could pull it up. RT A was not able to verbalize independently what the training he received was but read from his text that residents with increased agitation were at risk of dislodgement or injury so the nurse should be notified and the behaviors document. An observation on 04/22/25 at 05:20 AM revealed, Resident #18 in bed, with no abdominal binder on. In an interview on 04/22/25 at 05:25 AM, CNA A said she received training regarding G-tube safety on 04/20/25. She said when a resident with a G-tube was agitated or fidgety she is expected to observe them and document it in the POC. CNA A said Resident #18 did not have an abdominal binder on because it was only required when the resident was agitated which she was not at this time. In an interview on 04/22/25 at 05:29 AM, LVN B said he received training on G-tube safety on 04/21/25. He said residents with G-tubes that experienced behaviors were at risk for dislodgement, so they must notify the MD to receive an order for an abdominal binder or use one if order was in place. LVN B said Resident #18 did not have an abdominal binder in place because she only required one when she was agitated. In an interview on 04/22/25 at 08:50 AM, LVN D said she received training on G-tube safety on 04/21/25. She said residents with G-tubes that are fidgety are considered as having behaviors and that should be documented. In an interview on 04/22/25 at 09:18 AM, MA C said she had not received any training on G-tube safety. In an interview on 04/22/25 at 01:55 PM, MA C said she received training that day regarding residents with G-tubes displaying behaviors, communication & notifications of behaviors and the application of abdominal binders as ordered. She said if a resident with a G-tube was agitated they were at risk of G-tube dislodgement so interventions should be in place as ordered, nurse notified, and observations document ed in the residents POC. MA C said residents with behaviors like Resident #18 should have binders in place at all times except when care is provided. An observation on 04/22/25 at 02:00 PM, revealed Resident #22 sleeping in bed with her family member at her bedside. The family member said the resident currently had an abdominal binder on and had extra ones in her nightstand. In an interview on 04/22/25 at 02:18 PM, with the Interim Administrator and the DON, the Administrator said the facility performed an audit and identified 5 residents with a history of behaviors associated with pulling out their G tube. She said those resident's care plans have been updated, every shift monitoring has put in place and signs to have abdominal binders in place are located above the resident's beds. The Administrator said the facility failed to have a structure in place to track residents with behaviors. The DON said prior to the IJ notification the facility did not have interventions in place for G-tube residents with behaviors but now training was provided to CNAs, Nurses, RT about these behaviors, documenting behaviors, the use of abdominal binders and signage placed above the bed of residents that require abdominal binders. The DON said since the IJ notification the MDS nurse and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 3 of 8 residents (Resident # 30, Resident #42 Resident #52) reviewed for treatment and services for mental and psychosocial concerns. - The facility failed to provide appropriate treatment and services to prevent and correct Resident #30's escalating behaviors which resulted in a suicide attempt on 04/13/25 and the resident attempting to draw a police officer's firearm when she had to be forcefully restrained and removed from the facility. - The facility failed to provide appropriate treatment and services to prevent and correct Resident #52's escalating behaviors which resulted in suicide threats and an incident on 05/03/25 when the resident had to be forcefully restrained and removed from the facility. - The facility failed to provide treatment and services to correct Resident #42's continuous behaviors of pacing up and down the secure unit, banging on the doors, getting in residents and staff faces, touching their shoulder while asking if his RP was dead. An IJ was identified on 05/03/25. The template was provided to the facility on [DATE] at 01:58 PM. While the IJ was removed on 05/08/25 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. The IJ was called again on 06/07/25. The template was provided to the facility on [DATE] at 07:03 AM. While the IJ was removed on 06/19/25 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of minor and major injuries, suicide threats, attempted suicide, hospitalization, and death. Resident #30 Record review of Resident #30's Face Sheet dated 05/02/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: spinal cord injury, anemia, nicotine dependence, Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar disorder (mental health condition characterized by extreme mood swings, ranging from periods of intense happiness or irritability (mania or hypomania) to periods of deep sadness or despair) with sever psychotic features (hallucinations (seeing or hearing things that aren't real), delusions (false beliefs), and disorganized thinking) and paraplegia( paralysis of the legs and lower body, typically caused by a spinal cord injury). Record review of Resident #30's previous facility Progress Notes dated 12/26/24 at 02:21 PM revealed, Resident says she is hearing things and people talking about her. She is under mental distress. She is wanting to go to the psych hospital. Resident stated she no longer wanted to be here. Record review of the Resident #30's Quarterly MDS revealed, intact cognition as indicated by a BIMS score of 14 and use of antipsychotic medications during last 7 days. There were no evidence of an acute change in mental status, and no behaviors present. She had no potential indicators of psychosis such as hallucinations or delusions. Record review of Resident #30's undated Care Plan revealed, focus- history of being resistant to care at times and is at risk for injury; intervention- approach in a calm manner, talk while giving care. Focus- taking psychotropic medications and is at risk of adverse reactions and (depression, anxiety, and/or psychosis driven behaviors; interventions- monitor for psychosis driven behaviors such as aggressiveness, combativeness, manic episodes, observe and record any displayed behaviors or mood problems. Focus- Resident #30 verbalized suicidal ideations and became physically aggressive with police related to her diagnosis of bipolar and or anxiety, date initiated 04/13/25; interventions- provide medications as ordered, resident will be assisted with discharge planning as when needed, resident will be referred to inpatient geri psych placement as when needed, call 911 with request for the mental health team as/when needed. Record review of Resident #30's Progress Notes from 12/31/24 to 05/02/25 revealed : 01/01/25- EMS arrived at facility stating they received phone call from facility. This nurse was notified by CMA that this resident called EMS. Resident states that she is not feeling well and wants to go to the Hospital. Resident did not notify this nurse that she was not feeling well prior. Resident called EMS instead. EMS assessed resident. No abnormal findings. EMS spoke with resident about receiving care in facility before calling 911. Resident continues to state that she wants to go to the hospital. 01/02/25- Resident called 911 for pain pill when her pain was just due to be given to her, every effort to advise her to take her pain pill yield no result as she wants to go to hospital, NP made aware, administrator made aware, resident insisted on going to hospital, picked up in stable condition. 01/12/25- Note Text : On rounds at 7:04am resident did not complain of any discomfort, distress, or concerns, noted vaping in the room, was educated by this nurse that vaping is not proper and not allowed in the room, resident did not listen, but continue vaping. At about 7:54am, 911 ambulance arrived facility stated resident called them, complained of pain to lower back, sediment in urine, and brown urine output. Resident has UA result and labs pending ,this explained to resident Norco 5-325mg offered, resident refused, and still insisted going with 911 to the hospital, transferred by 911 to hospital ,per resident request. Resident is self-RP.NP notified. 01/22/25- SW informed nurse that resident was seen by Psych services today and was told that resident may be going through a manic episode. Resident is currently in bed with NAD. Given PRN pain medication. resident has no plan to harm herself stayed she is just little down today. MD informed stated to monitor for now and call her for any changes. 01/24/25- Resident informed SN that she called 911 due to pain on her lower back. Education provided on pain management such as other ways to manage pain without medications such as deep breathing, exercise , music therapy and others , resident verbalized understanding but still want to get stronger medication . NP notified . patient has been medicated with Norco Tablet 5-325 MG every 4 hours as needed, last one was at 1034am. Sn will continue to monitor. 01/31/25- Resident signed herself out after requesting (2) cigarettes. Resident was then transported to the ER by ambulance. Family notified. DON Notified. 02/01/25 at 08:01 AM- Resident requested cigarette, received her cigarette, signed out to go smoke out front where she then called 911 and requested transport. Resident would not specify where she wanted to be transported to. 911 arrived around 0710 and took resident on a stretcher to the ER. 02/01/25 at 03:15 PM- Resident returned from the hospital . Resident still appears anxious upon return and immediately returned to nurses' station to sign out with (4) cigarettes as of 0325 resident is signed out of the facility. 02/13/25 at 10:49 PM- Resident called 911 by herself twice this evening at 7:30pm and 9:40pm stating that she wants to go to the hospital because she is having spasms. Charge nurse informed her that he can notify her doctor and see if she can be given some new orders, but she refused. EMS arrived the first time and resident refused to go to the hospital they intended to transport her to. The second time the EMS arrived and took resident to Hospital at 10:00pm. 02/24/25- Note Text: At 21:30 hrs (09:30 PM), resident called the EMS via 911, requesting to be taken to the emergency room due to spasm and pain. Resident had already received her scheduled pain medication (Norco) at 20:00 hrs. Resident had not complained to Charge Nurse about being in pain prior to her calling 911, and charge nurse was not aware that she had called EMS 911 until the emergency personnel showed up in the unit. Resident was taken to the emergency room as she requested by the EMS technicians at 21:40 hrs. 03/02/25- Resident complains of hearing voices making fun of her, she said had been going on for a while now, she stated that she did not complain initially because she thought they might go away, but they getting louder, depriving her sleep. This morning observed resident in her sleep saying, stop stop stop. Resident also have diagnosis of schizophrenia and mild sleep disorder.NP notified, order received to consult psych. Order carry out. 03/08-25- Resident called EMS via 911, and they took her to the hospital at 18:45 hours for complaint of pain. Resident's emergency contact (family member)' and facility DON notified. 03/19/25- Resident came to Charge nurse and requested for her nightly medication to be administered to her, which was done. After taking her medications, she informed the Charge Nurse that she had called 911 so she can be taken to the hospital due to pain. Charge Nurse advised resident to give her pain pill (Norco) which she just took, time to become effective but she refused, insisting to go to the hospital. Charge nurse noted ant acute distress on resident both in her speech and behavior. Resident then wheeled herself in her wheelchair to the reception area awaiting the arrival of EMS ambulance. Upon arrival to the facility, the EMS personnel spoke briefly with resident and loaded her on their stretcher without asking the charge nurse any questions or informing him where they were taking resident to. When charge nurse inquired from them where they were taking resident to, they simply told him the hospital name and continued on. Facility Director of Nursing was notified. 03/22/25 T 05:53 AM- Behavioral Note-Resident removed her brief after ADL change claimed is too big despite the brief been her size and the large size that could be used for her. 03/22/25 at 10:09 AM- : Resident was observed alert and oriented with behavior, screamed , yelled, took clothes off. Attempted to talked to resident several times with no effect. NP. was notified order given Alprazolam 0.5mh twice a day for fourteen days for anxiety. 04/13/25 at 01:39 AM signed by LVN H- Patient called 911 at 11:00pm and had been disturbing other patients from sleeping. The two EMS that came refused to take her to hospital stated she has no good reason to go to hospital. Patient received all her pain med and other prescribed med, throwing stuff on the floor including her phone. Patient is threatening to kill herself. Nurse notified the physician, DON, and Administrator. 04/13/25 signed by SW- SW informed per staff that this resident had verbalized wanting to kill herself. SW visited with this resident, and she verbalized I tied something around my neck but, I could still breathe. I want my Xanax back. I want my Xanax back. I am going to get my Xanax back. SW attempted to contact resident's [family member], , unable to reach and voicemail full. Resident began to yell and scream as she exited the office. Staff was present to maintain visual of her per SW request while 911 contacted with a request for the Mental Health Response team. Upon 911 arriving officer was provided with the aforementioned information. He spoke with resident, and she informed him that she wanted to kill herself. He called for assistance and another officer arrived whom also spoke with resident and then SW observed resident began to hit the officers resulting in them restraining her until approximately 4 more officers arrived. SW was informed per that she was being transported to Hospital and that the District Attorney would be contacted but they were doubtful any criminal charges would be filed against her. SW informed the DON and LNFA and was able to contact her [family member] and informed him. He verbalized understanding. Care Plan updated to reflect. Record review of Resident #30's Hospital Progress note dated 04/22/25 at 01:22 PM revealed, Resident #30 continued to throw tantrums and screamed, covering her face with her pillow. The resident was requesting IV pain medication. Record review of Resident #30's Hospital Progress note dated 04/23/25 at 12:01 PM revealed, Resident #30 continued to throw tantrums and requested IV pain medication despite being notified that she was on oral pain medication. Record review of Resident #30's Hospital Progress note dated 04/24/25 at 11:52 AM revealed, Resident #30 called 911 from her hospital room and pretend to sleep when the MD entered her room. Record review of Resident #30's Hospital Psychiatric Consultation note dated 04/24/25 at 12:00 AM, revealed Resident #30 had bipolar disorder with discrete periods of mania and discreet periods of depression. She had poor impulse control and a history of PTSD and had attempted fake suicide in the past on multiple occasions by either choking herself or overdosing on medications. Resident #30 had a history of ideas of persecution, thinking that people were going to hurt her or that something negative was going to happen to her. Resident #30 had a history of auditory hallucinations commanding her to wrap a cord around her neck or to overdose on Seroquel. In the past Resident #30 contemplated starting a fire in her apartment following the command of the voices she heard, and she wished she had a weapon to hurt hospital or nursing staff. Resident #30 was admitted to a behavioral hospital in February of 2021 and in November of 2023 she was admitted to the hospital after typing a collar on her neck to kill herself. Record review of Resident #30's Progress Notes on 05/01/25 at 02:48 AM revealed, Note Text : Resident called EMS and requested to be taken back to the hospital for evaluation. Resident indicated to EMS personnel that she feels nauseated, dehydrated, and is not getting enough pain medications. Resident had not complained to Charge Nurse about any of these concerns tonight. Resident had received her nightly medications as ordered, including her PRN Norco pain medication. Charge Nurse offered to call resident's PCP to see if there may be any new orders, but she refused, stating her preference to go to the hospital. Upon resident's insistence to go to the hospital, EMS personnel took her to hospital. Record review of Resident #30's Order Summary Report that included all orders since admission on [DATE] and printed 05/02/25 at 01:50 PM revealed, Resident #30 had no behavior monitoring and behavior intervention orders. Record review of a 30-day lookback of Resident #30's Behavior Monitoring and Interventions dated 05/09/25 revealed, no documented behaviors observed prior to 05/09/25. On 05/09/25 at 10:30 AM Resident #30 was screaming and expressed frustration and angers at others. An observation an interview on 05/02/25 at 01:12 PM revealed, Resident #30 sitting in a wheelchair at the nursing station. There were other residents around her and no nursing staff within 15 feet on both sides of the nursing station. The resident said she just returned to the facility from the hospital, and she felt better now. Resident #30 said the voices got too loud so she hit herself in the face and tied a pillowcase around her neck to harm herself to stop the voices, but she could still breathe. As Resident #30 talked to the surveyors she swayed left to right & back and forth in her wheelchair. Resident #30 said she did not notify any staff of the voices prior to trying to harm herself but when she went to the hospital, they fixed her meds, so she did not hear the voices anymore and she did not want to harm herself. In an interview on 05/02/25 at 12:33 PM, the SW said Resident #30 was young and had obsessive drug seeking behaviors r/t to complaints of significant pain. She said the resident would call the police 1-2 times a week and had been hospitalized at least 6-7 times since admission. The SW said Resident #30 always yelled at staff and yelled to go to the hospital. The SW said in April she was notified that Resident #30 wanted to hurt herself. She said she first talked to the resident on the phone and then again when she arrived at the facility. The SW said Resident # 30 told her she tried to hurt herself by tying something around her neck, but she could still breathe, the resident became loud and said she was going to hurt herself, so she called 911 for a mental health response team. She said when the police arrived Resident #30 wheeled herself away from them down the hallway as they spoke to her and when both police officers approached her, Resident #30 started to scream and fought the police. The SW said Resident #30 attacked the police, the police tried to restrain her, the police drew then their guns and pointed them at the resident and Resident #30 was eventually handcuffed. She said Resident #30 was a risk to other patients because of her unpredict ableness. In an interview on 05/02/25 at 01:05 PM, MA C said Resident #30's normal behaviors included verbal aggression/yelling towards staff and other residents. She said the resident propels herself around the facility in her wheelchair cursing and yelling. She said the resident was not on any increased behavioral monitoring, not on 1-on-1 monitoring and was not safe to be in a room with others. In an interview on 05/02/25 at 01:21 PM, LVN J said Resident #30's regular behaviors included yelling and screaming at others. She said Resident #30's former roommate, Resident #22, was scared of her because of her yelling and screaming In an interview on 05/02/25 at 01:27 PM, Resident #22 said she was scared by her former roommates yelling and screaming, She said Resident #30 yelled and screamed at night, startling her. In an interview on 05/02/25, Anonymous A said Resident #30's regular behaviors included yelling/screaming and calling Anonymous A out of her name. Anonymous A staff said Resident #30's behaviors were towards anyone including residents and staff. Anonymous A said in one incident Resident #30 was screaming and she came down the hallway in her wheelchair with no clothes on. Anonymous A said last April, the social worker called the authorities because of Resident #30's behaviors and when they arrived, Anonymous A saw the resident attempt to pull the police officer's firearm. Anonymous A said Resident #30 liked to yell, scream and throw stuff at people and it makes Anonymous A antsy. In an interview on 05/02/25 at 01:36 PM, the MDS Nurse said she did not know Resident #30 had a history of attempted suicide or aggressive behaviors. She said the resident was always nice, but she liked to go to the ER on a weekly basis since arriving in the facility. The MDS nurse had she known of the resident's behaviors she would have included it in her care plan. In an interview on 05/02/25 at 02:04 PM, the Psychiatric NP said Resident #30 had a lot of anxiety and would call 911 often. She said the resident seemed hyper-manic and had racing thoughts. The Psychiatric NP said no one notified her that the resident was aggressive, she was unaware that the resident yelled at others, but she could believe Resident #30 rolled down the hall naked because the resident was always inappropriately dressed in her room. The Psychiatric Nurse said the resident had never shown any signs of suicidal ideation, or that she heard voices, but Resident #30 expressed anxiety and depression. She said she was unaware of Resident #30's previous history of suicide attempts, and she would have to review the hospital notes because based on what was discussed the resident's behaviors were more severe. The Psychiatric NP said Resident #30 should have a lot more monitoring by the staff and she did not know why the resident never communicated any of these issues with her. She said she had not read Resident #30's readmission clinicals from 04/30/25 but she assumes the resident is safe since she was discharged . The Psychiatric NP said based on Resident #30's behaviors she was not a safe person, and she expected the resident to have frequent assessments, close monitoring, increased therapy visits and should be encouraged to verbalize her feelings. She said Resident #30 needed additional monitoring to make sure nothing occurs. In an interview on 05/02/25 at 02:22 PM, the DON said prior to readmission she or her designee are supposed to receive and review the resident's hospital clinicals, but she did not, she said she thought the admitting nurse did. The DON said to her knowledge Resident #30 was not having behaviors in the hospital and since her return there had been no medication changes. She said since the resident returned to the facility there have been no interventions in place beyond the standard shift monitoring and based on her documented history of behaviors Resident #30 was not safe to be in a room with Resident #18 who was unable to communicate. In an interview on 05/02/25 at 02:27 PM, the Administrator said she did not know about Resident #30's aggressive behaviors or significant history of suicide, all she knew was that the resident would go to the hospital often. She said now that she knew the contents of the hospital psych consult notes and the resident's history of attempted suicide, the resident should be placed on 1on1 monitoring for at least 72 hours, because she was a resident safety risk having her unsupervised and ambulating in her wheelchair around the facility. In an interview on 05/02/25 at 02:37 PM, CNA T said in April she saw the police go towards the SWs office and then Resident #30 came down the hallway in her wheelchair. She said at first the police were talking to Resident #30, when she started yelling and screaming so the police tried to restrain the resident at which point Resident #30 attempted to pull the police officers firearm. CNA T said prior to the incident in April, Resident #30's regular behaviors included rolling around the facility in her wheelchair yelling/screaming/cursing at other residents and staff. In an interview on 05/02/25 at 02:46 PM, LVN T said she was the nurse scheduled when Resident #30 arrived at the facility, but she was on break, so the resident was already in the room when she returned. She said upon readmission Resident #30 had been roaming the facility unattended asking for cigarettes and pain medications. LVN T said in April she observed Resident #30 come out of SWs office screaming fuck you and the SW called 911 mental health. She said when the police talked to Resident #30, she said she was not suicidal but had attempted suicide the night before. LVN T said Resident #30 rolled away from the police, started fighting the police and when they attempted to restrain the resident grabbed their handcuffs and she heard the police say, let go of the gun. She said the SW thought they were going to shoot Resident #30, so she told her to get out of the way for safety. LVN T said more police arrived and then the ambulance took the resident away. LVN T said Resident #30's behaviors included hollering/yelling at people, calling people out of their name, calling Black people the n word, and she did all of this sometimes while going down the hall but the incident in April was the first time it had escalated to this point. LVN T said Resident #30, propelled herself freely in the facility down the halls, always yelling at others. She said when the resident returned on 04/30/25 , she did not receive the discharge clinicals that listed Resident #30's extensive suicide history, and the resident was not ordered or placed on 1on1 observation or suicide watch. In an interview on 05/02/25 at 02:57 PM, the ADON said Resident #30 can be extremely aggressive. She said the resident goes in and out of the hospital and calls 911 when she wants her pain medications, and the provider is aware of her behaviors. The ADON said she heard the resident was aggressive especially during night shift. She said everyone was aware of Resident #30's behaviors including social services, and it was documented in the resident's chart. The ADON said while she does not think Resident #30 is a threat to herself or others, she possibly made other residents feel scared. The ADON said when a resident has made threats of or attempted suicide interventions like 1on1 monitoring should be in place when they readmitted to the facility, but she did not know if Resident #30 had any others for this. The ADON said the IDT/Managers/Administration had not discussed interventions needed to ensure Resident #30's safety but management should absolutely have had that conversation. In an interview on 05//02/25 at 03;41 PM, the DON said she did not know Resident #30 had a history of attempted fake suicide, suicide attempts by tying a cord around her neck, auditory hallucinations telling her to harm herself by tying something around her neck or overdose on medications, wished to have a weapon to harm hospital and nursing staff or attempted suicide in November 2023. The DON said did not read the hospital discharge record sent to the facility prior to the resident readmitting that had the psychiatric consult notes describing all of Resident #30's previous behavioral issues and she honestly does not know why she did not. The DON said now that she knows Resident #30 had this history of behaviors the resident should have been somewhere more appropriate and based on the new information the facility had not provided Resident #30 adequate care. She said prior to today (05/02/25) Resident #30's behaviors placed the safety of herself and other residents in jeopardy. In an interview on 05/03/25 at 01:37 PM, the DON said since the surveyor alerted the facility of Resident #30's extensive history of fake suicide attempts, actual suicide attempts, auditory hallucinations, desire to harm others the resident was placed on 1on1 observation. She said the resident has had a sitter at all times, had not had any new behaviors and was doing well today. An observation and interview on 05/03/25 at 01:38 PM revealed, Resident #30 sitting in her wheelchair, writing in a notebook with headphones on. Resident #30 said she now had a sitter with her and has had no behaviors. She said she no longer heard voices since they put her on her proper meds in the hospital, but the doctor will take her off the medication in 10 days, and that is what keeps her calm. She said her Xanax helps her anxiety and bipolar and she was not drug seeking. Resident #30 said she was collating a list of songs for her online music store. In an interview on 05/03/25 at 01:42 PM, the DON said since Resident #30 had behaviors, received antidepressants and antipsychotic medications she should have had behavior monitoring orders. The DON said behavior monitoring orders are important for residents with behaviors in order to monitor for side effects or changes, and failure to have behavior monitoring orders would result in missed behaviors or change of condition. The DON looked through the resident's chart and said nope Resident #30 had no orders from her admission up until her suicide attempt on 04/13/25, and there were no orders entered when she returned to the facility on [DATE]. The DON said the lack of behavior monitoring played a part in the missed behavior monitoring and the missed residents change of condition. Resident #52 Record review of Resident #52's Face Sheet dated 04/24/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: schizophrenia ( mental disorder characterized by a breakdown in thought process, making it difficult to distinguish between reality and fantasy), and anxiety disorder. Record review of Resident # 52's Significant change in status MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15. Active diagnosis of anxiety disorder and schizophrenia, no presence of any behavioral symptoms such as physical (hitting, kicking, pushing), verbal (threatening, screaming, or cursing at others) and no other behavioral symptoms not directed toward others. Antipsychotics were received on a daily basis; no gradual dose reduction was attempted and there was no physician documentation indicating a GDR was clinically contraindicated. Record review of Resident #52's undated Care Plan revealed, focus- signs and symptoms of anxiety like hypersensitivity, paranoid, nervousness and is at risk for further episodes of anxiety and injury; intervention- medication as ordered. Focus initiated 01/07/25- psychotropic medications and is at risk for adverse reactions and behaviors; interventions- monitor for adverse reactions and hypnotic driven behaviors such as tiredness and weakness, monitor for psychosis driven behaviors such as aggressiveness, combativeness, and manic episodes. There was no focus areas addressing suicidal behavior or suicide threats. Record review of Resident #52's Progress Notes from 01/06/25 to 05/06/25 revealed: 01/19/25 at 04:53 PM signed by RN G- Resident has been very rude to RT she does not like her to enter room to give care to her roommate. She yells/curse and shout. Education given to resident that her room needs assistance and staff will provide assistance without bothering her, but resident stated now. Resident also continue to ask staff for cups thorough the shift. Education given to resident that she is currently NPO and cannot consume anything by mouth at this time for her safety. Education did not work. She continue to ask anyone walking pass her room. 02/01/25 at 09:46 PM signed by RN G- Resident is currently crying and screaming she would like to go the hospital due to pain in her left legs. Resident was given all of her scheduled medication and Tylenol PRN. She also received her pain cream diclofenac cream applied to her ankle. Resident also propels herself around the facility not crying screaming she became very aggressive with staff. Screaming cursing and grabbing of laptop and other staff equipment she is not able to be redirected. 02/08/25 at 05:42 PM signed by RN G- Resident throw a cup a writer on this shift then later came and apologize. she also snatched the phone causing the cords to come undone and later apologize for that she stated she was in a bad mood due to her mother and boyfriend not answering the phone. She was educated not to throw things at staff or at all. She stated okay. 02/08/25 a6 06:56 PM signed by RN G- Resident still present with behaviors she snatched all of the cords and laptop and phone off the nurse station. She Started hitting another nurse on duty throwing stuff and cruising. Resident shouting, she will kill herself. 911 called at this time social worker present. 02/08/25 at 07:19 PM signed by the SW- This resident became physically aggressive with nursing staff by hitting, kicking, grabbing, and attempting to bite them. She then began to yell and scream I'm going to kill myself. I am going to kill myself. Attempts to verbally redirect unsuccessful. SW contacted her r/p, and she informed SW that she was having one of her episodes and in the past, she was sent to a Behavioral Hospital. SW contacted Behavioral hospital intake Dept via and was informed that they have no available beds till Monday. Recommended that she be sent to ER for assessment due to her aggression. 02/08/25 at 07:25 PM signed by the SW- Note Text : Resident was able to talk with her r/p and also to one of her male friends. They were able to get her to calm down and she again began to apologize for her behavior. She denied [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided, met professional standard of quality for 1of 1 resident (Resident #6) reviewed for professional standards. - The facility failed to follow Resident #6's care plan by not applying a hand roll to his contracted left hand. This failure could place residents at risk of worsening of contractures, pain and deterioration of health. Findings included: Record review of Resident #6's face sheet dated 03/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] His initial admission was 11/21/2022 and his original admission was 02/26/2018. His diagnoses included acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), dependence on supplemental oxygen, Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body), stroke, chronic obstructive pulmonary disease (a lung condition caused by damage to the airway), anemia (reduced number of red blood cells), depression, functional quadriplegia (inability to completely move), congestive heart failure (is a condition where the heart is unable to pump enough blood to meet the body's needs), hypertension (elevated blood pressure) and anxiety. Resident #6 was his own RP. Record review of Resident # 6's Quarterly MDS (minimum data set, resident assessment, and care screening) dated 02/11/2025 revealed a BIMS score of 14 indicating he was cognitively intact. He had lower extremity impairment on both sides of the body that interfered with daily function. He was coded for no impairment to the upper extremity. He required total dependence on staff for lower body dressing and substantial maximum assist for upper body dressing and personal hygiene. He was always incontinent of urine and bowel. Record review of Resident #6's undated care plan revealed the skin injury to the finger on the left hand was not addressed. The resident's care plan only addressed bilateral feet contractures, his hand contractures or nail care were not documented. Focus: ADL self-care performance deficit related to impaired balance/coordination; intervention: personal hygiene- extensive assistance with 1-2 staff. Focus: deficit in the ability of sitting balance and postural stability r/t weakness and disease process, revised on 11/25/2020. The goal - Resident #6 will maintain current level of function, sitting balance and postural stability through the review period. Target date was 04/08/2025. Interventions included, staff will apply range of motion (ROM) during tasks and roll to the left hand daily, revised on 08/12/2022. An observation and interview on 03/10/25 at 04:30 PM [NAME] in bed on his back. His left arm was bent at the elbow and his fingernails were severely contracted. There was nothing between his hand and his fingers. Resident #6 said the left hand does not work d/t a stroke. He stated he used to have a hand roll to keep his contraction from getting worse, but he lost that a long time ago. He said he was not bothered by it too much. In an Interview on 3/11/2025 at 10:30 AM, the DOR stated Resident #6 was receiving passive ROM to the left arm/hand by OT. She stated the POC included passive ROM. She stated she could not locate information on when the hand roll was first ordered. She did not say why he didn't have a hand roll. She stated the last overview was regarding his feet and that he was due for an evaluation on 3/11/2025. In an interview on 3/11/25 at 10:55 AM, Resident #6 said he had a splint with his name on it long ago and it disappeared he has been here x 8 years and when he goes to hospital things go missing. Interview on 3/11/2025 at 11:15 AM, LVN B stated the purpose of the care plan was to know Resident #6's needs and if there was a new interaction that needed to be put into place. She stated she was unsure as to who would be responsible and why Resident #6 did not have a hand roll to his contracted hand. She stated the hand roll would be for exercise. She stated the risk would be lack of movement and then he would need therapy to prevent further stiffness. Interview on 3/11/2025 at 11:25 AM, the CNO stated the purpose of a care plan was to identify areas of actual and potential problems and set forth interventions that may facilitate in resolution of those problems. She stated the care plan is repetitive and requires re -evaluating if interventions are ineffective or resolved. She said tasks are usually disciplined specific. The assigned discipline for the task will be reflected in the resident's ADLs or Kardex (a documentation system that allows nurses to organize key resident information for their care plan). She stated staff have been educated on no skin on skin on contact. She stated a hand roll would aide in comfort and prevent skin breakdown. She stated the risks to the resident would be of macerated skin and impaired skin integrity. Record review of the facility's undated policy Care Plans, Comprehensive Person-Centered read in part: Policy Statement - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Record review of the facility's undated policy on Using the Care Plan read in part: Policy Statement - The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 1 resident (Resident #6) reviewed for quality of care. - The facility failed to provide follow up care to Resident #6's left hand middle finger after an injury involving staff resulted in bleeding and pain. This failure could place residents at risk of pain and infection. Findings included: Record review of Resident #6's face sheet dated 03/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] His initial admission was 11/21/2022 and his original admission was 02/26/2018. His diagnoses included acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), dependence on supplemental oxygen, Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body), stroke, chronic obstructive pulmonary disease (a lung condition caused by damage to the airway), anemia (reduced number of red blood cells), depression, functional quadriplegia (inability to completely move), congestive heart failure (is a condition where the heart is unable to pump enough blood to meet the body's needs), hypertension (elevated blood pressure) and anxiety. Resident #6 was his own RP. Record review of Resident # 6's Quarterly MDS (minimum data set, resident assessment, and care screening) dated 02/11/2025 revealed a BIMS score of 14 indicating he was cognitively intact. He had lower extremity impairment on both sides of the body that interfered with daily function. He was coded for no impairment to the upper extremity. He required total dependence on staff for lower body dressing and substantial maximum assist for upper body dressing and personal hygiene. He was always incontinent of urine and bowel. Record review of Resident #6's undated care plan revealed the skin injury to the finger on the left hand was not addressed. The resident's care plan only addressed bilateral feet contractures, his hand contractures or nail care were not documented. Focus: ADL self care performance deficit related to impaired balance/coordination; intervention: personal hygiene- extensive assistance with 1-2 staff. An observation and interview on 03/10/25 at 01:42 PM revealed, Resident #6 with unkempt hands/fingers. On his right hand he had dirty, long fingernails and his left hand was contracted with long dirty fingernails. His middle finger on the left hand was wrapped with a dressing that was held in place with scotch tape. The dressing was undated, and a circular red spot was seen through the dressing. Resident #6 said sometime in the previous week, he said his finger was injured when it got caught on his shirt as two CNAs quickly took off his long sleeve shirt due to an ant being on him. He e said when his finger got caught it was painful and bled a lot, he said the fingernail was long and ripped so the nurse had to clip it off. Resident #6 he was given pain medication after the incident. He said the wound care nurse applied the dressing to finger. He stated it currently felt sore. Resident #6 did not know which day it happened and did not know the names of the CNAs or the wound care nurse. An observation and interview of Resident #6 with the DON on 03/10/2025 at 4:30 PM revealed, the DON said she did not hear about any injury regarding Resident #6's left hand and she expected staff to report this to the nurse right away in an incident report and call the MD to get orders. The DON removed the dressing from Resident #6's left hand middle finger, using normal saline to loosen it from the dried blood stuck on the finger. Resident #6 winced in pain and said it was tender when touched. A large cut was observed just below the nail bed but there was no active bleeding. The nail below the dressing was short, and the fingertip had thick, dried, bumpy skin. The DON stated the risk of not reporting the injury would be missed treatment. She stated her next step would be to apply a clean bandage, call the NP and write an incident report. She stated the risk of an unreported injury would be a missed treatment for the resident. In an interview on 03/10/2025 at 4:45 PM, the CNO (Chief Nursing Officer) stated she would have to get more information as to why no incident report was made for Resident #6's skin injury. She stated her expectation would be that the incident report be written, actions to be completed as well as a root cause analysis. The CNO also expected the MD and family to be notified, interventions placed, MD orders to be put into action so the resident could get treatment and the care plan updated. Record review of Resident #6's order summary report as of 03/09/2025 revealed no physician order for treatment to the finger. Record review of Resident #6's medical chart on 3/10/2025 at 4:07 PM, revealed no change in condition form addressing the skin injury to the finger. There were no accident/incident reports or skin assessments addressing Resident #6's injured middle finger. Record review of Resident #6's progress notes for date range: 02/08/2025 to 03/11/2025 and uploaded on 03/10/2025 at 3:39 PM, revealed no documentation of the resident's skin injury to his middle finger of the left hand. Record review of the facility's undated policy for Accidents/Incidents/Events - Investigation and Reporting, read in part: Policy Statement - All accidents or incidents involving residents .etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident/incident/event

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for 1 (Resident #1) of 3 residents reviewed for notification of changes. -The facility failed to notify the primary doctor (MD B) of Resident #1's pressure ulcers that were observed 10/6/23 to11/16/23 resulting in Stage. An Immediate Jeopardy (IJ) was identified on 12/7/2023. The IJ template was provided to the facility on [DATE] at 4:03 pm. While the IJ was removed on 12/8/2023 at 3:45 pm, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delayed treatment, deteriorating pressure ulcers, infections, and hospitalization. Findings include: Record review of Resident #1's undated face sheet, revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with acute respiratory failure, type 2 diabetes (body does not produce insulin or resists it), nontraumatic intracerebral hemorrhage (bleeding to part of the brain), aphasia (unable to talk), anemia (low iron), epilepsy (seizures), anoxic brain injury (brain injury due to lack of oxygen), gastrostomy (tube into stomach for nutrition), and dependence on a ventilator (machine breathes for you). Record review of Resident# 1's entrance MDS, dated [DATE], revealed a blank BIMS score because it was unable to be performed due to the resident's cognition. The MDS also revealed the resident had impairment on both sides of his upper and lower extremities and was dependent with all activities. Resident #1 was always incontinent of bowel and bladder. The MDS revealed the resident was at risk of developing pressure ulcers/injuries but had no unhealed pressure ulcers/injuries at that time. It also indicated the resident had no venous/arterial ulcers, or any other wounds or skin problems. The MDS did not reveal a turning/re-positioning program, nutrition/hydration intervention, application of dressings, or pressure ulcer/injury care were being used. Record review of Resident #1's care plan, dated 10/3/23, revealed a Focus: Resident has an open wound to the sacrum and is at risk for infections. 11/8/23: 6cm x 5cm x 2cm, 11/15/23: 8cm x 7cm x 3cm- post debridement. Resident has an open wound to left ischium (hip area) and is at risk for infections. 11/8/23: 12cm x 4cm x 0cm, 11/15/23: 11cm x 6cm x 0cm- post debridement. Resident has a DTI to right heel. 11/8/23: 4cm x 6cm x 0cm, 11/15/23: 4cm x 6cm x 0cm. Resident has a DTI to left heel. 11/8/23: 4cm x 6cm x 0cm, 11/15/23: 4cm x 6cm x 0cm. Goal: Area will show signs of healing or heal without complications through/by next review date. Interventions: Follow up with MD as appropriate and scheduled. Keep dressing clean, dry, and intact. Observe dressing every shift and replace as needed for soiling, strike through drainage/bleeding. Provide treatment as ordered. Observe wound when changing dressing for S/S of healing or complications (odor, increased drainage etc.) or wound shows no improvement in 2 weeks notify MD of findings. Refer to wound care nurse as indicated. Focus: Resident #1 is bedfast most/all of the time and is at risk for skin break down. Goal: Resident #1 will have no increase in skin break down over the next 90 days. Interventions: Assess skin weekly for skin break down. Keep sheets clean and wrinkle free. Turn and re-position during rounds/PRN. Use positioning devices to prevent skin break down. Focus: Resident #1 is at risk for skin break down and injury AEB immobility and incontinence. Goal: Resident #1's skin will remain clean/dry, intact without evidence of break down over the next 90 days. Interventions: Assess skin on a weekly basis and PRN-report any break down to MD/RP. Assist with re-positioning as needed using padding between pressure areas. Check for incontinence during rounds and PRN-change promptly. Provide pressure reducing and positioning devices on resident's bed/wheelchair as indicated. Focus: Resident #1 is incontinent of (bladder/bowel) and is at risk for skin break down and pressure wound formation. Goal: Resident #1 will remain clean, dry, odor free and dignity will be maintained over the next 90 days. Interventions: Check for incontinent episode during rounds, change promptly and apply a protective skin barrier. Observe for s/sx of skin break down-report to nurse. Re-assess for possible toileting program-quarterly and PRN. Focus: Resident #1 is at risk for decline in ADL functions and injury r/t ICH, decreased mobility, anoxic brain damage. Goal: Resident #1 will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Interventions: Bed Mobility-Provide total assistance with 1-2 persons assistance. Dressing-Provide total assistance with 1-2 persons assistance. Personal hygiene/grooming-Provide total assistance with 1-2 persons assistance. Toileting-Provide total assistance with 1-2 persons assistance. Transfers- Provide total assistance with 1-2 persons assistance. Record review of Resident #1's previous hospital records dated 9/24/23, revealed a progress note from MD A which said, there was no rash or skin change. Record review of Resident #1's medical record revealed a Braden Scale for Predicting Pressure Sore Risk, dated 10/3/23 which indicated the resident was at moderate risk of developing pressure sores. Record review of Resident #1's Weekly Skin Monitoring dated 10/3/23, revealed an assessment from LVN A which indicated the resident had a small excoriation (scratch) on his left buttock. Record review of Resident #1's Weekly Skin Monitoring dated 10/6/23, revealed an assessment from the Wound Care Nurse which indicated the resident had a closed, dry area on sacrum (portion of spine between lower back and tailbone), a dry sore to the left buttocks, a dry sore to the left, rear, shoulder, a dry sore to the left knee, and bilateral (both) heel DTIs. Record review of Resident #1's Weekly Skin Monitoring dated 10/13/23, revealed an assessment from LVN B which indicated there were no skin issues on the resident. Record review of Resident #1's Wound-Weekly Observation Tool dated 10/18/23, revealed an assessment from the Wound Care Nurse saying the resident had a Stage II (only involves upper most layer of skin, shallow), acquired sacrum (portion of spine between lower back and tailbone) pressure ulcer, which measured 3.5cm x 3cm x 1cm. Record review of Resident #1's Weekly Skin Monitoring dated 10/20/23, revealed an assessment from the Wound Care Nurse which indicated the resident had redness to his sacrum (portion of spine between lower back and tailbone), redness to ischium (curved bone forming the base of pelvis) but it did not say which side, and bilateral (both) heel DTIs. Record review of Resident #1's Wound-Weekly Observation Tool dated 10/25/23, revealed an assessment from the Wound Care Nurse saying the resident had a Stage III (extends through skin into deeper into tissue and fat), acquired sacrum (portion of spine between lower back and tailbone) pressure ulcer, which measured 3.5cm x 3cm x 1cm. Record review of Resident #1's Weekly Skin Monitoring dated 10/27/23, revealed an assessment from the Wound Care Nurse which indicated the resident had redness and shearing (tearing) to his sacrum (portion of spine between lower back and tailbone), redness to the left ischium (curved bone forming the base of pelvis), and bilateral (both) heel DTIs. Record review of Resident #1's Weekly Skin Monitoring dated 11/3/23, revealed an assessment from the Wound Care Nurse which indicated the resident had a pressure wound to his sacrum (portion of spine between lower back and tailbone), shearing (tearing) to his left buttock, and bilateral (both) heel DTIs. Record review of Resident #1's medical record on 12/7/23 revealed no SBAR or Change in Condition documentation until 11/16/23. Record review revealed a Change in Condition Evaluation dated 11/16/23 and revealed there was a change in condition regarding a skin wound or ulcer that started on 11/16/23. It said Skin Evaluation-Describe Skin Changes: Wound. Describe the Wound: Any wound that will not stop bleeding OR that exposes subcutaneous tissue. Site: Sacrum- Exposed subcutaneous tissue. MD B was notified at 4:00 pm on 11/16/23. Record review of Resident #1's Physician Orders revealed there were no wound care orders until 11/16/23 by MD B: -Follow MD parameters as ordered. Notify MD for all changes in condition. Ordered 10/2/23. -PERFORM HEAD TO TOE ASSESSMENT. ASSESS ALL AREAS OF SKIN. Ordered on 10/2/23. -Skin assessment is to be done weekly, every day shift, every Mon for skin integrity support. Ordered 10/2/23. -Apply skin prep to both heels, every day shift. Ordered on 11/16/23. -Clean wound to left ischial (curved bone forming the base of pelvis) with NS, apply Alginate (type of wound dressing), cover with dry dressing, every day shift. Ordered 11/16/23. -Clean wound to sacrum (portion of spine between lower back and tailbone) with NS, pat dry, apply Alginate (type of wound dressing), cover with dry dressing, every day shift. Ordered 11/16/23. -Off load heels while in bed, every shift. Ordered 11/16/23. -Meropenem Intravenous Solution Reconstituted 1gm, Use 1gm intravenously every 8 hours for wound infection and severe leukocytosis for 14 days. Ordered 11/16/23. -Vancomycin HCl Intravenous Solution 1000mg/10ml, Use 1gm intravenously every 12hrs for wound infection and severe leukocytosis for 14 days. Ordered 11/16/23. -Zinc Oral Tablet, Give 50mg via G-tube one time a day to promote wound healing. Ordered 11/16/23. Record review of Resident #1's medical records revealed a Transfer Form filled out by RN A, dated 11/22/23, which indicated the resident was being transferred to the hospital for abnormal labs/wound infection. It also said the resident had started IV antibiotics (Vancomycin and Meropenem) on 11/17/23 for a possible wound infection and had no MDROs. The transfer form revealed the resident had an unstageable pressure ulcer to his sacrum (portion of spine between lower back and tailbone) and right buttocks, and DTIs to both heels. Interview with a family member on 12/1/23 at 9:58 am she revealed when Resident #1 first came to the facility, he had no wounds. Interview and observation with the hospital RN on 12/1/23 at 12:38 pm, Resident #1 was observed in ICU laying on his back on a bariatric air mattress. He had heel protecting boots on, had a foley (catheter into bladder to drain urine), PEG (tube into stomach for nutrition) tube running, and IV with antibiotics running, and was on a ventilator (machine breathes for you). She revealed Resident #1 had just returned from a debridement surgery for his wounds. She stated the resident came in with wounds to his sacrum (portion of spine between lower back and tailbone), both buttocks, both heels, and both ankles. She also said the resident had been running fever every night and was on contact isolation for Pseudomonas, Klebsiella, ESBL, VRE, and Staph Enterococcus (resistant bacteria). She said he had osteomyelitis (bone infection) to his sacrum (portion of spine between lower back and tailbone). Interview with LVN C on 12/5/23 at 10:25 am she revealed she informed the Wound Care Doctor verbally about pressure ulcers when he came to the facility weekly. She said nothing was documented that she spoke to the doctor. Interview with RN B on 12/5/23 at 10:30 am she revealed she would assess the residents with wound care orders to see if they had any other skin issues, and if they did, she would report it to the staff nurse. The staff nurse would notify the doctor. RN B said she had no communication with the doctor. Interview with LVN B on 12/5/23 at 11:12 am, she revealed she performed wound care over the weekend and saw two wounds she thought were worsening but did not remember which residents they were. She said she informed the DON and he said he would notify the doctor. She said she had no communication with the doctor. Interview on 12/7/23 at 12:05 pm with MD B, he said staff would update him verbally on wounds while he was in the facility, but he was unsure when Resident #1's wounds first started. He said there was not any documentation that he or his NP were notified. Record review of the facility's policy and procedure on Skin Assessment Monitoring Guidelines (revised 10/2021) read in part: Policy: All residents will be assessed upon admission, quarterly and with a significant change in condition to identify risk factors that may lead to impaired skin integrity .If a skin concern is noted, do not assume that the nursing team is aware. Validate that there is a treatment or monitoring order, that physician and resident/representative are aware and care plan reflects area of concern. If it is determined to be a new area note on 24-hour report, add to Alert Charting. Notify resident/representative and Director of Nursing/designee, note new treatment/monitoring orders, revise care plan as indicated. The Director of Nursing (DON)/designee will monitor Weekly Skin Monitoring UDAs in [EMR] to validate completion and follow up to any new skin areas identified. The Skin Committee will meet weekly and as needed to review Weekly Wound/Skin Report and make recommendations as deemed appropriate. Record review of the facility's policy and procedure on Wound Monitoring Guidelines (no revision date) read in part: Policy: It is the goal of the facility to maintain skin integrity. A resident who has developed or is admitted with a wound .will receive necessary treatment and services to promote healing, prevent infection and prevent new wounds from developing .Procedure: The licensed nurse will perform the following procedures for this classification of wounds identified on Admission, during Weekly Skin Monitoring Assessments or any other daily care: 1. Notify the physician for orders to treat each wound identified, including type. Wounds will be treated per established protocol unless otherwise specified by the physician. Transcribe orders onto Treatment Administration Record (TAR). Validate wound type/identification, goals and interventions are addressed on the resident's Care plan. Notify resident/resident representative regarding change in condition if applicable .6. All wounds .will be assessed on a weekly basis using the Weekly Wound Observation Tool (One Wound per UDA) in [EMR]. The Director of Nursing/designee will be responsible to validate that documentation is accurate and performed in a timely manner. 7. The Director of Nursing/designee will be responsible for completing and maintaining the Wound Log. Special Note: It is recommended that if a wound is initially classified as pressure injury/ulcer, however, the wound presents as vascular/arterial wound that prompt notification of physician with clarification orders related to type and classification of wound are obtained .Wound classification should be consistent throughout the resident medical record, including Weekly Skin Head to Toe UDAs, Wound Clinic notes, Physician Orders, Progress Notes and Care Plan. Consistency of documentation should be validated in Weekly Skin and Weight Meeting. On 12/7/2023 at 4:03pm the Administrator and DON were notified that an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 4:03pm. The Plan of removal was accepted on 12/8/2023 at 12:47pm. The plan of removal reflected the following: The facility needs to notify the Primary Care MD of any change in status to residents so treatment can start without delay. R[Resident] #1 was discharged from the facility on 11/22/2023. 1). Action: Chief Nursing Officer updated and re-educated facility Administrator and Director of Nursing on the Policy and Procedure for a). Change in a Resident's Condition or Status and b). Charting and Documentation on 12/07/2023. Mode of Education was a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 12/07/2023. Comprehension was assessed by the Chief Nursing Officer via the teach-back method on 12/07/2023. Start Date: 12/07/2023 Completion Date: 12/07/2023 Responsible: Chief Nursing Officer 2). Action: The Director of Nursing re-educated facility Licensed Nurses (RNs/LVNs) on duty of the facility Policy and Procedure for a). Change in a Resident's Condition or Status and b). Charting and Documentation on 12/07/2023. Staff not on duty during the training period will receive 1:1 training before starting their next shift from the Director of Nursing, or Assistant Director of Nursing or the facility Administrator. c) Nurses educated on notifying/consulting the physician for change of condition and wound or skin changes. Mode of Education was /will be a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 12/07/2023 and ongoing until all Licensed Nurses (RNs/LVNS) have been re-educated. Education is to be added as part of the orientation for ongoing training of new hires, agency, and PRN staff through a combination of employee training, employee monitoring, and reporting processes. The teach-back method will be used to assess comprehension on 12/07/2023 and will be ongoing until all Licensed Nurses (RNs/LVNS) have been re-educated. Start Date: 12/07/2023 Completion Date: 12/08/2023 Responsible: The Director of Nursing 3). Action: The Director of Nursing educated Licensed Nurses (RNs/LVNs) specific education for reporting wound or skin changes of condition; nurses were/will be educated to report any exposed subcutaneous tissue; presence of or increased drainage; presence of or increase in odor; signs of infection, i.e. increased redness (erythema), swelling (induration), fever, increased size, or undermining AND any wound not responding to treatment upon weekly evaluation. The Director of Nursing educated Nurses on notifying/consulting the physician for change of condition and wound or skin changes. The director of Nursing will ensure that off-cycle Wound Observation Tool is completed within 24 hours upon discovery or a new wound and changes in current wounds and weekly thereafter. The Director of Nursing will provide additional education as deemed necessary to maintain ongoing compliance. Weekend Supervisor or Designee will do the same Saturday and Sunday. Compliance checks will be completed weekly by the Administrator by checking wound report to Wound Observation Tools completed in [EMR]. Start Date: 12/07/2023 Completion Date: 12/08/2023 Responsible: The Director of Nursing and Administrator 4). Action: The Director of Nursing and Assistant Director of Nursing have completed an audit of the development of new wounds or worsening wounds have been completed for the past 30 days, Wound Observation Tools have been completed and Interact Changes of Condition/SBAR Communication form have been completed in [EMR] for residents with Pressure Ulcers/injuries; both tools indicate MD notification. Start Date: 12/07/2023 Completion Date: 12/08/2023 Responsible: The Director of Nursing and Administrator 5). Action: The Director of Nursing and Administrator will review the 24-hour Report daily Monday through Friday in morning stand-up for potential and actual changes in resident's condition or status to ensure appropriate assessment, notification, and documentation. The facility will ensure the RNs/LVNs have complete Wound Observation Report and notified the MD upon a Resident Change of Condition or Status by ensuring the Interact SBAR Communication form is completed in [EMR]. The Administrator and Director of Nursing will provide additional education as deemed necessary to maintain ongoing compliance. Weekend Supervisor or Designee will do the same Saturday and Sunday. Compliance checks will be completed as part of monthly QAPI. Start Date: 12/07/2023 Completion Date: 12/08/2023 Responsible: The Director of Nursing and Administrator On 12/8/23 a monitoring visit was conducted to ensure the facility was following its POR. The visit revealed: Record review and interview on 12/8/23 at 9:12am revealed all facility residents were assessed by either the DON, ADON, or the CNO. Per the CNO they used the CNA Shower Sheet because it was the only form, they had with a body on it to mark an area. She also said if the CNA had marked something, the ADON, DON, or CNO still went back and double checked the skin. Out of all 65 facility's residents, 17 residents had redness or some kind of skin issues documented. After speaking with the CNO about some of the residents she went back and re-assessed them. Some of the residents did not have redness or scratches on them. There were 7 residents who had PUs. 1 of the resident's left the facility and the other one got better. Review of the resident's charts in [EMR] revealed the skin issues were documented. Interview on 12/8/23 at 11:27 am, LVN E revealed she had in-services on change in conditions and who to report them to. She said if there was a change in condition she would report it to the MD, and her supervisor. Then she would document it under the Change of Condition form in [EMR]. Interview on 12/8/23 at 11:33 am LVN F revealed she had training on change in condition and notifying the MD of a change in condition. She said if there was a change in condition, she would notify the MD and document it on the change of condition document in [EMR]. Interview on 12/8/23 at 11:49 am LVN G said she had in-services on change of condition. She said if there was a change in condition she would report it to the DON, the family, and the MD. She would report the change in [EMR] on the progress note. Record review on 12/8/23 at 12:56 pm revealed an in-service was given on 12/7/23 regarding Weekly Skin Monitoring to RNs and LVNs. 12 facility staff members signed the attendance sheet. The in-service was about skin assessment monitoring guidelines, wound monitoring guidelines, pressure injury management guidelines (with pictures), the Braden Scale, wound care insider (with pictures), skin monitoring: comprehensive CNA shower review, clinically unavoidable skin breakdown, and examples in [EMR]. In an interview with the DON on 12/8/23 at 1:00 pm he revealed they were putting red binders at every nurse's station that held information about examples of change in condition, who to notify, and SBAR sheets to use. Record review on 12/8/23 at 1:07 pm revealed an in-service was given on 12/7/23 regarding Change in Resident's Condition with 12 staff members signature in attendance. Record review also revealed in-services performed on 12/8/23 regarding Change in Resident Condition or Status and Charting Documentation for RNs and LVNs. 5 staff members signed for attendance. Interview on 12/8/23 at 3:07 pm, LVN E revealed the facility provided more in-services on wound care, wound measuring, and change of conditions and who to report to. Interview on 12/8/23 at 3:10 pm LVN F revealed there was another in-service on wound care, what to report to the MD regarding wounds, and what was considered a change in condition. Interview on 12/8/23 at 3:15 pm LVN G said there was another in-service about wounds, measuring wounds, and what was a change in condition. Record review on 12/8/23 at 3:18 pm revealed the Weekly Wound Observation Tool and the Interact Change in Condition, were completed for the 7 residents with wounds. Record review on 12/8/23 at 3:27 pm revealed the 24hr report for the morning, for Halls A & B on 12/8/23 was completed. The 24hr report included new admissions/discharges, residents with risk management cases (falls/chest pain), residents on antibiotics/new antibiotics ordered, residents with radiology/labs ordered, and residents who dad appointments/referrals. A copy of the 24hr report was kept for records. An Immediate Jeopardy (IJ) was identified on 12/7/2023. The IJ template was provided to the facility on [DATE] at 4:03pm. While the IJ was removed on 12/8/2023 at 3:45pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 3 (Resident #1, Resident #2, and Resident #3) of 7 residents reviewed for pressure ulcers. -The facility failed to turn/re-position Resident #1 and Resident #2 every 2 hours who were completely dependent and bed bound to prevent Pressure Ulcer development. -The facility failed to perform accurate skin assessments for Resident #1 (10/13/23 to 10/27/23) and Resident #2 (11/7/23 to 12/4/23) for Pressure Ulcers. -The facility failed to treat Resident #1's facility acquired pressure ulcers for over a month after being identified by Wound Care Nurse on 10/6/23 (sacrum, knee, buttocks, bilateral heels) . -The facility failed to identify Residents #2's risk for Presure Ulcers related to incontinence of bowl/bladder and bedbound, treat, and prevent further damage of Resident #2's Stage II (shallow, affected upper layer of skin) facility aquired pressure ulcer. -The facility failed to identify Resident #3's facility acquired MASD (moisture associated skin damage) who was incontinent of bowl/bladder and bedbound. An Immediate Jeopardy (IJ) was identified on 12/6/2023. The IJ template was provided to the facility on [DATE] at 3:22pm. While the IJ was removed on 12/8/2023 at 12:45pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of developing pressure ulcers/wounds, worsening pressure ulcers/wounds, and could cause pain, infection, hospitalization, or death. Findings include: Resident #1 Record review of Resident #1's undated face sheet, revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with acute respiratory failure, type 2 diabetes (body does not produce enough insulin or is resistant to it), nontraumatic intracerebral hemorrhage (bleeding into the brain), aphasia (unable to talk), anemia (low iron), epilepsy (seizures), anoxic brain injury (brain injury due to lack of oxygen), gastrostomy (tube in stomach for nutrition), and dependence on a ventilator (machine that breathes for you). Record review of Resident# 1's entrance MDS, dated [DATE], revealed a blank BIMS score because it was unable to be performed due to the resident's cognition. The MDS also revealed the resident had impairment on both sides of his upper and lower extremities and was dependent with all activities. Resident #1 was always incontinent of bowel and bladder. The MDS revealed the resident was at risk of developing pressure ulcers/injuries but had no unhealed pressure ulcers/injuries at that time. It also indicated the resident had no venous/arterial ulcers, or any other wounds or skin problems. The MDS did not reveal a turning/re-positioning program, nutrition/hydration intervention, application of dressings, or pressure ulcer/injury care were being used. Record review of Resident #1's care plan, dated 10/3/23, revealed a Focus: Resident has an open wound to the sacrum and is at risk for infections. 11/8/23: 6cm x 5cm x 2cm, 11/15/23: 8cm x 7cm x 3cm- post debridement. Resident has an open wound to left ischium (hip area) and is at risk for infections. 11/8/23: 12cm x 4cm x 0cm, 11/15/23: 11cm x 6cm x 0cm- post debridement. Resident has a DTI to right heel. 11/8/23: 4cm x 6cm x 0cm, 11/15/23: 4cm x 6cm x 0cm. Resident has a DTI to left heel. 11/8/23: 4cm x 6cm x 0cm, 11/15/23: 4cm x 6cm x 0cm. Goal: Area will show signs of healing or heal without complications through/by next review date. Interventions: Follow up with MD as appropriate and scheduled. Keep dressing clean, dry, and intact. Observe dressing every shift and replace as needed for soiling, strike through drainage/bleeding. Provide treatment as ordered. Observe wound when changing dressing for S/S of healing or complications (odor, increased drainage etc.) or wound shows no improvement in 2 weeks notify MD of findings. Refer to wound care nurse as indicated. Focus: Resident #1 is bedfast most/all of the time and is at risk for skin break down. Goal: Resident #1 will have no increase in skin break down over the next 90 days. Interventions: Assess skin weekly for skin break down. Keep sheets clean and wrinkle free. Turn and re-position during rounds/PRN. Use positioning devices to prevent skin break down. Focus: Resident #1 is at risk for skin break down and injury AEB immobility and incontinence. Goal: Resident #1's skin will remain clean/dry, intact without evidence of break down over the next 90 days. Interventions: Assess skin on a weekly basis and PRN-report any break down to MD/RP. Assist with re-positioning as needed using padding between pressure areas. Check for incontinence during rounds and PRN-change promptly. Provide pressure reducing and positioning devices on resident's bed/wheelchair as indicated. Focus: Resident #1 is incontinent of (bladder/bowel) and is at risk for skin break down and pressure wound formation. Goal: Resident #1 will remain clean, dry, odor free and dignity will be maintained over the next 90 days. Interventions: Check for incontinent episode during rounds, change promptly and apply a protective skin barrier. Observe for s/sx of skin break down-report to nurse. Re-assess for possible toileting program-quarterly and PRN. Focus: Resident #1 is at risk for decline in ADL functions and injury r/t ICH, decreased mobility, anoxic brain damage. Goal: Resident #1 will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Interventions: Bed Mobility-Provide total assistance with 1-2 persons assistance. Dressing-Provide total assistance with 1-2 persons assistance. Personal hygiene/grooming-Provide total assistance with 1-2 persons assistance. Toileting-Provide total assistance with 1-2 persons assistance. Transfers- Provide total assistance with 1-2 persons assistance. Record review of Resident #1's previous hospital records dated 9/24/23, revealed a progress note from MD A which said, there was no rash or skin change. Record review of Resident #1's medical record revealed a Braden Scale for Predicting Pressure Sore Risk, dated 10/3/23 which indicated the resident was at moderate risk of developing pressure sores. Record review of Resident #1's Weekly Skin Monitoring dated 10/3/23 at 6:04 am, revealed an assessment from LVN A which indicated the resident had a small excoriation (scratch) on his left buttock. Record review of Resident #1's Weekly Skin Monitoring dated 10/6/23 at 4:12 pm, revealed an assessment from the Wound Care Nurse which indicated the resident had a closed, dry area on sacrum (portion of spine between lower back and tailbone), a dry sore to the left buttocks, a dry sore to the left, rear, shoulder, a dry sore to the left knee, and bilateral (both) heel DTIs. Record review of Resident #1's Weekly Skin Monitoring dated 10/13/23 4:39am, revealed an assessment from LVN B which indicated there were no skin issues on the resident. Record review of Resident #1's Wound-Weekly Observation Tool dated 10/18/23 at 6:11pm, revealed an assessment from the Wound Care Nurse saying the resident had a Stage II (shallow, affects upper most layer of skin), acquired sacrum (portion of spine between lower back and tailbone) pressure ulcer, which measured 3.5cm x 3cm x 1cm. Record review of Resident #1's Weekly Skin Monitoring dated 10/20/23 at 10:24 am, revealed an assessment from the Wound Care Nurse which indicated the resident had redness to his sacrum (portion of spine between lower back and tailbone), redness to ischium (curved bone forming the base of pelvis) but it did not say which side, and bilateral (both) heel DTIs. Record review of Resident #1's Wound-Weekly Observation Tool dated 10/25/23 at 6:10 pm, revealed an assessment from the Wound Care Nurse saying the resident had a Stage III (extends through skin into deeper tissue and fat), acquired sacrum (portion of spine between lower back and tailbone) pressure ulcer, which measured 3.5cm x 3cm x 1cm. Record review of Resident #1's Weekly Skin Monitoring dated 10/27/23 2:19 pm, revealed an assessment from the Wound Care Nurse which indicated the resident had redness and shearing (tearing) to his sacrum (portion of spine between lower back and tailbone), redness to the left ischium (curved bone forming the base of pelvis), and bilateral (both) heel DTIs. Record review of Resident #1's Weekly Skin Monitoring dated 11/3/23 at 12:04pm, revealed an assessment from the Wound Care Nurse which indicated the resident had a pressure wound to his sacrum (portion of spine between lower back and tailbone), shearing (tearing) to his left buttock, and bilateral (both) heel DTIs. Record review of Resident #1's Visit Report dated 11/1/23, from the Wound Care Doctor revealed Wound #1 was a Stage III ( (extends through skin into deeper tissue and fat) pressure ulcer to the sacrum (portion of spine between lower back and tailbone), acquired 10/2/23, and measured 5cm x 5cm x 0cm. Wound #2 was a pressure ulcer to the left heel, acquired 10/2/23, measured 4cm x 6cm x 0cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. Wound #3 was a pressure ulcer to the right heel, acquired 10/2/23, measured 4cm x 6cm x 0cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. According to the Visit Report, the Wound Care Doctor performed a surgical debridement on the same day to Wound #1, and subcutaneous (fatty tissue) slough (dead tissue) was removed. Record review of Resident #1's Wound-Weekly Observation Tool dated 11/1/23, revealed an assessment from the Wound Care Nurse saying the resident had a left and right heel DTI that he was admitted with, and measured 4cm x 6cm x 0cm, and there was a Stage II (only upper most layer of skin, and does not extend into fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis) from admission, that measured 12cm x 4cm x 0cm. She also recorded a sacrum (portion of spine between lower back and tailbone) Stage III (extends through skin into deeper tissue and fat) pressure ulcer that she indicated he was admitted with, and measured 5cm x 5cm x 0cm. Record review of Resident #1's Visit Report dated 11/8/23, from the Wound Care Doctor revealed Wound #1 was a deteriorating Stage IV (deep, extends into muscle, tendon, or bone) pressure ulcer to the sacrum (portion of spine between lower back and tailbone) and measured of 6cm x 5cm x 2cm. Wound #1 had exposed ligament (tissue connects bone to bone), with exposed ligament necrosis (dead tissue connects bone to bone) and exposed adipose necrosis (dead fat tissue). Wound #2, the pressure ulcer of the left heel, had no change and measured 4cm x 6cm x 0cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. Wound #3, the pressure ulcer to the right heel, had no change and measurements 4cm x 6cm x 0cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. The Visit Report revealed there was a new wound. Wound #4 was a Stage III (extends through skin into deeper tissue and fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis), acquired on 10/2/23, and measured 12cm x 4cm x 0cm. According to the Visit Report, the Wound Care Doctor performed a surgical debridement on the same day to Wound #1, and ligament (tissue connects bone to bone) and subcutaneous (fatty tissue) slough (dead tissue) were removed. The Wound Care Doctor also performed a surgical debridement of Wound #4, and subcutaneous (fatty tissue) slough (dead tissue) was removed. Record review of Resident #1's Wound-Weekly Observation Tool dated 11/8/23, revealed an assessment from the Wound Care Nurse saying the resident had a left and right heel DTI that was unchanged, and measured 4cm x 6cm x 0cm. She said there was now a Stage III (extends through skin into deeper tissue and fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis), that measured 12cm x 4cm x 0cm. There was also record of the sacrum (portion of spine between lower back and tailbone) worsening to a Stage IV (deep, extends into muscle, tendon, or bone) pressure ulcer, and measured 6cm x 5cm x 2cm. Record review of Resident #1's Visit Report dated 11/15/23, from the Wound Care Doctor revealed Wound #1 was a deteriorating Stage IV (deep, extends into muscle, tendon, or bone) pressure ulcer to the sacrum (portion of spine between lower back and tailbone), and measured 8 cm x 7 cm x 3 cm. Wound #1 had exposed ligament (tissue connects bone to bone), with exposed ligament necrosis (dead tissue connects bone to bone) and exposed adipose necrosis (dead fat tissue). Wound #2, the pressure ulcer of the left heel, had no change and measured 4 cm x 6 cm x 0 cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. Wound #3, the pressure ulcer to the right heel, had no change and measured of 4 cm x 6 cm x 0 cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. Wound #4, the Stage III (extends through skin into deeper tissue and fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis) had no change, except it had signs of infection with infectious drainage and measured of 11 cm x 6 cm x 0 cm. According to the Visit Report, the Wound Care Doctor performed a surgical debridement on the same day to Wound #1, where ligament (tissue connects bone to bone) and subcutaneous (fatty tissue) slough (dead tissue) were removed. The Wound Care Doctor also performed a surgical debridement of Wound #4 where subcutaneous (fatty tissue) slough (dead tissue) was removed. Record review of Resident #1's Wound-Weekly Observation Tool dated 11/15/23, revealed an assessment from the Wound Care Nurse saying the resident had a left and right heel DTI that was unchanged, and measured 4 cm x 6 cm x 0 cm. She said there was a worsening Stage III (extends through skin into deeper tissue and fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis), that measured 11 cm x 6 cm x 0 cm. There was also record of the sacrum (portion of spine between lower back and tailbone) Stage IV (deep, extends into muscle, tendon, or bone) pressure ulcer worsening, and measured 8 cm x 7 cm x 3 cm. Record review of Resident #1's Change in Condition dated 11/16/23, revealed an unknown nurse indicated the resident had a change in condition due to a skin wound or ulcer. The nurse indicated the resident had a sacrum (portion of spine between lower back and tailbone) wound with exposed subcutaneous tissue and had abnormal CBC results. The WBC was 21,000 (normal < 11), which indicated an infection. Record review of Resident #1's Weekly Skin Monitoring dated 11/17/23, revealed an assessment from the Wound Care Nurse which indicated the resident had a Stage IV (deep, extends into muscle, tendon, or bone) pressure wound to his sacrum (portion of spine between lower back and tailbone), a Stage III (extends through skin into deeper tissue and fat) pressure wound to his left buttock, and bilateral (both) heel DTIs. Record review of Resident #1's Physician's Orders as of 11/20/23, revealed the following orders from the MD B: -Apply skin prep to both heels, every day shift. Ordered 11/16/23, to start 11/17/23. -Clean wound to left ischial (curved bone forming the base of pelvis) with NS, apply Alginate (type of wound dressing), cover with dry dressing, every day shift. Ordered 11/16/23, to start 11/17/23. -Clean wound to sacrum (portion of spine between lower back and tailbone) with NS, pat dry, apply Alginate (type of wound dressing), cover with dry dressing, every day shift. Ordered 11/16/23, to start 11/17/23. -Off load heels while in bed, every shift. Ordered 11/16/23, to start 11/17/23. -Perform head to toe assessment. Assess all areas of skin. Ordered on 10/2/23. Record review of Resident #1's Physician Orders revealed there were no wound care orders prior to 11/16/23. Record review also revealed there were no orders for turning/re-positioning. Record review of Resident #1's November 2023 MAR revealed: -Clean wound to left ischial [curved bone forming the base of pelvis] with NS,apply Alginate (wound dressing), cover with dry dressing, one time a day. On 11/9/23-11/16/23 there was a 9 documented, which according to the MAR legend meant Other/See Nurse Notes. Record review of the nurse's notes revealed no documentation of the treatment. -Apply zinc (type of barrier cream) to shearing on left buttocks, one time [NAME]. On 11/4/23-11/8/23 there was a 9 documented, which according to the MAR legend meant Other/See Nurse Notes. Record review of the nurse's notes revealed no documentation of the treatment. -Clean wound to sacrum [portion of spine between lower back and tailbone] with NS, pat dry, apply Alginate (wound dressing), cover with dry dressing, one time a day. On 11/4/23-11/16/23 there was a 9 documented, which according to the MAR legend meant Other/See Nurse Notes. Record review of the nurse's notes revealed no documentation of the treatment. -Off load heels while in bed, one time a day. On 11/11/23-11/16/23 there was a 9 documented, which according to the MAR legend meant Other/See Nurse Notes. Record review of the nurse's notes revealed no documentation of the treatment. Record review of Resident #1's medical records revealed a Transfer Form filled out by RN A, dated 11/22/23, which indicated the resident was being transferred to the hospital for abnormal labs/wound infection. It also said the resident had started IV antibiotics (Vancomycin and Meropenem) on 11/17/23 for a possible wound infection and had no MDROs. The transfer form revealed the resident had an unstageable pressure ulcer to his sacrum (portion of spine between lower back and tailbone) and right buttocks, and DTIs to both heels. Interview with a family member on 12/1/23 at 9:5am she revealed when Resident #1 first came to the facility, he had no wounds. She stated staff wound never turn him or change him often enough, and she would try to get staff to turn him and change him every time she went to the facility. She said staff would argue with her that they had just turned him or changed him when she knew they had not because she would sit there all day. Interview and observation with the hospital RN on 12/1/23 at 12:3pm, Resident #1 was observed in ICU laying on his back on a bariatric air mattress. He had pressure relieving boots on, a foley (catheter into bladder for urine drainage), PEG (tube into stomach for nutrition) tube running, and IV with antibiotics running, and was on a ventilator (machine that breathes for you). She revealed Resident #1 had just returned from a debridement (removal of dead skin/tissue) surgery for his wounds. She stated the resident came in with wounds to his sacrum (portion of spine between lower back and tailbone), both buttocks, both heels, and both ankles. She also said the resident had been running fever every night and was on contact isolation for Pseudomonas, Klebsiella, ESBL, VRE, and Staph Enterococcus (different resistant strains of bacteria). She said he had osteomyelitis (bone infection) to his sacrum (portion of spine between lower back and tailbone). Record review of Resident #1's Emergency Department Note dated 11/22/23 from ER MD, revealed the resident was sent to the ER from the facility for an elevated WBC and low Hgb of 6.5. The progress note revealed the resident had a large decubitus ulcer, was started on broad-spectrum antibiotics, and was found to be anemic (low Hgb) with a Hgb of 4.1 (normal is > 12). The resident's lactic acid (an indicator of systemic infection) was 2.8 (normal is < 2) and his procalcitonin (an indicator of systemic infection) was 0.42 (normal is < 0.1). His WBC (indicator of infection) was 26.5 (normal is < 11). The admitting diagnoses were acute sepsis (systemic infection), leukocytosis (high WBC), acute anemia (low Hgb), and decubitus ulcer (pressure ulcer) of sacral region (portion of spine between lower back and tailbone) and he was admitted to ICU. Record review of Resident #1's Surgery Progress Note dated 11/25/23 from the Surgical MD, revealed he had sepsis (systemic infection), necrotic (dead tissue) decubitus wounds (pressure wounds) and protein-calorie malnutrition (not consuming enough proteins and calories to meet nutritional needs). The Progress Note revealed on 11/24/23 Resident #1 had debridement (surgical removal) involving bone and it was sent to pathology for review. The Progress Note said the resident was going to need a diverting colostomy (opening in the abdomen to the outside where the stool goes, to divert from the trauma and avoid contamination) and additional debridement (surgical removal). The plan and treatment: local wound care, antibiotics per ID, optimize nutrition, keep foley catheter (tube into bladder for constant drainage of urine) for wound care management, rectal tube (tube into rectum for constant drainage of feces), and surgery for colostomy (opening to outside of abdomen for stool to drain into) and additional debridement (surgical removal). According to the note the sacral (portion of spine between lower back and tailbone) wound was 11 cm x 8.5 cm 3.5 cm and the left ischial (curved bone forming the base of pelvis) wound was 11 cm x 10 cm x 7 cm. Record review of Resident #1's Surgery Progress Note dated 11/30/23 from Surgical MD, revealed on 11/27/23 the resident had a laparoscopic colostomy (minimally invasive surgery to divert stool from colon to exterior collection bag outside of abdomen) and debridement (surgical removal). The note also said the bone removed previously, came back from pathology revealing acute osteomyelitis (bone infection) of the left ischium (curved bone forming the base of pelvis), and the wounds were growing MDR organisms. He was also having low-grade fevers and still had leukocytosis (high WBC). Per Surgical MD, Resident #1 would need additional debridement (surgical removal) of the decubitus wounds. The sacral (portion of spine between lower back and tailbone) wound measured 11cm x 8cm x 4cm with scattered areas of necrosis (dead tissue) and the left ischial (curved bone forming the base of pelvis) wound measured 13cm x 13cm x 6cm with necrosis (dead tissue) along the bone and tendon (tissue that connects bone to bone). Record review of Resident #1's ICU Progress Notes dated 12/1/23 from ICU MD, revealed: -11/23/23: Consulted ID for sacral (portion of spine between lower back and tailbone) wound. The wound appeared to be the source of infection. Consulted surgery for possible debridement (surgical removal). -11/24/23: Resident had surgery for debridement (surgical removal) to sacral(portion of spine between lower back and tailbone) wound. Podiatry (foot doctor) was consulted for heel eschars (dead tissue). -11/25/23: Surgery planned for Monday (11/27/23). Needs a diverting colostomy (opening in the abdomen to the outside where the stool goes, to divert from the trauma and avoid contamination) and further debridement (surgical removal). -11/26/23: Surgery tomorrow (11/27/23). -11/27/23: Plan for ostomy (allows bodily waste to pass through a surgically created stoma on the abdomen)/debridement (surgical removal) today per surgery. -11/30/23: Plan for repeat debridement (surgical removal) tomorrow. Record review of Resident #1's lab results dated 11/30/23, revealed: -Left Ischium Bone: Klebsiella Pneumoniae-MDRO and Enterococcus Faecium, VRE-MDRO (Multi-Drug Resistant Bacteria) -Sacral Tissue: Enterococcus Faecium, VRE-MDRO and Staphylococcus, Not S. Aureus (Multi-Drug Resistant Bacteria) Interview with the Administrator on 12/5/23 at 10:10 am, she revealed the former Wound Care Nurse was let go 11/27/23. She said the ADON and DON performed wound care on 11/28/23 and 11/29/23. Then she said, RN B performed wound care the rest of the week, except on Saturday 12/2/23. The Administrator said on 12/2/23, LVN B performed wound care, then RN B would take back over again. The Administrator said the new Wound Care Nurse was starting on 12/7/23. Interview with LVN C on 12/5/23 at 10:25 am she revealed she informed the Wound Care Doctor verbally about pressure ulcers when he came to the facility, weekly. She said nothing was documented that she spoke to the doctor. She also said she monitored the wound status by looking at the wounds, but there were not orders to monitor every shift, so she would do it whenever she remembered to. LVN C said to prevent pressure ulcers, residents needed to be turned every 2 hours. Interview on 12/5/23 at 10:30 am with RN B she revealed she only worked PRN and had only been the Wound Care Nurse for the past 3-4 days. She said she did not monitor the wound progress by measuring or anything, she only followed the MD orders. She could observe for oozing/foul odor and see that the wound looked worse, but she had only been performing wound care for 3-4 days. She said she would see the residents who were on the wound list that was given to her, and she would assess them to see if they had any other skin issues. She said if the resident had any other skin issues, she would report it to the nurse and the nurse would notify the MD. She had no communication with the MD. Interview with the Wound Care Nurse on 12/5/23 at 10:34 am she said she quit at the facility on 11/27/23 because there were too many residents with wounds, and she did not have enough help. She said there were not enough CNAs, so residents were not being turned and mostly on Hall A the wounds were worsening. She revealed that she would have a resident with redness on Friday and then she would be off for the weekend and when she came back on Monday, there would be an open wound because the resident was not turned all weekend. She said she would tell the Administrator about the wounds worsening and about needing more help, but she never received any. The Wound Care Nurse said she remembered Resident #1 and that he did not have any wounds when he came to the facility, and that his wounds did worsen. Interview with the Wound Care Doctor on 12/5/23 at 11:02 am he said he compared the measurements of the wound from the previous week to the measurement of the current week to see if the wound was worsening. He said he did not see Resident #1 until 11/1/23, which was a month after he was admitted , and he did not know what happened between when he was admitted until when he saw him. Interview with LVN B on 12/5/23 at 11:12 am she said she was the PRN Wound Care Nurse who had only performed wound care once for the facility and it was on 12/1/23. She said she had an in-service on wound care, but that was all. She said she saw 2 residents who she thought had worsening wounds and she reported them to the DON, but she could not remember which residents they were. She said the DON told her he would take care of it and notify the Wound Care Doctor. She also said she had no communication with the Wound Care Doctor because she was only PRN. Interview with the Administrator and DON on 12/5/23 at 3:20 pm they revealed they had done a PIP at the end of November 2023 regarding skin assessments. The DON said the skin assessments the nurses were performing/documenting were not matching the Wound Care Doctor's skin assessments. The DON said the Wound Care Nurse was not assessing the residents like she was supposed to and then the staff nurses would assess the residents, so there would be different assessments with different findings on the same resident. The DON said the Wound Care Nurse was responsible for performing the admission assessment, any new wound, and then all the current wound assessments. He said if the staff nurse found a new wound, they were to tell the Wound Care Nurse and then she performed an assessment on the resident and then managed the resident. The Administrator said the Wound Care Nurse was not keeping up with the assessments on all the residents. The Administrator did not think the Wound Care Nurse was too overwhelmed with wounds or lack of help. The DON said he performed a skin sweep on 11/27/23 after they found out not all the assessments were being performed. Resident #2 Record review of Resident #2's undated face sheet, revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of chronic respiratory failure (not being getting enough oxygen), traumatic brain injury, traumatic subarachnoid hemorrhage (bleeding to part of the brain), moderate protein-calorie malnutrition, dependence on respirator (a machine to breathe for him), tracheostomy (a tube in his throat), and gastrostomy (a tube in his stomach for nutrition). Record review of Resident #2's entrance MDS, dated [DATE], revealed a blank BIMS score because it was unable to be performed due to the resident's cognition. According to the MDS, the resident had impairment on both sides of his upper and lower extremities and was dependent with all activities. The resident was always incontinent of bladder and bowel. The MDS revealed the resident was at risk of developing pressure ulcers/injuries but had 0 unhealed pressure ulcers/injuries. He also had 0 venous/arterial ulcers or any other wounds and skin problems. According to the MDS the resident was not receiving pressure ulcer/injury care, turning/re-positioning program, or application of any dressings. Record review of Resident #2's care plan, dated 11/15/23, revealed Focus: The resident has potential/actual impairment to skin: abrasion. Initiated 12/5/23. There were no goals or interventions listed. There was not anything care planned for potential skin break down, incontinence, or that he was bedbound. Record review of Resident #2's Receiving Nurse's Note dated 11/7/23 from unknown nurse, revealed A 32yrs old male, arrived the facility .skin intact . Record review of Resident #2's initial Weekly Skin Monitoring dated 11/7/23 from the Wound Care Nurse, revealed the resident had redness to both buttocks. Record review of Resident #2's Progress Note dated 11/9/23 from MD B, revealed for skin: no rash or lesions. Record review of Resident #2's Braden Scale for Predicting Pressure Ulcer Risk dated 11/14/23 by LVN D, revealed the resident was at a very high risk of developing pressure ulcers. Record review of Resident #2's Skilled Nursing Notes dated 11/11/23, 11/12/23, 11/14/23, 11/18/23, 11/19/23, 11/20/23, 11/22/23, 11/23/23, 11/26/23, 11/27/23, 12/1/23, and 12/5/23 from unknown nurse, revealed skin concern noted; redness to buttocks. Record review of Resident #2's Weekly Skin Monitoring dated 11/21/23 from the Wound Care Nurse, revealed the resident had redness to both buttocks. Record review of Resident #2's Weekly Skin Monitoring dated 11/27/23 from the ADON, revealed the resident had no skin issues documented. Record review of the MDS Resident Matrix, printed 12/1/23, revealed Resident #2 had no pressure ulcers listed. Record review of Resident #2's Weekly Skin Monitoring dated 12/2/23 from LVN B, revealed the resident had no skin issues documented. Record review of Resident #2's Weekly Skin Monitoring dated 12/4/23 from the ADON, revealed the resident had no skin issues documented. Record review of Resident #2's Weekly Skin Monitoring dated 12/5/23 from the DON, revealed the resident had sacrum excoriation. Record review of Resident #2's Wound Weekly Observation Tool dated 12/6/23, revealed bilate[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that it is not possible for 1 (CR #24) of 17 residents reviewed for weight loss. The facility failed to ensure CR #24 did not have unplanned weight loss of 14.68 percent in 30 days. A 3-month significant wight loss was unavailable due to the facility's failure to weigh resident upon admission. The facility failed to have CR #24 consult the Speech Language Pathologist (SLP) for diet texture upgrade to mechanical soft. The facility failed to ensure CR #24 was weighed weekly for 4 weeks to re-establish his baseline weight. These failures could place residents at risk of not maintaining their nutritional needs. An Immediate Jeopardy (IJ) was identified on 11/18/2022. While the IJ was removed on 11/23/2022, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The findings included: CR #24 Record review of CR #24's face sheet revealed a [AGE] year-old male with an original admitted date of 08/29/2022 and re-entry date of 10/27/2022. Diagnoses included dysphagia (difficult in swallowing food or liquid) following unspecified cerebrovascular disease (affects the blood flow to the brain), non-Alzheimer's dementia, history of malignant neoplasm of larynx (cancer of voice box), and gastro-esophageal reflux disease without esophagitis (repeated back flow of stomach acid). Record review of CR #24's admission MDS dated [DATE] revealed the resident's BIMS score was left blank. The resident required limited assistance with one person assist for mobility, locomotion on and off unit, and eating. The resident required extensive assistance with 1 person assist for dressing and transfers. The resident was totally dependent with 1 person assist for toileting. Section D0500. Mood: E. Poor appetite or overeating was left blank. Section I5600. Nutritional noted Malnutrition (protein or calorie) or at risk for malnutrition. Section K0300.Weight Loss noted no or unknown weight loss. Section K0510. Nutritional Approaches: C. noted Mechanically altered diet - required change in texture of food or liquids. Record review of CR #24's Care Plan revised on 8/29/2022, read in part . Focus: Has nutritional problem or potential nutritional problem. Goal: Will comply with recommended diet for weight reduction daily through review date. Interventions: Monitor/document/report as needed any signs/symptoms of dysphagia . including refusing to eat, appears concerned during meals. House Shakes as ordered. Provide, serve diet as ordered. Monitor intake and record each meal. Staff to assist with feeding. Registered Dietician evaluate and make diet change recommendations as needed. Weigh at same time of day and record: The resident is weighed at same time using same scale . Record review of CR #24's Care Plan revised on 10/27/2022, read in part . Focus: The resident has an ADL self-care performance need. Goal: The resident will maintain current level of function in ADLs through the review date. Interventions: Eating: The resident is independent for eating . Record review of dietician's consulting notes dated 10/25/2022 read in part ., recommended he be weighed weekly, for four weeks, so a weight baseline could be reestablished . Record review of order summary report dated 11/18/2022 read in part . pureed texture, regular/thin liquids consistency, house shakes three times a day; yogurt with meals fortified meal plan . Record review of CR #24's weight logs titled Weight Summary Report dated 11/17/2022 read in part . 09/10/2022: 116 lbs., 10/11/2022: 115 lbs., and 10/25/2022: 107.6 lbs. Observation on 11/15/2022 at 10:57 a.m. revealed CR #24 was sitting in his wheelchair in the day room, in the secure unit. A head-to-toe visual assessment revealed he had a stoma (opening on the abdomen), was thin (cheek bones were noticeable on his face), and his skin looked pale. Observation and interview on 11/18/2022 at 10:34 a.m. revealed the ADON weighing CR #24 on a flat weight scale. The ADON went to CR #24's room and got the wheelchair. She took the wheelchair to the flat scale and weighed the empty wheelchair. She recorded the weight of the empty wheelchair. She went to CR #24's room and transferred him to his wheelchair. She propelled him to the flat scale and weighed him. She noted the resident's weight with him in the wheelchair and she subtracted the weight of the empty wheelchair to arrive at resident's last weight which was recorded at 91.8 lbs. During an interview on 11/18/22 at 12:46 p.m. CEO/Owner said he had been part owner of the facility for about 4-5 months. He said he believed the DON notified him about the broken weight scale at the facility. He said he could not recall the date but believed it was right away. He said if the facility needed a piece of equipment to be replaced, the Administrator and/or the DON would notify him. He said once notified, he would move forward with the purchase, especially when it affected patient care. He said he instructed the DON and the Administrator to locate a scale to rent. He said a vendor to rent from could not be located. He said he could not recall what vendors had been contacted. He said the weight scale was purchased on 11/01/2022. During an interview on 11/18/2022 at 1:43 p.m. with the RA, she said she had been at the facility for about 12 years. She said on or about 10/01/2022 CR #24 had a healthy appetite, was very active, but his health had declined when she returned to work on 11/11/2022. She said CR #24 only drank his mighty protein shakes. She said she reported it to RN A. She said she got him a mighty shake with all his meals. She said she helped him drink his shakes. She said he would drink them with assistance. She said he had not been eating. She said she would get him ice cream to help him with his caloric intake. She said she reported the resident's change in condition to LVN F. During a telephone interview on 11/18/22 at 2:21 p.m. with CR #24's family member, he said he had concerns with CR #24's eating and weight loss, but the facility had not communicated to him that he had not been eating. Resident's family member said he found out about resident not eating when he visited the facility and told them he was concerned about resident's respiratory care. CR #24's family member visited the facility about 3 weeks ago. Resident's family member said they were not notified about any changes to the resident's diet. The resident's family member said the resident did not have an active diagnosis of cancer but had a history of cancer that went back prior to 2011. Family member said he was sent to the emergency room last month; family member said the ER doctor, from the same hospital, instructed him to ask the hospital about the resident's dehydration. Record review of CR #24's laboratory work from the emergency room noted he had a high blood urea nitrogen level of 39 milligrams per deciliter, a high Creatinine level of 1.45 milligrams per deciliter, and a normal Albumin level of 3.8 grams per deciliter. During a telephone interview on 11/18/22 at 2:48 p.m. with the facility's RDC, she said she arrived at the facility on 09/15/2022. She said she visited the facility 2-3 times per month, and she had completed a comprehensive assessment on CR #24 on 11/9/2022. She said she recommended liquid protein be added to his diet due to CR #24's rapid weight loss. She said she had a colleague, RCD #1, who saw CR #24 on 10/25/2022. She said RDC #1 recommended CR #24 be weighed weekly, for four weeks, so a weight baseline could be reestablished. RCD said she was not aware that the RDC said she was not told about the broken scale until 11/09/2022 when she was leaving the facility. Interview on 11/18/2022 at 4:15 p.m. with the Maintenance Director he said he had worked at the facility for about a month. He said he did not know if the new scale had been calibrated because it was recently delivered; he could not remember the date. The Maintenance Director said he forgot and said he had calibrated the scale. He said he used two different methods to calibrate the scale. He said he first weighed himself and the scale gave him an accurate reading, and then he took a notebook binder full of papers, weighed it, removed some papers, reweighed the binder, placed the papers back into the binder, and reweighed the binder one last time. The Maintenance Director said the weight of the binder did not change, so he knew the scale worked properly. He said he believed the scale was dropped off at the front door of the facility on Friday, 11/11/2022, and he assembled it the following Monday, 11/14/2022. He said the scale needed to be calibrated every 3 months and/or every month. The Maintenance Director said a brand-new scale must be calibrated before it is used. He said he did not recall any of the staff members asking him if the scale had been calibrated prior to use. He said he did not document when he calibrated the scale. The Maintenance Director said as far as he knew, no one contacted an outside company to calibrate the scale. He said he had not received training on how to calibrate the scale from the facility. He said he just knew how it was done from prior work experience. During a telephone interview on 11/18/2022 at 6:05 p.m. with the Speech and Language Pathologist, she said she was familiar with CR #24. She said CR #24 was eating double portions at the time of admission. She said CR #24's physical endurance started to go down because of the disease process. She said she had not conducted a swallow test. She said she did not recall receiving the recommendation from RDC #1 requesting a swallow test for CR #24. She said CR #24 was on a puree diet. She said CR #24 liked the pureed meals. She said going from pureed to mechanical soft diet would require a swallow test. She said CR #24 had a recent stay at the hospital where a swallow test should have been performed. She said she had not done any swallow test for CR #24 in the past three months. She said she went to visit CR #24 on same day to conduct a swallow test. She said CR #24 refused the shake. She said the puree diet physician order for CR #24 was sustaining him. During an interview on 11/19/2022 at 10:38 a.m. with RN A. She said she had been at the facility for about 8-9 months. She said her responsibilities included conducting assessments, monitoring residents, and talking to their doctors. She said CR #24 was sent to the hospital in the morning because he became unresponsive. She said she started CPR, one of the facility's residents' aides called 911. She said EMS arrived and changed positions with the first responder. She said CR #24 was transported to the hospital. She said she was the nurse who fed CR #24 in the morning. She said he ate grits, a little bit of oatmeal, and drank some of his milkshake. She said she left after CR #24 finished eating. During an interview on 11/19/2022 at 10:38 a.m. with the Registered Nurse A said CR #24 became unresponsive approximately 45 minutes to an hour after he finished eating breakfast. She said Cardiopulmonary Resuscitation (CPR) was preformed, 911 and called, and emergency medical services took over upon their arrival at the facility. She said resident was transported to the hospital. The Charge Nurse said she fed the resident this morning, but he did not eat much (2-3 spoonsful of grits, oatmeal, and all his milkshake). She said when she the unit he was responsive and sitting up in his wheelchair. During a telephone interview on 11/19/2022 at 11:12 a.m. with CR #24's Nurse Practitioner he said he received the terminal cancer diagnosis from resident's clinical history records. He said the facility did not provide him and he did not see any documentation that CR #24 had an active and current diagnosis of cancer before signing the Clinically Unavoidable Weight Loss form on 11/17/2022. He said the cancer diagnosis was part of CR #24's past history and that the resident had radiation in 2003. He said the resident was admitted to the facility with weight concerns and were providing shakes to him. The Nurse Practitioner asked Surveyor what the point of the investigation was and said the resident ate when he wanted. The Nurse Practitioner did not want to answer any more questions and ended the interview. During an interview on 11/19/2022 at 1:41 p.m., Administrator #2 said she had been working at the facility for about 1 month. She said she discovered that the flat weight scale was not working on 10/18/2022. Administrator #2 said she was told by corporate maintenance on 10/18/2022, during their morning meeting, the scale was broken and a new one would be purchased within that day by regional maintenance. She said she requested an update from corporate office on the scale via text on 11/01/2022 and was told it would be delivered between 11/07/2022 and 11/10/2022. She said between 10/19/2022 and 11/01/2022, corporate never provided her with an update on the purchase of the new scale. Administrator #2 said her expectation was to have one purchased and delivered sooner. She said she was still learning and did not know how larger items were purchased but called two scale vendors the following week and was told they did not rent scales. She said the risk posed to residents when there was not a functioning scale in the facility. She said it could have the potential to affect residents' quality of care. She said residents could decline, they could have excessive weight loss, and/or weight gain, and weight variations indicative of other health issues. Administrator #2 said the risk posed to residents that required to be weighed weekly created a lack of care for their required nutritional needs. She said the delivery of the flat weight scale was scheduled to arrive on 11/11/2022. She said her expectation was that the scale needed to be setup and operational the day it was received. She said maintenance was responsible for completing the task but does not work onsite on the weekends. She said she followed up with maintenance on Monday, and it was setup and operational. She said she was not aware the scale was being used without having been calibrated until yesterday. She said when a recommendation for a diet change was made for a resident by a registered dietician, her expectation was for the order to be implemented within 24 to 72 hours. She said she was not aware if the facility had a policy for addressing specific timeframes for following through on dietician recommendations. Record review of the facility's policy related to weight loss, titled Weight Assessment and Intervention not dated read in part .Policy Statement The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation Weight Assessment 1. The nursing staff will measure resident weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Admissions and monthly weights will be recorded in each unit's Weight Record chart or notebook and the individual's medical record. Weekly weeks will be tracked separately. Analysis 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; d. Whether and to what extent weight stabilization or improvement can be anticipated. Interventions 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary team effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacy, and the resident or resident's legal surrogate. Interventions 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: b. Nutrition and hydration needs of the resident . The Administrator was notified on 11/18/2022 at 7:10 p.m. that an IJ was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on 11/21/2022 at 5:24 p.m. and included: Plan of Removal The facility (Dietary Manager and DON) conducted order and tray card audits on 11/19/2022 to ensure resident supplements are accurate and available as ordered. All nutrition recommendation orders from the last dietician visit on 11/9/2022 were reviewed by the DON, dietary manager, and physician/NP on 11/19/2022 to ensure implementation. Upon review on 11/18/2022, there have been no new admissions to the facility. On the 11/17/2022, the physician signed an Unavoidable Weight Loss form. On 11/18/2022, the diet, supplement, meal intake, and weight variance of CR #24 was reviewed by nursing management due to the triggered weight loss. Education was presented by the DON on 11/19/2022 to nursing management on Change of Condition notification. There was no diagnosis given by physician for dehydration. CNAs document through the Point of Care system the percentage intake of each resident. The documentation is reviewed at each clinical meeting Clinical meetings are Monday through Friday, excluding major holidays. This is effective as of 11/21/2022. CNAs/nursing staff report intake changes to the charge nurse and/or nursing supervisor. Then the resident is assessed by a licensed nurse and appropriate interventions are implemented. Nursing staff was educated on focused meal assessment and appropriate interventions on 11/21/2022 by the DON an regional nurse. CNAs were trained to verbally report residents who have a decline in percentage of intake. The nursing staff was educated on reporting meal intake was completed on 11/21/2022 by the DON and regional nurse. Any meal with poor intake is reported to the charge nurse/nurse supervisor. Two or more meals in less than 24 hours are identified by clinical alerts on the Point of Care dashboard and/or verbal report from nursing staff prompt a notification to the RD by the nursing management team. The notification to RD education was completed by the Regional nurse with the nursing management team on 11/21/2022. The RD reviews intakes during the assessment of the residents. Each Kardex in the Point of Care system identifies residents that require assistance with meal intake and hydration. The Kardex is updated during the clinical meetings and reviewed by the nurse management team. Kardex updates are made during the clinical meetings. As of 11/21/2022, the Kardex is current and has been reviewed by the DON and ADON. On 11/18/2022, the facility manually calibrated a new scale and assessed Resident #1 to begin to establish an accurate baseline weight. Resident #1 had a weight of 93.6 pounds. The physician was notified on 11/18/2022. The resident is not presently in the facility, discharged to the hospital. The new floor scale arrived for the facility on 11/11/2022 and was manually calibrated by the maintenance department on 11/18/2022. Hoyer lift scales were verified by an outside vendor for accuracy on 11/18/2022. A training on the use of the Hoyer lift scales was initiated on 11/19/2022 by the maintenance department for nursing management and with the designated staff assigned with weighing the residents. Additional training was provided by the maintenance director for use of the platform scale on 11/19/2020. Any suspicion of inaccuracy must be immediately reported to maintenance (via maintenance log), DON, or Administrator. Record review of CR #24's electronic Weight Summary, noted the following: August 2022: Resident was not weighed upon admission. September 6, 2022, at 3:04 p.m.: 116.0 pounds October 7, 2022, at 4:35 p.m.: 115.0 pounds October 21, 2022, at 10:26 a.m.: 107.6 pounds Record review of RDC #1's Nutrition Recommendation Form, dated 09/19/2022, noted Speech Language Pathologist consult for diet texture upgrade to regular. Record Review of CR #24's Care Plan Conference meeting notes, dated 10/19/2022, noted resident's family members and facility staff were in attendance. No nutritional and or weight concerns noted. Noted under Consults Needed section was none. Record review of RDC #2's Progress Notes for CR #24, dated 10/25/2022, noted resident had a 7.2% weight change in the past 30 days and there were no recent labs to review. RDC #2 noted the new scale was being used, possibly needed to be calibrated, and plan was placed to weigh resident weekly for the next four weeks to reestablish baseline weight. Record review of CR #24's emergency room report, dated 10/27/2022, noted resident was admitted , on 10/26/2022 at 8:38 p.m., for vomiting. Further review noted, resident had a history of Squamous Cell carcinoma of larynx (diagnosed 01/2003 and surgery completed on 04/16/2022) and history of cancer. Per family member, resident vomited yesterday (10/25/2022) and today (10/26/2022) at the facility. Noted on the report, under Assessment and Plan read in part, Per nutrition: suspect malnutrition, pureed menu, small frequent meals, continue boost plus. Record review of CR #24's electronic RDC #1 notes, dated 11/09/2022, noted resident lost a significant amount of weight since returning from hospital and being admitted (-8% x 60 days). RDC #1 noted resident's intake was okay and was mostly at 51-75%. RDC #1 requested liquid protein with a goal of weight remaining stable. RDC #1 recommended 30 ml (milliliter) of Protein liquid daily. Goal included maintaining a stable weight at 107 pounds (lbs.) and/or weight gain of 160 lbs. x 30 days. Goal also included an intake of meals/snacks/supplements by mouth improving to greater than (>) 75% x 30 days. Record review of CR #24's electronic Orders noted, Protein Liquid was ordered on 11/16/2022 and started on 11/17/2022, due to unspecified protein-calorie malnutrition. (The protein supplement order was placed 7 days and started 8 days after the RDC #2's recommended request on 11/09/2022.) All 54 residents have the potential to be affected, all residents will be weighed weekly for 4 weeks to reestablish baseline weights beginning 11/18/2022, with the first weekly weights being completed on 11/19/2022. Weekly weights will be monitored by DON/designee for weight variance greater than equal to 3% and/or 3 pounds beginning 11/20/2022. Any weekly weights greater than the parameter will receive physician and dietician notification in order to mitigate any patient decline beginning December 3 (week 3). Three residents were identified with weight loss. The RPs, physicians, and dietician were notified on 11/20/2022. The recommendation by the Physician was to continue with the current plan of care until the nest scheduled visit. On 11/18/2022, the facility completed a manual calibration in-service by maintenance department for the current scale with the nursing management and designees. A floor scale and two Hoyer scales are available for resident assessments. As of 11/18/2022, the scale is installed, calibrated, and operational. Baseline weights are being established on all residents in the facility. The first week of weights was completed on 11/19/2022 by nursing management and an additional nursing designee. The scale was calibrated prior to being used to record resident weights. All residents are potentially at risk, the dietician and medical director have been notified on 11/19/2022 for additional recommendations regarding weight loss concerns for the residents, as well as identifying the ideal weights for the residents. The pharmacy consultant has been contacted on 11/19/2022 to conduct a medication review for proper dosage corresponding to accurate weight. The facility (IDT team) will discuss weights during the morning meeting, weekly during the risk assessment meetings, monthly during QAPI, and as needed. The findings will be documented on QA forms and verified by the Administrator beginning 11/19/2022. By 11/19/2022, all residents will have a new initial weight established. On 11/19/2022, all supplement orders were audited for accuracy with dietary and nursing. The orders were accurate. The DON and Administrator made necessary notifications to the Medical Director, Pharmacy consultant, and dietician. The RP of Resident #1 was contacted (no answer, voice message left) to discuss care intentions. There was an emergency QAPI meeting held on 11/19/2022 at 3:12 pm via zoom with the Medical Director, DON, Administrator, DOR, Dietary Manager, Unit Manager, and corporate maintenance to discuss the preliminary findings, in-services, and interventions. The policies and procedures reviewed by QAPI committee in emergency meeting on 11/19/2022 include Change of condition; procedures for weighing residents; abuse and neglect; when to notify DON, Administrator, family and/or physician; and clinical meeting responsibilities The DON, Administrator, and regional nurse were responsible for preparing the QA tracking tools. The training occurred on 11/19/2022 with the facility staff and will be ongoing to capture staff on leave/absent and as part of new hire orientation. The DON and ADON were responsible for the training. A training will be placed in staffing sign in book on 11/20/2022 as a reference and for any agency staff to be available prior to a shift. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 11/22/2022 through 11/23/2022. Monitoring of the POR included: Observations and interview on 11/22/2022 at 10:15 a.m. revealed the facility had one platform scale and two Hoyer lift scales installed and operational. The Restorative Aide checked the platform scale for accuracy using hand weights and the scale displayed the same weight as the hand weights. CNAs were observed documenting meal intakes and checked meal assistance needs. RA verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/22/2022 at 10:30 a.m. with CNA L. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/22/2022 at 10:45 a.m. with CNA P. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/22/2022 at 11:00 a.m. with LVN D. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/22/2022 at 11:00 a.m. with LVN F. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/23/2022 at 2 p.m. with LVN G. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/23/2022 at 2:15 p.m. with DON. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/23/2022 at 2:35 p.m. with ADON A. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/23/2022 at 2:45 p.m. with Dietary Manager. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/23/2022 at 3:00 p.m. with Regional Maintenance Director. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on 11/23/2022 at 3:00 p.m. with QA Lead Corporate Nurse. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. Interview on 11/23/2022 at 10:18 a.m., the DON said if a resident ate less than 50% for 2 or more meals, the facility would offer a supplement, identify food preference, and notify the nurse, who would assess the resident. She said the nurse would notify the DON, MD, and RD. She said the scales could not be manually calibrated but could be checked for accuracy by putting a weight on it. She said the scales would be calibrated at least quarterly. The DON said the weights would be monitored weekly for 4 weeks to establish a baseline and any weekly weight that has a 3-to-5-pound discrepancy would be reported to the RD for intervention; if it was a huge loss, the MD would also be notified. Record review of the facility's in-service training related to a resident's change in condition dated 11/21/2022 confirmed that DON, ADON A, LVN F, LVN D, LVN G, CNA L, CNA P, RA, Dietary Manager, Regional Maintenance Director, and the QA Lead Corporate Nurse were all in attendance. The topic included training on how to report residents who were showing a decline in food intake. Record review of the facility's in-service training related to procedures for weighing residents dated 11/21/2022 confirmed that DON, ADON A, LVN F, LVN D, LVN G, CNA L, CNA P, RA, Dietary Manager, Regional Maintenance Director, and the QA Lead Corporate Nurse were all in attendance. The topic included training on how to weigh residents using the facility's scale. Record review of the facility's in-service training related to procedures for abuse and neglect dated 11/21/2022 confirmed that DON, ADON A, LVN F, LVN D, LVN G, CNA L, CNA P, RA, Dietary Manager, Regional Maintenance D[TRUNCATED]