Every finding on record at Agawam North Rehab and Nursing

Based on observations, interviews, and record review, the facility failed to ensure the main facility kitchen and one (C Wing) kitchenette, out of the four facility kitchenettes, used to store, prepare and distribute resident food and beverages were maintained in a clean and sanitary manner in accordance with food service safety standards.Specifically, the facility failed to ensure that:-the floor of the walk-in freezer was appropriately cleaned as required and food was stored off the freezer floor. -the commercial food processor used to prepare a variety of the Resident's therapeutic diets was appropriately cleaned as required.-the facility and Resident food items stored on the C Wing Kitchenette were properly labelled, dated, stored and/or discarded timely. Findings include: Review of the Food Drug Administration (FDA) Food Code 2017 (www.fda.gov), indicated the following: -Food Preparation: >During preparation, unpackaged food shall be protected from environmental sources of contamination. -Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: >the objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. >Microorganisms may be transmitted from food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. >Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. >Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. >The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. -Cleaning, Frequency and Restrictions: >Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when food is in protected storage and when food is not being served or prepared. Review of the instructions provided by the facility for the commercial food processor, dated 3/5/23, indicated:>CLEANING:-the bowl and lid attachments should be cleaned per the following instructions or as required by the local health department regulations.-the bowl, blade, lid, pushers, and plates are dishwasher safe. All of the attachments listed above can be washed in a dish machine or three-tank system pot sink. -Pre-rinse the attachments before washing to remove any bulk food on the parts.-A stiff bristle brush or power sprayer faucet attachment is effective in knocking the food out of the crevices as a pre-rinse procedure. -the washer should have an industry standard wash, rinse and sanitization cycle.-Clean the outside of the bowl, the lid and around the switch pin to ensure that they are clean. Use a brush on these areas if necessary. Review of the facility policy titled Food Storage Areas, last revised 11/5/25, indicated:-food storage areas shall be maintained in a clean, safe and sanitary manner.-food services, or other designated staff, will maintain clean food storage areas.-all foods stored in walk-in refrigerators and freezers will be stored on shelves, racks, dollies or other surfaces that facilitate through cleaning. -prepared food stored in the refrigerator until service shall be dated. Such food will be tightly sealed with plastic wrap, foil or a lid. Review of the facility policy for Food Brought by Families and Visitors, last revised 11/5/25 indicated: -perishable foods must be discarded after an appropriate time (specific to food and temperature). -Food kept in the refrigerator for a resident must be labeled with the resident's name and the date. On 6/4/26 at 7:27 A.M., the surveyor observed the following during the initial main kitchen walk through: >In the walk-in freezer:-Four boxes (croissants, tortillas, steak) placed on the floor in the middle of the freezer.-the floor of the freezer had scattered peas on the ground, along with dark brown grainy particles on the floor and under the shelving units. During an interview at the time, Dietary Staff #1 said that the boxes of food should not have been on the floor and moved them onto the shelves. >In the main kitchen: -a commercial food processor with a long cylindrical compartment located on the side of the bowl that was filled from top to bottom with a pureed mixture of multi-colored substance (dark, light brown, black). The surface of the lid and the machine base were also covered in red and white dust. During an interview at the time, Dietary Staff #1 said that the machine had last been used the previous day and had not been cleaned since. During an interview on 6/4/26 at 7:41 A.M., the Food Service Director (FSD) said that she did not know how to remove the old food from the cylindrical compartment of the food processor. The FSD said that she should have put in a work order to the facility's maintenance system to address the concern, but she had not. On 6/5/26 at 11:25 A.M., the surveyor observed the following during the follow-up visit to the main kitchen: >In the walk-in freezer:-the scattered peas and dark brown grainy particles remained on the floor, in addition to a 20-ounce juice cup. During an interview at the time, the FSD said that the floor was dirty and that she would clean it up. The FSD also said regarding the food processor that she was unaware of how to take the compartment apart to clean it and that the cylindrical compartment was not being cleaned until the surveyor had brought it to the FSD's attention the previous day. On 6/8/26 at 2:27 P.M., the surveyor and the FSD observed the following on the C Wing kitchenette: >In the cupboards: -one clear, four-ounce unsealed plastic container with a white creamy substance, unlabeled and undated.-one clear, two-ounce covered plastic container, with a creamy brown substance, unlabeled and undated.-one opened, undated, 17.7-ounce container of Breakfast Essentials milk chocolate powder, with no resident identifier. -two opened 1.36 Liter containers of orange juice thirster, unrefrigerated and undated. -one opened liter of ginger ale, unrefrigerated and undated. >In the refrigerator:-one opened 15-ounce jar of Lay's French Onion Dip, dated 4/8/26.-one opened 1-pound (lb.) container of oven roasted turkey breast, dated 4/27/26. >In the freezer:-one unsealed, opened 1lb. box of corn dogs, dated 3/19/26. During an interview at the time, the FSD said that all the old, unlabeled opened food items should have been thrown in the garbage. The FSD also said that the concern with the old, unlabeled, and undated food was that staff did not know how long it had been there and that it had the potential to make the residents ill.

Based on observations, interviews, and records reviewed, the facility failed to provide rehabilitative services per the Resident's plan of care, for one Resident (#98), out of a total sample of 22 residents.Specifically, for Resident #98, the facility failed to address timely the Consulting Provider's recommendations for Physical Therapy services for left leg strengthening, resulting in delayed implementation of therapy services. Findings include:Review of the facility policy titled Rehabilitation Services in Skilled Nursing Facility, revised 1/20/26, indicated but was not limited to the following:-Rehabilitation services, including physical therapy.will be delivered by licensed and qualified staff in accordance with best practices, resident-centered care, and regulatory guidelines.-A comprehensive evaluation and/or screen will be conducted by a licensed therapist when clinically indicated/ordered by a physician.-Rehabilitation services will be provided based on the established care plan. Resident #98 was admitted to the facility in April 2025, with diagnoses including acquired absence of right leg below knee, muscle weakness, and acquired absence of left toe. During an interview on 6/4/26 at 9:51 A.M., Resident #98 said his/her right leg was amputated several years ago, and recently his/her left great toe required amputation. Resident #98 said since the left great toe amputation, he/she transfers (chair/bed to chair) using a Hoyer (mechanical lift), when previously he/she transferred using a stand/pivot method. Resident #98 said things would be better if he/she was able to start rehabilitative services. Resident #98 said he/she preferred when he/she was able to get out of bed without the use of the Hoyer. Review of Resident #98's Physical Therapy Discharge Summary indicated:-Dates of service: 10/20/25 through 12/18/25.-Transfers: Patient is able to perform 75 percent (%) or more of the activity but requires weight bearing assistance from one caregiver to complete. Review of Resident #98's Report of Consultation with the Vascular Specialist dated 4/28/26 indicated:-Okay to work with Physical Therapy for left leg strengthening.-Left great toe amputation fully healed. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #98:-was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15 points.-required substantial/maximal assistance with chair/bed-to-chair transfers.-Did not have the ability to walk at least ten feet during the observation period. Review of Resident #98's Progress Note dated 5/6/26 and signed by Medical Records staff indicated therapy was asking for the weight bearing status of the Resident's left foot from the Vascular Specialist, and the Vascular Specialist's office would fax over the response to the facility. Review of fax communication between the facility and the Vascular Specialist's office indicated the facility contacted the Vascular Specialist's office on 5/6/26 requesting clarification on weight-bearing status of Resident #98's left foot. The Vascular Specialist indicated on 5/6/26 that the Resident could weight-bear on the left foot as tolerated. During an interview on 6/9/26 at 11:08 A.M., Occupational Therapist (OT) #2 said Resident #98's care was provided at bed level due to an infection in his/her left foot, which was chronic since the toe amputation. OT #2 said the Resident required a Hoyer transfer. OT #2 said there had not been any referrals placed for Occupational Therapy services since the Resident's OT evaluation on 3/17/26. During an interview on 6/9/26 at 11:24 A.M., the Director of Rehabilitative (Rehab) Services said Resident #98 was most recently discharged from Physical Therapy services on 12/18/25. The Director of Rehab said the Rehab department had not received any referrals for Rehab services since the Resident's discharge from services on 12/18/25. The Director of Rehab said Resident #98 told her that he/she wanted to receive rehab therapy, but there was not any justification for services, as the Resident's transfer status and weight-bearing status had not changed. The Director of Rehab said for Resident #98 to resume therapy he/she would see the Specialist relative to determining weight-bearing status on the Resident's left foot, and then the nursing staff would receive the Consultation Report and write a referral for a Rehab screen if the Specialist indicated that the Resident was able to bear weight on the left foot. During a follow-up interview on 6/9/26 at 12:00 P.M., The Director of Rehab said Resident #98 had an appointment scheduled with his/her Vascular Specialist on 6/10/26 relative to the left great toe amputation and weight-bearing status. The Director of Rehab said she would review the Consultation Report from 6/10/26 appointment to determine whether the Resident was allowed to bear weight on the left foot. During an interview on 6/9/26 at 3:27 P.M., Unit Manager (UM) #1 said she reviewed Resident #98's Consultation Report from an appointment with the Vascular Specialist on 4/28/26. UM #1 said the report indicated Resident #98 was okay to work with Physical Therapy for left leg strengthening, and that the left great toe amputation had fully healed. UM #1 said the facility contacted the Vascular Specialist on 5/6/26 to request clarification relative to the Resident's weight-bearing status. UM #1 said the Resident should have been referred to Rehab when the facility was notified of the Resident's weight-bearing status of the left foot on 5/6/26. During an interview on 6/9/26 at 3:41 P.M., the Director of Nursing (DON) said Resident #98 attended an appointment on 4/28/26, and the Rehab department requested clarification of the Resident's weight-bearing status on 5/6/26. The DON said the clarification was provided to the facility, however the documentation that clarified the Resident's weight-bearing status had not been provided to the team for review, as was the typical process. The DON said that as a result, the team was not aware that the Resident's weight-bearing status had changed. The DON said the expectation was once the weight-bearing status had been determined to have changed; the Provider would be contacted so that the Provider could give orders such as participation in Rehab therapy. The DON said the recommendations from the Vascular Specialist were not followed, which was a concern because it could affect the Resident's plan of care.

Based on observation, interview and record review, the facility failed to adhere to infection control standards of practice, increasing the risk of contamination and spread of infections for one Resident (#6), out of a total sample of 22 residents. Specifically, for Resident #6, the facility failed to ensure that hand hygiene and glove changes were performed during wound care dressing changes as required to prevent the potential for infection and/or deterioration of the wounds. Findings include: Review of the facility policy titled Wound Care, revised October 2025, included but not limited to:*The purpose of this procedure is to provide guidelines for the facility staff in providing wound care. -General Guidelines>Hand hygiene.>DON (put on) PPE (personal protective equipment- items such as gowns and gloves worn to prevent the spread of infection).>Remove dressing to be changed and discard.>Remove gloves and discard. Hand hygiene. DON new gloves.>Clean wound bed per order.>Remove gloves and discard. Hand hygiene. DON gloves>Place new dressing.>Remove gloves and discard. Hand hygiene. Review of the facility policy titled Standard Precautions, revised October 28, 2025, included but not limited to: *It is this facility's policy that Standard Precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection disease process. Standard precautions assume all blood, body fluids and secretions/excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. -Procedure-Hand Washing>After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn.>Immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganism to other residents or environments; and>Between tasks and procedures on the same resident to prevent cross-contamination of different body sites.-Gloves Use>Staff will wear clean non-sterile gloves:>When touching blood, body fluids, secretions, excretions, and contaminated items; and.>Before touching mucous membranes and broken skin.>Gloves will be changed between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms.>Gloves will be removed promptly after use, before touching non-contaminated items and environment surfaces, and before going to another resident.>Hands should be washed immediately after removal of gloves to avoid transfer of microorganisms to other residents or environments. Resident #6 was admitted to the facility in December 2025 with diagnoses including Type 2 Diabetes Mellitus without complications, essential primary hypertension and wound on right buttock. Review of the Minimum Data Set (MDS) Assessment, dated 3/24/26, indicated Resident #6: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15. -had a surgical wound. Review of Resident #6's June 2026 Physician's orders included: -Right buttock: Cleanse with NS (normal saline), pat dry, apply collagen (topical dressing used to speed up and regulate the healing of skin wounds), and cover with a superabsorbent pad as needed for soiling, saturation, or accidental removal, initiated 5/27/26. -Right buttock: Cleanse with NS, pat dry, apply collagen, and cover with a superabsorbent pad every day shift for wound examination, initiated 5/27/26.-Infection Precautions -Enhanced Barrier - wound: staff wear gown/gloves when in direct patient contact every shift: Signage on door. Gown and gloves required for the following high-contact care activities: Dressing, Bathing/Showering, Transfer, Changing Linens, Providing Hygiene, changing briefs/assist with toileting, Device care/use and or wound care, initiated 5/21/26. On 6/5/26 at 11:00 A.M., the surveyor observed the following during wound care performed by Nurse #2: -Signage posted outside of Resident #6's room indicating that the Resident was on Enhanced Barrier Precaution (EBP's - use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing). -Nurse #2 used alcohol-based hand rub (ABHR), donned gloves and a gown, and entered the Resident's room with the following items: wound cleanser solution, a sachet of collagen, 4x4 gauze sponges, superabsorbent dressing, a box of gloves. -Nurse #2 cleaned the bedside table with a cleaning agent, allowed it to dry and placed the wound dressing supplies on the bedside table. -Nurse #2 assisted the Resident in repositioning to his/her left side on the bed, doffed (removed) his gloves, used ABHR and reapplied his gloves. -Nurse #2 adjusted the Resident's briefs to reveal the right buttock wound and no dressing was observed in place on the Resident's right buttock. -Nurse #2 cleaned the Resident's right buttock wound with 4x4 gauze sponges, sprayed with wound cleanser, and disposed of the 4x4 gauze in the trash container, and did not change gloves or perform hand hygiene. -Nurse #2 began to pat dry the wound with a new 4x4 gauze sponge without changing gloves or performing hand hygiene. -Nurse #2 applied collagen to a 4x4 gauze sponge and applied the collagen to the wound bed and covered the wound with the superabsorbent dressing utilizing the soiled gloves used to clean the wound. During an interview on 6/5/26 at 11:10 A.M., Unit Manager (UM) #2 said Nurse #2 should have changed his gloves and performed hand hygiene after positioning the Resident, after cleaning the wound, and before applying collagen and dressing to the wound. UM #2 said it was important for Nurse #2 to change his gloves and perform hand hygiene frequently when providing wound care to Resident #6. UM #2 said the risk to the Resident was the transfer of germs from Nurse #2's gloves after cleaning the wound, which could lead to deterioration and infection of Resident #6's wound.

Based on interviews, and record review, the facility failed to ensure that professional standards of practice for medication administration were maintained, resulting in significant medication error for one Resident (48) out of a total sample size of 22 residents.Specifically, for Resident #48, the facility failed to ensure that Midodrine (medication used to treat low blood pressure [hypotension]) medication was administered within the prescribed parameters per Physician's order to hold (not administer) the medication for a Systolic Blood Pressure (SBP - top number of a blood pressure reading) greater than 100 millimeters of Mercury (mmHg), when the Resident was administered the Midodrine medication outside of the prescribed parameters, placing him/her at risk for cardiac complications and high blood pressure. Findings include: Review of the facility policy titled Administering Medication, revised 10/15/25, included but was not limited to:*To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations.-Medications shall be administered according to Physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards. -Vital signs shall be evaluated as clinically indicated.-Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall chart in the Electronic Medical Record (eMAR) and sign off for that particular drug and document a rationale.-Should a medication be withheld or refused, the Physician will be notified when three (3) consecutive doses or a pattern of frequent withholding or refusal is noted. Documentation identifying the explanation of withholding or reason for refusal will be documented in the medical record. Review of the facility policy titled Specific Medication Administration Procedures, dated November 2021, included but was not limited to:*To administer medications in a safe and effective manner.-Review 5 Rights (3) times:-Prior to removing the medication package/container from the cart/drawer;>Check MAR (Medication Administration Record)/TAR (Treatment Administration Record) for order.>Note any allergies or contraindications the resident may have prior to drug administration.>Check for vital signs, other tests to be done during/prior to medication administration.>Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration.-Notification of Physician/Prescriber.>Held medications for pulse, blood pressure, low or high blood sugar, or other abnormal test results, vital signs, resulting in medications being held. Review of the facility policy titled Change in Condition Procedure, revised October 24, 2025, included but was not limited to:*This facility will provide guidelines for the appropriate handling of a resident's change in condition. We recognize that each situation is unique and must be handled in the manner that is most appropriate at the time and for the nature of the change in condition. -The following guidelines will be utilized as appropriate to each situation and change in condition:-Full Assessment by nursing staff may be include but not limited to:>Full vitals (T-temperature, P-Paulse, R-Respiration, BP-Blood Pressure, & Spo2-Peripheral Oxygen Saturation).>Notify Medical Doctor (MD) of change and give assessment information. Receive orders, if any.>If unable to reach provider, contact Medical Director or Medical Director Associate. Resident #48 was admitted to the facility in April 2026 with diagnoses including orthostatic hypotension, personal history of Transient Ischemic Attack and Cerebral Infarction without residual deficits. Review of Resident #48's June 2026 Physician's orders included:-Midodrine HCl (Hydrochloride) Oral Tablet (Midodrine HCl). Give 10 milligrams (mg) by mouth three times a day for Hypotension. Give 1 tablet by mouth three times a day for orthostatic hypotension, hold for systolic blood pressure greater than 100, initiated 5/15/26.-Vital Signs for Admission/readmission every (q) shift x 72 hours (hrs.), then per MD order every day shift, initiated 4/30/26. Review of Resident #48's May 2026 MAR (Medication Administration Record) indicated:>Midodrine HCl 10 mg was administered to Resident #48 outside the Physician's ordered parameters as follows: -5/16/26 at 6:00 A.M.: SBP - 101 mmHg.-5/20/26 at 6:00 A.M.: SBP - 116 mmHg.-5/23/26 at 6:00 A.M.: SBP - 102 mmHg.-5/23/26 at 8:00 P.M.: SBP - 105 mmHg.-5/24/26 at 6:00 A.M.: SBP - 104 mmHg. -5/26/26 at 6:00 A.M.: SBP - 101 mmHg.-5/26/26 at 8:00 P.M.: SBP - 111 mmHg.-5/27/26 at 6:00 A.M.: SBP - 114 mmHg. -5/27/26 at 8:00 P.M.: SBP - 101 mmHg. Review of Resident #48's June 2026 MAR indicated:>Midodrine HCl 10 mg was administered to Resident #48 outside the Physician's ordered parameters as follows: -6/2/26 at 12:00 P.M.: SBP - 114 mmHg.-6/5/26 at 6:00 A.M.: SBP - 103 mmHg.-6/7/26 at 9:00 P.M.: SBP - 112 mmHg. During an interview on 6/9/26 at 1:00 P.M., the surveyor and Unit Manager (UM) #2 reviewed Resident #48's MAR for May 2026 and June 2026 and UM #2 said the Physician's orders indicated to hold and not administer Midodrine 10 mg to Resident #48 when the SBP was greater than 100 mmHg. UM #2 said the Midodrine medication should have been held as ordered when the Resident's SBP was greater than 100 mmHg. UM #2 also said the Physician should have been notified for further orders when Resident #48's SBP reading was outside the Physician ordered parameters.During an interview on 6/9/26 at 1:07 P.M., the surveyor, the Director of Nursing (DON), and UM #2 reviewed Resident #48's May 2026 and June 2026 MAR and the DON said that the check mark on the MAR indicated that the medication was administered to Resident #48. The DON said Midodrine 10 mg should not have been administered to the Resident and the medication should have been held according to the Physician orders when the SBP was greater than 100 mmHg. The DON said the Physician should have been notified of the Resident's SBP (out of parameter). The DON further said that the risk to the Resident receiving Midodrine when the SBP was greater than 100 mmHg was a change in mental status.

Based on observation, interview, and record review, the facility failed to notify the Physician/Nurse Practitioner (NP) timely of a change in condition for two Residents (#13 and #47) out of a total sample of 23 residents. Specifically: 1. For Resident #13, the facility staff failed to: -notify the Physician/NP timely when a right heel wound change in condition was identified resulting in delayed treatment and monitoring of the Resident, deterioration of the wound and hospitalization for infection and management of worsening wound condition. 2. For Resident #47, facility staff failed to: -obtain weight when the Resident was readmitted to the facility after a hospitalization . -notify the Physician/NP and/or Dietician of a significant weight loss (greater than 5%) in one month, resulting in delayed treatment of the weight loss and continued weight loss experienced by the Resident. Findings include: Review of the facility's policy titled Change in Condition Procedure, revised date October 2024, indicated: -This facility will provide guidelines for the appropriate handling of a resident's change in condition. We recognize that each situation is unique and must be handled in the manner that is most appropriate at the time and for the nature of the change in condition. - Full assessment by nursing staff including but not limited to: >Full Vitals >Level of consciousness. >Functional status: >Pain. -Notify Medical Doctor (MD) of change and give assessment information. Receive orders, if any. -Initiate vital signs every shift for a minimum of 72 hours or until condition stabilizes or improves. -If not during normal business hours for provider, place call to provider to update on resident's condition if issue unresolved or there is a significant change. Review of the facility's policy titled Skin Prevention, Assessment and Treatment, revised date October 2024, indicated: -If an infection is suspected, notify the physician and obtain clinically appropriate orders. -Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher-risk residents, those that do not heal as anticipated, and those that develop complications. 1. Resident #13 was admitted to the facility in November 2023, with diagnoses including Paraplegia, Polyneuropathy, Peripheral Vascular Disease (PVD) and Unspecified Dementia. Review of the Skin Care Plan, initiated on 5/14/24, indicated Resident #13: -was at risk for skin breakdown related to moisture due to incontinence, impaired mobility, involuntary bilateral lower extremity spasms causing friction, and Dementia. The Skin Care Plan included the following intervention: -will be monitored for a change in condition and the Medical Doctor (MD) will be notified, initiated 5/15/24. Review of the Comprehensive Minimum Data Set (MDS) Assessment, dated 12/7/24, indicated Resident #13: -had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a total of 15 points. -was at risk for developing pressure injuries. -had one Stage 2 Pressure Injury (partial-thickness skin loss with exposed inner layer of skin), that was not present upon admission. -has diagnoses that included osteomyelitis (bone infection). Review of the Weekly Skin checks, dated 12/5/24 and 1/25/25, indicated a scab was present over a wound on Resident #13's right heel. Review of Resident #13's medical record failed to indicate any evidence that the scabbed area identified on the 12/5/24 and 1/25/25 skin checks was reported to the Physician or assessed as a newly identified skin issue. Review of the Physician Progress note, dated 3/25/25, indicated Resident #13: -had worsening redness to the right heel and had a scab present centrally. -had increased warmth to the right heel and foot. -had Antibiotics started. -will have x-ray of the right heel to be obtained the following day to rule out osteomyelitis. Review of the Provider (Physician Assistant [PA]) Progress note, dated 3/27/25, indicated Resident #13: -had redness of the right foot that was darkening and turning black. -had an x-ray of the right heel that revealed findings suspicious of calcaneal osteomyelitis. -in the setting of worsening wound appearance, fever and concern for osteomyelitis, the decision was made to transfer the Resident to the emergency room (ER). During an interview on 4/9/25 at 8:41 A.M., CNA #7 said on 3/23/25 she and CNA #8 noticed Resident #13's right foot and heel were swollen, and the right heel had a new black area surrounding the original scabbed area. CNA #7 said she notified the Resident's Nurse (the Assistant Director of Nursing [ADON]) and Nurse #5 who was being trained. CNA #7 said both Nurses evaluated the right foot and heel on 3/23/25 and said that since the Resident's foot was not hot, to just leave it alone at that time. During an interview on 4/9/25 at 10:18 A.M., CNA #8 said that while working on 3/23/25, she and CNA #7 noticed that the Resident had right foot swelling and redness, and the right heel wound looked different. CNA #8 said she noticed that the Resident was acting differently and was kind of quiet, which was not the Resident's usual behavior. CNA #8 said that both she and CNA #7 were concerned, and that CNA #7 reported the change in heel condition to the Resident's Nurses (Nurse #5 and the ADON). During an interview on 4/9/25 at 10:50 A.M., the ADON said that she worked on 3/23/25 from 7:00 A.M. to 7:00 P.M., but did not recall hearing anything about a change in Resident #13's condition. The ADON said it could have been because she had worked 27 hours that weekend due to a staffing shortage. The ADON said that if there was any change in condition then the Physician should have been notified right away, and further said she did not recall notifying the Physician. During an interview on 4/9/25 at 1:02 P.M., Nurse #5 said she worked on 3/23/25 on the 7:00 A.M. to 3:00 P.M. shift. Nurse #5 said that the CNA's had reported that Resident #13's right heel had increased redness. Nurse #5 said that she did not recall the change in condition being reported to the Provider on 3/23/25, but believed the ADON was reporting the change in condition. Nurse #5 said she worked the following day (3/24/25) and Resident #13 was not assigned to her but she remembered hearing that the Resident's right heel had worsened. Nurse #5 said the Resident had been sent to the hospital. Review of Resident #13's medical record failed to indicate documented evidence that the Resident's right heel was assessed on 3/23/25 and that a change in condition was reported to the Provider. During an interview on 4/9/25 at 12:56 P.M., with Physician Assistant's (PA) #1 and #2, PA #1 said that she was notified of the heel wound worsening on 3/25/25 (two days after the change in condition was identified) and first examined the Resident on 3/25/25. PA #1 said that she was not notified that the right heel wound had worsened on 3/23/25 but should have been. PA #2 reviewed the Provider Triage Notes in the Provider portal and said that Resident #13's change in condition had not been reported to any Providers on 3/23/25. PA #2 said if the facility staff had called any Provider on 3/23/25, the communication would have been logged into the system and the Provider would have made new recommendations at that time or recommended a hospital transfer. During an interview on 4/9/25 at 2:52 P.M., the Director of Nursing (DON) said that if a resident has a change in condition such as a change in skin condition or worsening of a wound, the change should be reported to the Provider that same shift or sooner if emergent. The DON said that Nurses were responsible for performing weekly skin checks on every resident and reporting any new changes or concerns to the Provider. The DON said that Resident #13 was a very high risk for infection due to a history of wounds and infections, and any change to the right heel wound or foot should have been reported immediately. The DON said if staff did not report increased redness, swelling or a change in wound condition immediately to the Provider, this would put Resident #13 at a higher risk for developing a serious infection. 2. Review of the facility policy titled Weight Assessment & Interventions, revised 12/30/24, indicated: -It is the policy of the facility to prevent significant unplanned or unavoidable weight loss for our residents. -Any weight change of five or more pounds within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will notify: >The Provider >Dietary Manager/Dietician. Resident #47 was admitted to the facility in February 2025 with diagnoses including multiple fractures of ribs, Pneumonia, Acute Respiratory Failure (ARF), and muscle weakness. Review of the Resident #47's Nutritional Risk Care Plan, initiated 2/24/25, indicated: -Monitor weight, initiated 2/21/25. -Monitor weight changes and notify MD and Dietician as needed, initiated 2/24/25. Review of the Dietician's Assessment on 2/24/25 indicated Resident #47: -weighed 148.4 pounds (lbs.) on 2/21/25. Review of the Comprehensive MDS Assessment, dated 2/28/25, indicated Resident #47: -had a mild cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a total of 15. -weighed 148 lbs. -had no weight loss. -had no weight gain. Review of Resident #47's Weight Record indicated the following: -2/25/25: 142.4 lbs. -2/25/25: 142.4 lbs.(re-weigh) -3/2/25: 143.0 lbs. -3/18/25: 131.6 lbs. -3/25/25: 130.4 lbs. -4/1/25: 131.2 lbs. -4/4/25: 125.8 lbs. Review of Resident #47's medical record indicated that the Resident was hospitalized [DATE] through 3/11/25, and returned to the facility on [DATE]. Review of the Hospital Transfer Summary, dated 3/11/25, indicated Resident #47 weighed 131 lbs. on 3/11/25 while in the hospital. Further review of the Resident's medical record failed to indicate any evidence that a weight was obtained when Resident #47 was readmitted from the hospital on 3/11/25 or that the hospital weight of 131 lbs. was reported to the Provider and/or Dietician upon readmission. During an interview on 4/7/25 at 3:50 P.M., Unit Manager (UM) #4 said a Resident that experienced a significant weight loss was considered a change in condition and should be reported to the Dietician and Provider. UM #4 said when a Resident loses or gains weight, the Resident should be re-weighed the next day and all weights are documented in the Resident's electronic medical record (EMR). UM #4 was unable to provide any evidence that Resident #47's weight was obtained when the Resident returned to the facility on [DATE], or that the Resident's Provider and/or Dietician was notified of the 131 lbs weight obtained in the hospital on 3/11/25. UM #4 was also unable to provide evidence that the weights obtained in the facility on 3/18/25 and 3/25/25 which indicated significant weight loss were reported to the Provider and/or Dietician. UM #4 said that the Resident should have been weighed on 3/11/25, upon return to the facility from the hospital. UM #4 said Resident #47's continued weight loss should have been reported to the Provider and Dietician but was not reported. During an interview on 4/7/25 at 4:45P.M., the DON said the facility staff were unable to provide evidence that Resident #47 was weighed upon return to the facility from the hospital on 3/11/25, or that the Provider and/or Dietician were notified of any subsequent weight loss that occurred after 3/11/25. The DON said that the staff should obtain resident weights upon admission and re-admission. The DON said that facility staff should be reporting any weight loss immediately to the Provider and Dietician but did not report Resident #47's weight loss. During an interview on 4/8/25 at 10:54 A.M., PA #1 said she reviewed the Provider documentation and could not find evidence that the Providers were notified of Resident #47's weight loss when the Resident returned from the hospital on 3/11/25. PA #1 also said she was not made aware of the Resident's continued weight loss since re-admission. PA #1 said that if she had been made aware of the weight loss, she would have implemented interventions such as health shakes right away, but health shakes were not implemented until 4/2/25. PA #1 said that she knows the Resident was receiving diuretic therapy (medications that help reduce fluid buildup in the body) and was not sure if the weight loss was related to fluid loss but regardless would expect the Dietician to be notified by the facility staff of a Resident's weight loss immediately so interventions can be recommended. Please refer to F686.

Based on observation, interview, and record review, the facility failed to notify the Physician/Nurse Practitioner (NP) timely of a change in condition for two Residents (#13 and #47) out of a total sample of 23 residents. Specifically: 1. For Resident #13, the facility staff failed to: -notify the Physician/NP timely when a right heel wound change in condition was identified resulting in delayed treatment and monitoring of the Resident, deterioration of the wound and hospitalization for infection and management of worsening wound condition. 2. For Resident #47, facility staff failed to: -obtain weight when the Resident was re-admitted to the facility after a hospitalization. -notify the Physician/NP and/or Dietician of a significant weight loss (greater than 5%) in one month, resulting in delayed treatment of the weight loss and continued weight loss experienced by the Resident. Findings include: Review of the facility's policy titled Change in Condition Procedure, revised date October 2024, indicated: -This facility will provide guidelines for the appropriate handling of a resident's change in condition. We recognize that each situation is unique and must be handled in the manner that is most appropriate at the time and for the nature of the change in condition. - Full assessment by nursing staff including but not limited to: >Full Vitals >Level of consciousness. >Functional status: >Pain. -Notify Medical Doctor (MD) of change and give assessment information. Receive orders, if any. -Initiate vital signs every shift for a minimum of 72 hours or until condition stabilizes or improves. -If not during normal business hours for provider, place call to provider to update on resident's condition if issue unresolved or there is a significant change. Review of the facility's policy titled Skin Prevention, Assessment and Treatment, revised date October 2024, indicated: -If an infection is suspected, notify the physician and obtain clinically appropriate orders. -Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher-risk residents, those that do not heal as anticipated, and those that develop complications. 1. Resident #13 was admitted to the facility in November 2023, with diagnoses including Paraplegia, Polyneuropathy, Peripheral Vascular Disease (PVD) and Unspecified Dementia. Review of the Skin Care Plan, initiated on 5/14/24, indicated Resident #13: -was at risk for skin breakdown related to moisture due to incontinence, impaired mobility, involuntary bilateral lower extremity spasms causing friction, and Dementia. The Skin Care Plan included the following intervention: -will be monitored for a change in condition and the Medical Doctor (MD) will be notified, initiated 5/15/24. Review of the Comprehensive Minimum Data Set (MDS) Assessment, dated 12/7/24, indicated Resident #13: -had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a total of 15 points. -was at risk for developing pressure injuries. -had one Stage 2 Pressure Injury (partial-thickness skin loss with exposed inner layer of skin), that was not present upon admission. -has diagnoses that included osteomyelitis (bone infection). Review of the Weekly Skin checks, dated 12/5/24 and 1/25/25, indicated a scab was present over a wound on Resident #13's right heel. Review of Resident #13's medical record failed to indicate any evidence that the scabbed area identified on the 12/5/24 and 1/25/25 skin checks was reported to the Physician or assessed as a newly identified skin issue. Review of the Physician Progress note, dated 3/25/25, indicated Resident #13: -had worsening redness to the right heel and had a scab present centrally. -had increased warmth to the right heel and foot. -had Antibiotics started. -will have x-ray of the right heel to be obtained the following day to rule out osteomyelitis. Review of the Provider (Physician Assistant [PA]) Progress note, dated 3/27/25, indicated Resident #13: -had redness of the right foot that was darkening and turning black. -had an x-ray of the right heel that revealed findings suspicious of calcaneal osteomyelitis. -in the setting of worsening wound appearance, fever and concern for osteomyelitis, the decision was made to transfer the Resident to the emergency room (ER). During an interview on 4/9/25 at 8:41 A.M., CNA #7 said on 3/23/25 she and CNA #8 noticed Resident #13's right foot and heel were swollen, and the right heel had a new black area surrounding the original scabbed area. CNA #7 said she notified the Resident's Nurse (the Assistant Director of Nursing [ADON]) and Nurse #5 who was being trained. CNA #7 said both Nurses evaluated the right foot and heel on 3/23/25 and said that since the Resident's foot was not hot, to just leave it alone at that time. During an interview on 4/9/25 at 10:18 A.M., CNA #8 said that while working on 3/23/25, she and CNA #7 noticed that the Resident had right foot swelling and redness, and the right heel wound looked different. CNA #8 said she noticed that the Resident was acting differently and was kind of quiet, which was not the Resident's usual behavior. CNA #8 said that both she and CNA #7 were concerned, and that CNA #7 reported the change in heel condition to the Resident's Nurses (Nurse #5 and the ADON). During an interview on 4/9/25 at 10:50 A.M., the ADON said that she worked on 3/23/25 from 7:00 A.M. to 7:00 P.M., but did not recall hearing anything about a change in Resident #13's condition. The ADON said it could have been because she had worked 27 hours that weekend due to a staffing shortage. The ADON said that if there was any change in condition then the Physician should have been notified right away, and further said she did not recall notifying the Physician. During an interview on 4/9/25 at 1:02 P.M., Nurse #5 said she worked on 3/23/25 on the 7:00 A.M. to 3:00 P.M. shift. Nurse #5 said that the CNA's had reported that Resident #13's right heel had increased redness. Nurse #5 said that she did not recall the change in condition being reported to the Provider on 3/23/25, but believed the ADON was reporting the change in condition. Nurse #5 said she worked the following day (3/24/25) and Resident #13 was not assigned to her but she remembered hearing that the Resident's right heel had worsened. Nurse #5 said the Resident had been sent to the hospital. Review of Resident #13's medical record failed to indicate documented evidence that the Resident's right heel was assessed on 3/23/25 and that a change in condition was reported to the Provider. During an interview on 4/9/25 at 12:56 P.M., with Physician Assistant's (PA) #1 and #2, PA #1 said that she was notified of the heel wound worsening on 3/25/25 (two days after the change in condition was identified) and first examined the Resident on 3/25/25. PA #1 said that she was not notified that the right heel wound had worsened on 3/23/25 but should have been. PA #2 reviewed the Provider Triage Notes in the Provider portal and said that Resident #13's change in condition had not been reported to any Providers on 3/23/25. PA #2 said if the facility staff had called any Provider on 3/23/25, the communication would have been logged into the system and the Provider would have made new recommendations at that time or recommended a hospital transfer. During an interview on 4/9/25 at 2:52 P.M., the Director of Nursing (DON) said that if a resident has a change in condition such as a change in skin condition or worsening of a wound, the change should be reported to the Provider that same shift or sooner if emergent. The DON said that Nurses were responsible for performing weekly skin checks on every resident and reporting any new changes or concerns to the Provider. The DON said that Resident #13 was a very high risk for infection due to a history of wounds and infections, and any change to the right heel wound or foot should have been reported immediately. The DON said if staff did not report increased redness, swelling or a change in wound condition immediately to the Provider, this would put Resident #13 at a higher risk for developing a serious infection. 2. Review of the facility policy titled Weight Assessment & Interventions, revised 12/30/24, indicated: -It is the policy of the facility to prevent significant unplanned or unavoidable weight loss for our residents. -Any weight change of five or more pounds within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will notify: >The Provider >Dietary Manager/Dietician. Resident #47 was admitted to the facility in February 2025 with diagnoses including multiple fractures of ribs, Pneumonia, Acute Respiratory Failure (ARF), and muscle weakness. Review of the Resident #47's Nutritional Risk Care Plan, initiated 2/24/25, indicated: -Monitor weight, initiated 2/21/25. -Monitor weight changes and notify MD and Dietician as needed, initiated 2/24/25. Review of the Dietician's Assessment on 2/24/25 indicated Resident #47: -weighed 148.4 pounds (lbs.) on 2/21/25. Review of the Comprehensive MDS Assessment, dated 2/28/25, indicated Resident #47: -had a mild cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a total of 15. -weighed 148 lbs. -had no weight loss. -had no weight gain. Review of Resident #47's Weight Record indicated the following: -2/25/25: 142.4 lbs. -2/25/25: 142.4 lbs.(re-weigh) -3/2/25: 143.0 lbs. -3/18/25: 131.6 lbs. -3/25/25: 130.4 lbs. -4/1/25: 131.2 lbs. -4/4/25: 125.8 lbs. Review of Resident #47's medical record indicated that the Resident was hospitalized [DATE] through 3/11/25, and returned to the facility on 3/11/25. Review of the Hospital Transfer Summary, dated 3/11/25, indicated Resident #47 weighed 131 lbs. on 3/11/25 while in the hospital. Further review of the Resident's medical record failed to indicate any evidence that a weight was obtained when Resident #47 was re-admitted from the hospital on 3/11/25 or that the hospital weight of 131 lbs. was reported to the Provider and/or Dietician upon readmission. During an interview on 4/7/25 at 3:50 P.M., Unit Manager (UM) #4 said a Resident that experienced a significant weight loss was considered a change in condition and should be reported to the Dietician and Provider. UM #4 said when a Resident loses or gains weight, the Resident should be re-weighed the next day and all weights are documented in the Resident's electronic medical record (EMR). UM #4 was unable to provide any evidence that Resident #47's weight was obtained when the Resident returned to the facility on 3/11/25, or that the Resident's Provider and/or Dietician was notified of the 131 lbs weight obtained in the hospital on 3/11/25. UM #4 was also unable to provide evidence that the weights obtained in the facility on 3/18/25 and 3/25/25 which indicated significant weight loss were reported to the Provider and/or Dietician. UM #4 said that the Resident should have been weighed on 3/11/25, upon return to the facility from the hospital. UM #4 said Resident #47's continued weight loss should have been reported to the Provider and Dietician but was not reported. During an interview on 4/7/25 at 4:45P.M., the DON said the facility staff were unable to provide evidence that Resident #47 was weighed upon return to the facility from the hospital on 3/11/25, or that the Provider and/or Dietician were notified of any subsequent weight loss that occurred after 3/11/25. The DON said that the staff should obtain resident weights upon admission and re-admission. The DON said that facility staff should be reporting any weight loss immediately to the Provider and Dietician but did not report Resident #47's weight loss. During an interview on 4/8/25 at 10:54 A.M., PA #1 said she reviewed the Provider documentation and could not find evidence that the Providers were notified of Resident #47's weight loss when the Resident returned from the hospital on 3/11/25. PA #1 also said she was not made aware of the Resident's continued weight loss since re-admission. PA #1 said that if she had been made aware of the weight loss, she would have implemented interventions such as health shakes right away, but health shakes were not implemented until 4/2/25. PA #1 said that she knows the Resident was receiving diuretic therapy (medications that help reduce fluid buildup in the body) and was not sure if the weight loss was related to fluid loss but regardless would expect the Dietician to be notified by the facility staff of a Resident's weight loss immediately so interventions can be recommended. Please refer to F686.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent and treat a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin decline for one Resident (#13), of 5 applicable residents, out of a total sample of 23 residents. Specifically, for Resident #13, the facility failed to: -appropriately and timely assess an identified scab of the right heel after a previous wound had healed, when the Resident was identified as being at high risk for developing pressure ulcers. -assess the Resident's condition timely after an identified change in condition of the Resident's right heel and surrounding skin was identified by staff, resulting in hospitalization for infection of the right foot that required surgical debridement. Findings include: Review of the facility's policy titled Skin Prevention, Assessment and Treatment, revised October 2024, indicated: -To identify factors that place the residents at risk for the development of pressure ulcers. -To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. -To promote healing of existing pressure ulcers. -All residents should have their skin integrity examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. -Certified Nurses Aides (CNAs) should observe skin integrity during the daily provision of routine care and report any impairments to the charge nurse for appropriate follow-up. -The skin care program will be utilized following the guidelines of the National Pressure Ulcer Advisory Panel and current standards of clinical practice. -Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee in the medical record. -Upon identification of the development of a wound, the wound assessments/ treatments will be documented in the medical record and start the Weekly Wound Log. -If infection is suspected, notify the physician and obtain clinically appropriate orders. -Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher-risk residents, those that do not heal as anticipated, and those that develop complications. Resident #13 was admitted to the facility in November 2023, with diagnoses including Paraplegia, Polyneuropathy, Peripheral Vascular Disease (PVD) and Unspecified Dementia. Review of Resident #13's person-centered Skin Care Plan, initiated 11/30/23, indicated: -was at risk for skin breakdown related to moisture due to incontinence, impaired mobility, involuntary bilateral lower extremity spasms causing friction, and Dementia. The Skin Care Plan included the following interventions: >Weekly Nurse Skin Review, initiated 11/30/23. >Pay attention to heels, initiated 11/30/23. >Skin and wound checks weekly, initiated 11/30/23. >low air mattress, set to Resident's weight, help prevent skin breakdown per patients request for comfort, initiated 7/10/24 Review of the Comprehensive Minimum Data Set (MDS) Assessment, dated 12/7/24, indicated Resident #13: -had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of a total of 15 points. -had Range of Motion (ROM) impairments on both sides of his/her upper and lower extremities. -was dependent on staff for completion of Activities of Daily Living (ADLS). -was always incontinent of bowel and bladder. -was at risk for developing pressure injuries. -had one Stage 2 Pressure Injury (PI: partial-thickness skin loss with exposed inner layer of skin), that was not present upon admission. -had diagnoses that included osteomyelitis (bone infection). Review of Resident #13's Wound Logs, indicated the following: -2/9/24: right heel Stage 1 pressure injury. -3/13/24, 4/17/24, 5/29/24: right heel Stage 2 pressure injury -6/20/24, 7/19/24, 8/20/24, 9/23/24, 10/28/24: right heel Stage 3 pressure injury. Review of the Wound Physician Progress Note, dated 11/18/24, indicated Resident #13: -right heel pressure injury was healed. -recommendation to start Skin prep (liquid film-forming treatment that forms a protective film on the skin) to the right heel. Review of Weekly Skin Checks, documented on 12/5/24 and 1/25/25, indicated Resident #13 had a scabbed area over a wound on the right heel. Review of Resident #13's medical record failed to indicate any evidence that the scabbed area identified on 12/5/24 and 1/25/25 were reported to the Physician and/or Wound Physician or assessed as a newly identified skin issue. Further review of Resident #13's medical record failed to indicate any updated care planning relative to the scabbed right heel area identified on 12/5/24 and 1/25/25. Review of Resident #13's Treatment Administration Record (TAR) for November 2024, December 2024, January 2025, February 2025, and March 2025 indicated that Skin Prep was applied as ordered from 11/23/24 to 3/26/25. Review of the Resident's Wound Care Specialist's Progress Note, dated 3/24/25, indicated the Resident was examined for a wound located on the left ischium (lower back part of the hip bone). Further review of the Wound Care Specialist's Progress Note failed to indicate any evidence that the Wound Care Physician examined the Resident's right heel during the 3/24/25 visit. Review of Physician Assistant (PA) #1's Progress Note dated 3/25/25, indicated Resident #13: -had right heel redness, and right foot/ankle swelling -was started on an antibiotic for suspicion of cellulitis (skin infection) -had a history of recurrent wounds on bilateral heels -had a history of osteomyelitis -had Nurses applying skin prep to prevent opening of right heel -right heel had a scab present centrally Review of the Nursing Progress Note dated 3/26/25, indicated Resident #13: -developed a body temperature of 101.9 degrees -redness to the right heel. -had an x-ray ordered and was pending. Review of the Nursing SBAR Note, dated 3/27/25, indicated Resident #13: -needed to be evaluated at the hospital for increased body temperature. -increased pain and redness to the right foot with swelling. -right heel scab had turned red/black in color. -x-ray showed possible osteomyelitis which the Resident had in the past. Review of the Provider (Physician Assistant [PA] #1) Progress Note, dated 3/27/25, indicated Resident #13: -had redness of the right foot that was darkening and turning black. -x-ray of the right heel revealed findings suspicious for calcaneal osteomyelitis. -had worsening wound appearance, fever and concern for osteomyelitis, and the decision was made to transfer Resident #13 to the emergency room (ER). Review of the Physician Progress Note, dated 4/3/25, indicated Resident #13: -returned from a hospitalization after being transferred to the hospital from the facility for evaluation of worsening right heel/abscess/cellulitis. -was given IV (intravenous) antibiotics (medications used to treat infection) in the hospital. -had an incision and drainage of the right heel while hospitalized that resulted in [NAME] pus drainage. -it was recommended that the Resident have an above the knee amputation. -condition was discussed with the Resident Representative who opted for Hospice care. -hospital diagnoses included abscess of the right heel, sepsis (life threatening emergency when the body has an extreme response to an infection), cellulitis, and osteomyelitis. During an interview on 4/8/25 at 1:08 P.M., Resident Representative (RR) #1 said the Resident's right heel wound developed in the facility. RR #1 said he/she was very upset that the wound deteriorated. RR #1 said during the hospitalization when told the Resident needed to have an amputation, he/she did not think the Resident could tolerate an amputation and made the decision to consider Hospice care to be initiated for the Resident. During an interview on 4/9/25 at 8:35 A.M., CNA #6 said Resident #13 had a right heel wound that healed several months ago and the Nurses started applying skin prep on the right heel. CNA #6 said the Resident's healed right heel wound was a scabbed area measuring approximately one and a half inches in diameter. CNA #6 said Resident #13's right heel was scabbed, flat to the skin level and had a black spot in the center of the scab that was half the size of the scab that never went away. CNA #6 said the black area was surrounded by white skin and had been present since the time the right heel was said to be healed. CNA #6 said at one point the Resident's right heel became swollen, red and looked worse and the Resident was sent to the hospital in March 2025. During an interview on 4/9/25 at 8:41 A.M., CNA #7 said on 3/23/25, she and CNA #8 observed Resident #13's right heel and foot to be swollen and had a new black area surrounding the original scabbed area on the right heel. CNA #7 said she told the Resident's Nurse at that time who was the Assistant Director of Nurses [ADON], and Nurse #5 (who was being trained by the ADON). CNA #7 said both Nurses assessed the Resident's right foot and heel on 3/23/25 and said that since the Resident's foot was not hot, instructed CNA #7 to leave the Resident's heel/foot alone at that time. During an interview on 4/9/25 at 10:18 A.M., CNA #8 said that while working on 3/23/25, she and CNA #7 identified that the Resident had right foot swelling and redness, and that the Resident's right heel wound looked different. CNA #8 said she had also noticed the Resident was acting differently and was quiet, which was not the Resident's usual behavior. CNA #8 said both she and CNA #7 were concerned, and CNA #7 reported the concern about the Resident's change in condition to Nurse #5 and the ADON. During an interview on 4/9/25 at 10:50 A.M., the ADON said she had worked on 3/23/25 from 7:00 A.M. to 7:00 P.M., but did not recall hearing anything about Resident 13's change in condition relative to his/her right heel. The ADON said she may have been unable to recall hearing anything because she had worked 27 hours that weekend, after working her regular 40-hour schedule, due to a staffing shortage. The ADON said if there was any change in the Resident's condition the Resident's Physician should have been notified right away. The ADON said she could not recall notifying the Resident's Physician about a change in the Resident's condition on 3/23/25. Review of Resident #13's medical record failed to indicate any evidence that the Resident's right heel wound was assessed on 3/23/25 and that a Provider was notified of the right foot/ heel redness, swelling and changes to the right heel wound. On 4/9/25 at 11:08 A.M., the surveyor with Nurse #6 observed Resident #13's right heel wound was open and had a deep pink wound base mixed with slough (yellow non-viable tissue) at the base. The surveyor further observed there was scant (minimal) light pink drainage present. During an interview at the time, Nurse #6 said the Resident's heel wound had been surgically debrided (removal of dead/ infected skin tissue to help heal a wound) while he/she was in the hospital. During an interview on 4/9/25 at 1:02 P.M., Nurse #5 said she had worked on 3/23/25 on the 7:00 A.M. to 3:00 P.M. shift. Nurse #5 said the CNA's had reported that Resident #13's right heel had increased redness. Nurse #5 said that she was unable to recall if the change in condition to the Resident's right heel had been reported to the Provider, but believed the ADON was reporting the change. Nurse #5 said she had worked the following day (on 3/24/25) and Resident #13 was not assigned to her but recalled hearing that the Resident's right heel had worsened. Nurse #5 said the Resident was sent to the hospital on 3/27/25. During an interview on 4/9/25 at 12:56 P.M, with Physician Assistant's (PA) #1 and #2, PA #1 said she was first notified of the Resident's right heel wound worsening on 3/25/25 and evaluated the Resident on 3/25/25. PA #1 said she was not made aware that the Resident's right heel wound had worsened on 3/23/25 (two days prior) and should have been made aware on that day when the facility staff noticed a change. PA #2 reviewed the Provider Triage Notes in the Provider portal and said that nothing had been reported to any Providers relative to a change in condition for Resident #13 on 3/23/25. PA #2 said if the facility staff had contacted any Provider on 3/23/25, the communication would have been present in the Provider portal system and the Provider would have made new recommendations at that time or recommended a hospital transfer. During an interview on 4/9/25 at 2:52 P.M., the Director of Nursing (DON) said that if a Resident has a change in condition such as a worsening wound, the change in condition should be reported to the Resident's Provider that same shift or sooner if emergent. The DON said when the Wound Physician identifies a wound was healed, that meant the wound was completely healed, but if staff notice a change to an area such as a scab, then the scab should be reported to the Physician and the Wound Physician. The DON said the facility staff should monitor the scab as an active wound and conduct weekly skin checks. The DON said a scab like appearance to skin is not considered healed and should be monitored. The DON said when nursing staff identified a new scabbed area on 12/5/24, it should have been reported to a Physician and monitored weekly with the Wound Physician. The DON said Resident #13 was very high risk for infection due to a history of wounds and infections. The DON said any change to the Resident's right heel wound, or foot should have been reported immediately. The DON said that not reporting increased redness, swelling or a change in wound condition would put Resident #13 at a higher risk for developing a serious infection.

Based on observations, interviews and record review, the facility failed to maintain a clean and sanitary facility kitchen and on two units (A-Wing and F-Wing) out of four units observed. Specifically, the facility failed to: -ensure Dietary Staff adhered to the hair restraint policy to minimize the potential for physical contamination during food preparation and meal service in the main facility kitchen. -label, date and store foods in the facility kitchen to decrease potential for food contamination and food-borne illnesses. -ensure that outside windows to the facility kitchen had screens to prevent pests/rodents from entering. -maintain and store food service equipment in a clean and sanitary manner in the main facility kitchen and on A-Wing and F-Wing units. Findings include: Review of the facility policy titled Staff Attire, revised 10/2023, indicated all employees wear approved attire for the performance of their duties. The Staff Attire policy also included the following: -All staff members will have their hair off their shoulders, confined in a hair net or cap, and facial hair properly restrained. Review of the facility policy titled Environment, revised 9/2017, indicated all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Environment policy also included the following: -The Food Service Director (FSD) will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. -The FSD will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment after each use. -All food contact services will be cleaned and sanitized after each use, including tables, chairs, and floors. Review of the Labeling and Dating Inservice, undated, indicated the following: -Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are past their due date are discarded. -All foods should be dated upon receipt before being stored. -Food labels must include: >the food item name >the date of preparation/receipt/removal from freezer >the use by date as outlined in the attached guidelines -Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date as outlined in the Retention Guide . -Leftovers should be labeled and dated with the date they were prepared and the use by date. On 4/6/25 from 7:15 A.M. through 7:38 A.M., the surveyor conducted an initial tour of the kitchen and observed the following: -two Dietary Aides preparing the breakfast meal with no facial hair restraints being worn. -ice machine external filter had evidence of dust. The ice scoop was observed hanging on the outside of the ice machine exposing it to dust and potential contamination. -reach-in refrigerator had two bagels that were not labeled and dated, and an unlabeled energy drink. -walk-in refrigerator: >contained a rack that had uncovered raw hamburger patties on a tray with a use by date 3/26/25. >Below the raw hamburger tray was a tray of individual covered cups of cranberry sauce that were unlabeled and undated. >The bottom of the rack had a tray containing a closed package of raw white meat that was unlabeled and undated. >Another rack had multiple trays with styrofoam cups which were uncovered (open to air) and had applesauce and canned fruit that were unlabeled and undated. -shelving near the walk-in refrigerator was observed to be dirty, with debris and had clean pans stored. -closed container of a sugar-like substance that was unlabeled and undated. A container of thickener was undated, loosely covered and left open to air. -the ovens had dark dried cooked on debris on the bottom and internal doors. During an interview at the time, the [NAME] said he thought the ovens were cleaned monthly. -shelving over the three compartment sink was dirty with multiple different colored substances, and was tacky and greasy to the touch. -A window sill located next to the shelf and over the three compartment sink had multiple plates, a knife and cleaning pads. -a window located next to a pot/pan storage rack was open and did not have a screen. -a vent above the clean pot/pan storage rack had a thick gray coating of dust. -an open plastic bag with stained rags was on the floor next to the pot/pan storage rack and had fallen over and stained rags were observed spilling onto the floor. The surveyor observed an ice machine on the A-Wing unit, an ice scoop that was stored uncovered on a hook hanging on the outside of the ice machine with the ice scoop open to air on the following days: -4/6/25 at 9:45 A.M. -4/7/25 at 12:45 P.M. On 4/8/25 at 7:21 A.M., the surveyor conducted another walk through of the facility kitchen with the FSD and observed the following: -the [NAME] serving the breakfast line did not have a facial hair restraint on. -the ice machine external filter had evidence of dust. The ice scoop was observed hanging on the outside of the ice machine exposing it to dust and contamination. During an interview with the [NAME] at 8:42 A.M., he said he thought the ice scoop should be in a closed container to protect it from dust, debris and potential contamination. -visible dust was observed on the ceiling and lighting over the food preparation and service areas, in the vents near shelving above the food preparation sink and the dust was visibly blowing outward into the kitchen, and the vent above the clean pot/pan storage rack had a thick gray coating of dust. During an interview at the time, the surveyor relayed previous observations from 4/6/25 with the FSD and she said she heard the kitchen was a mess when the initial tour was conducted. The FSD said the maintenance department takes care of the dust on the vents, ceiling and lighting, but she was not sure how often this was done. The FSD said the kitchen windows should not be open unless there was a screen because it could allow pests/rodents to enter into the kitchen. The FSD said she saw the open window on 4/6/25 when she came into work that day. The FSD said that the ice scoop was supposed to be in a housing station, she had asked for one and was awaiting approval. The FSD said the way the ice scoop was stored currently was a potential infection control issue because it was exposed and could be contaminated and then used to get ice. During an interview on 4/8/25 at 1:14 P.M., the Director of Maintenance (DOM) said the vents in the facility kitchen were cleaned about two months ago and probably needed to be cleaned more frequently. The DOM said the dust on the walls, ceiling and lights in the facility kitchen were the responsibility of the kitchen staff. On 4/8/25 at 1:30 P.M. on the F-Wing unit, the surveyor observed an ice machine with an ice scoop stored uncovered on a hook hanging on the outside of the ice machine. On 4/9/25 at 3:40 P.M., the surveyor conducted another observation of the facility kitchen with the Regional FSD, and observed the following: -two Dietary Staff in the kitchen with no facial hair restraints on. During an interview at the time, the Regional FSD said hair restraints including facial hair restraints, should be worn to cover head and facial hair, if present. The surveyor relayed previous observations from 4/6/25 and 4/8/25 to the Regional FSD who said he understood the concerns relative to kitchen sanitation. During an interview on 4/9/25 at 3:52 P.M., the [NAME] said hair restraints should be worn to prevent hair from contaminating the food, that the hair restraint should cover all hair and included facial hair. The [NAME] said when items were pulled from the freezer, they should be dated when the item was pulled, covered and have a use by date. The [NAME] said all food items should be labeled and dated. The [NAME] further said the cranberry sauce observed on 4/6/25 should not have been stored under the tray of raw meat and that the hamburger patties should have been covered and discarded if the use by date was 3/26/25.

Based on interviews, and record reviews, the facility failed to ensure that six Residents (#2, #45, #48, #108, #3 and #9) and/or their Resident Representatives were afforded the right to participate in the scheduled interdisciplinary (IDT) care plan meetings, out of a total sample of 23 residents. Specifically, the facility failed to: -For Resident #2, Resident #45, and Resident #108, ensure quarterly IDT care plan meetings occurred and that the Resident was invited to participate in the meetings. -For Resident #48, ensure quarterly IDT care plan meetings occurred and the Resident and/or Resident Representative were invited to participate in the meetings. -For Resident #3, and Resident #9, ensure IDT care plan meetings occurred and the Resident and/or Resident Representative were invited to participate in the meetings. Findings include: Review of the facility policy titled Care Plans, revised 11/20/24, indicated the following: -The resident, the resident's family and/or the legal representative/guardian or surrogate are encouraged to participate in the development of any revisions to the resident's care plan. -Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. -The mechanics of how the IDT meets its responsibilities in the development of the interdisciplinary care plan (face-to-face, teleconference, written communication .) is at the discretion of the care planning committee. 1. Resident #2 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Dementia and Adult Failure to Thrive. Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated for Resident #2: -he/she was understood and understands -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of 15 possible points -Health Care Proxy (HCP: designated person who makes medical decisions if the resident was no longer able) was invoked. Review of the IDT Care Plan Meeting schedule indicated meetings were scheduled for the following dates/times: -9/19/24 at 1:00 P.M. -12/19/24 at 1:30 P.M. -4/16/25 at 1:30 P.M. Review of the Resident's clinical record failed to indicate documented evidence that IDT care plan meetings on 9/19/24 and 12/19/24 occurred as scheduled for Resident #2. During an interview on 4/9/25 at 2:56 P.M., Unit Manager (UM) #1 said she was unable to find evidence that an IDT care plan meeting occurred on 12/19/24 as scheduled. UM #1 further said that even though the Resident's HCP was invoked, the Resident should be invited to attend the meeting and there should be documentation that the Resident was invited and declined to attend the 9/19/24 IDT care plan meeting. 2. Resident #45 was admitted to the facility in April 2024 with diagnoses including Osteoporosis, Parkinson's Disease, dizziness and giddiness, difficulty walking and unsteadiness on feet, and Hypotension. Review of the MDS Assessment, dated 3/25/25, indicated the following relative to Resident #45: -he/she understands and was understood -was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points. Review of the Resident's clinical record failed to indicate documented evidence of the required quarterly IDT care plan meetings for Resident #45. On 4/8/25 at 3:33 P.M., the surveyor requested evidence of the IDT care plan meetings since admission for Resident #45 from UM #1. During an interview on 4/8/25 at 3:35 P.M., Resident #45 said he/she was not aware of any IDT care plan meetings about his/her care. Resident #45 said if there were meetings to discuss his/her care, he/she would like to be included in them. During an interview on 4/8/25 at 4:30 P.M., UM #1 said the Resident's IDT care plan meeting was not held on 10/10/24 because the Resident was out of the facility on a medical leave of absence. UM #1 said there was no evidence that the IDT care plan meeting was held when the Resident returned to the facility and UM #1 was only able to find evidence that a meeting occurred with the Social Worker and the Resident Representative via telephone on 1/9/25. UM #1 said there was no indication of any other IDT members that participated in the meeting on 1/9/25 or that Resident #45 was invited to attend. UM #1 further said she was unable to find evidence of other scheduled IDT care plan meetings for Resident #45. 3. Resident #48 was admitted to the facility in November 2024 with diagnoses including Parkinson's Disease, Depression and Dementia. Review of the MDS Assessment, dated 1/6/25, included the following relative to Resident #48: -he/she understands and was understood -was moderately cognitively impaired as evidenced by a BIMS score of 11 out of a possible 15 points. Review of the Social Service Note, dated 1/31/25, indicated an IDT care plan meeting was scheduled for 2/6/25 at 10:30 A.M. Review of the April 2025 Physician's orders indicated Resident 48's HCP was invoked on 1/18/25. Review of the Resident's clinical record failed to indicate documented evidence that IDT care plan meetings were held and that the Resident and/or HCP were invited to attend. During an interview on 4/9/25 at 11:06 A.M., Resident #48's HCP said he/she has not been invited to participate in any IDT care plan meetings scheduled for Resident #48 since his/her admission. Resident #48's HCP said he/she would like to be included in any IDT care plan meetings as the Resident was requesting a plan to be discharged from the facility. During an interview on 4/9/25 at 2:23 P.M., UM #1 said the facility was unable to find evidence that an IDT care plan meeting occurred on 2/6/25. 50563 4. Resident #108 was admitted to the facility in February 2025 with diagnoses including Traumatic Subdural Hemorrhage and Anxiety Disorder. Review of Resident #108's MDS Assessment, dated 3/1/25, indicated the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a total possible score of 15. Review of Resident #108's medical record failed to indicate documented evidence that an IDT care plan meeting took place at the facility since his/her admission in February 2025. During an interview on 4/8/25 at 2:35 P.M., UM #2 said that there was no evidence that Resident #108 had an IDT care plan meeting that involved the Resident. UM #2 further said Resident #108 was not involved in the care plan process for the comprehensive care plan that was developed based off the MDS assessment completed on 3/1/25. 5. Resident #3 was admitted to the facility in March 2025 with diagnoses including Schizophrenia. Review of Resident #3's MDS assessment dated [DATE], indicated the Resident had severe cognitive impairment as evidenced by a BIMS score of six out of a total possible score of 15. Review of Resident #3's medical record indicated the following: -the Resident had a court appointed Guardian -no evidence that the Resident's Representative had been included in the care planning process after completion of the MDS Assessment. During a telephone interview on 4/8/25 at 2:31 P.M., Resident Representative #3 said he/she had not been invited to a care plan meeting for Resident #3. During an interview on 4/8/25 at 2:35 P.M., UM #2 said that there was no evidence that Resident #3 had an IDT care plan meeting that involved the Resident Representative. UM #2 further said that the Resident and Resident Representative were not involved in the care plan process for the comprehensive care plan that was developed based off the MDS assessment completed on 3/11/25. 42690 6. Resident #9 was admitted to the facility in December 2024 with diagnoses including Cerebral Palsy, suicidal ideation (SI), and Depression. Review of Resident #9's medical record failed to indicate documented evidence that an IDT care plan meeting took place at the facility since his/her admission in December 2024. Review of the MDS assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a BIMS score of 15 out of 15. During an interview on 4/8/25 at 11:26 A.M., Resident #9 said he/she did not recall participating in any type of team meeting at the facility that included different departments from the facility. During an interview on 4/8/25 at 11:20 A.M., the Social Worker Assistant said that she could not find evidence that any care plan meetings took place for Resident #9. During an interview on 4/8/25 at 11:53 A.M., MDS Nurse #1 said that a 48-hour or 72-hour meeting occurs when a Resident was admitted to the facility. MDS Nurse #1 said that a care plan meeting was scheduled within two weeks after a Resident's quarterly assessment had been completed. MDS Nurse #1 said to the best of her knowledge, no care plan meetings were scheduled in between the date of admission and that first quarterly assessment.

Based on interviews, and record review, the facility failed to ensure that four Resident's (#12, #6, #45 and #84), out of a total sample of 23 residents, had the right to privacy when receiving letters, packages and other materials delivered to the facility via postal services. Specifically, for Resident's #12, #6, #45 and #84, the facility failed to ensure that mail addressed to the Residents' was delivered unopened. Findings include: Review of the facility policy titled Communication Rights, revised on 11/5/24, indicated the following in part: -The resident has the right to send and receive mail and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a Postal Service including the right to privacy . During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed: -Resident #12 said he/she had received his/her mail opened about two weeks ago. Resident #12 said the opened mail was a letter from his/her doctor's office and that the facility did not have the right to open the mail. Resident #12 said he/she spoke to the person who opened the mail and declined to provide additional information to the surveyor. -Resident #6 said he/she received his/her mail opened about one month ago. Resident #6 said while it was only junk mail, it had his/her name, and that the facility should not be opening his/her mail. -Resident #45 said he/she received his/her mail opened about one month ago. Resident #45 said it was a letter from his/her brother, and the facility should not have opened his/her mail because it was a federal offense. During an interview on 4/7/25 at 3:05 P.M., the Director of Activities and the Activity Assistant (AA) said the mailman brings the mail to the facility, separated by department and then the mail goes into the Activities mailbox. The Director of Activities said she and her staff distribute the resident mail every day except Sundays. The Director of Activities said that she recently encountered an opened box that belonged to Resident #84. The Director of Activities said she was not aware of who opened the box belonging to Resident #84 and said residents' mail should never be opened prior to giving it to them, as it was a privacy concern.

Based on observations, interviews, and record review, the facility failed to ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on four units (A-Wing, C-Wing, D-Wing, and F-Wing), out of a total of four units, and for three Residents (#51, #45, and #13), out of a total sample of 23 residents. Specifically, 1. The facility failed to ensure that staffing levels on the A-Wing, C-Wing, D-Wing and F-Wing were provided to meet the residents needs of each unit safely. 2. For Resident #51, the facility failed to ensure toileting assistance was provided promptly when the Resident was indisposed and had the call light on for over 20 minutes. 3. For Resident #45, the facility failed to provide assistance of two staff with transfers as required resulting in a fall when the Resident was transferred with one staff memebr. 4. For Resident #13, the facility failed to provide timely notification to the Physician when the Resident experienced a change in condition and the Nurse responsible for providing care had worked 27 hours that weekend in addition to her regularly worked 40-hour schedule. Findings include: 1. Review of the Facility Assessment (self-completed assessment that indicate what types of care the facility provided as well as what their staffing and educational plans are to meet the residents residing in the facility's needs), dated 1/28/25, failed to indicate evidence that the facility had assessed for how many Certified Nurses Aides (CNAs) were required per resident, unit or shift to ensure appropriate care was provided to the residents residing in the facility. During an interview on 4/8/25 at 11:37 A.M., the Director of Nursing (DON) said the facility staffing plan was to have: -three CNAs on each unit for the Day (7:00 A.M. to 3:00 P.M.) shift -three CNAs on each unit for the Evening (3:00 P.M. to 11:00 P.M.) shift -two CNAs on each unit for the Night (11:00 P.M. to 7:00 A.M.) shift. The DON said in an ideal world they would additionally have one CNA split between the A-Wing and C-Wing, and one split CNA between the D-Wing and F-Wing during day and evening shifts, but that the facility could run adequately with three CNAs on each unit. During a follow-up interview on 4/8/25 at 1:58 P.M., the DON said he knew there were staffing shortages, and it was visible on the schedule. Review of the CNA schedule from 3/2/25 through 4/5/25 indicated the following: -On 3/2/25: F-Wing was staffed with two CNAs working on the Day shift and was staffed with two CNAs for the Evening shift -On 3/4/25: A-Wing was staffed with one CNA working on the Evening shift -On 3/5/25: C-Wing was staffed with two CNAs working on the Day shift -On 3/7/25: A-Wing was staffed with two CNAs working on the Day shift and C-Wing was staffed with two CNAs working on the Evening shift -On 3/10/25: C-Wing was staffed with two CNAs working on the Day shift -On 3/15/25: C-Wing was staffed with two CNAs working on the Evening shift -On 3/16/25: A-Wing was staffed with two CNAs working on the Evening shift -On 3/18/25: C-Wing was staffed with two CNAs working on the Day shift -On 3/24/25: C-Wing was staffed with two CNAs working on the Day shift and D-Wing was staffed with one CNA working on the Day shift -On 3/25/25: F-Wing was staffed with two CNAs working on the Day shift -On 4/2/25: A-Wing was staffed with two CNAs working on the Evening shift Review of the Resident Council Meeting Minutes, dated 2/19/25, indicated the following: -Residents shared concerns about staffing levels affecting timely care. Review of the Resident Council Meeting Minutes, dated 3/26/25, indicated the following: -Concerns relative to slow response times -Delay in help -Staff not listening During the initial pool process on 4/5/25 and 4/6/25, the following included information shared with the survey team: -Resident #41 said the facility was short-staffed and the 11:00 P.M. to 7:00 A.M. (Night) shift was the worst. Resident #41 said there are usually two CNAs at night but sometimes there is one CNA. Resident #41 said he/she would have to wait 35-40 minutes several times a week for staff assistance. Resident #41 said the DON was aware of these concerns. -Resident #94 said it could take up to one to two hours for staff to answer his/her call light and provide assistance. Resident #94 said that he/she needed assistance from staff to use the bathroom and facility staff have told him/her to hold it until they are able to assist him/her. Resident #94 said this occurred on all shifts at least weekly, and that he/she had not been incontinent but had to try hard to not have incontinence happen. -Resident #18 said it took sometimes an hour for facility staff to assist him/her with toileting assistance and has had episodes of incontinence due to having to wait for staff assistance. -Resident #108 said he/she sometimes had to wait up to a half hour for the call light to be answered and that this occurred typically on the Day shift. During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed: -Resident #6 said that the call bell wait times can range anywhere from five minutes to one hour. Resident #6 further said that his/her experience with long call bell wait times had primarily been with the Evening shift. -Resident #11 said that his/her experience with long waiting times had been mainly on the Day shift. Resident #11 said about a week ago, he/she called for help, but no one came for quite some time. Resident #11 said that he/she could not wait any longer, so he/she walked to the nurses station alone, even though there is a sign in his/her room on the mirror, that says to call before you fall. Resident #11 said he/she went to the nurses station, there was no one around, he/she was afraid that he/she might fall but needed help and could not wait any longer for someone to answer the call bell. Resident #11 said that he/she could not recall how long he/she waited but it was well over five minutes. During an interview on 4/7/25 at 2:30 P.M., two CNAs, who requested to remain anonymous said the following: -one CNA felt it could be neglectful to not have at least three CNAs on the unit for care because the CNAs are rushing and unable to provide the time and care to the residents. -the second CNA said he/she had told administration about the need for three CNAs on the shift, that they were exhausted, burnt out and unable to provide the care that they deserve to the residents. The second CNA said they did not feel appreciated and administration staff did not usually assist on the units with resident meals or check in with the staff to see how they were managing their residents. During an interview on 4/8/25 at 9:05 A.M., a Nurse, who requested to remain anonymous, said there were currently four CNAs on the unit today which was not typical. The Nurse said they usually have three CNAs and often have two CNAs for 30 to 31 residents which was not enough. The Nurse said when there was a call-out of staff on one of the other floors, administration will pull a CNA from his/her unit, even if there were three CNAs, leaving them with two CNAs. The Nurse said when the main dining room was open, it was difficult to manage the unit because a Nurse had to be in the main dining room from 11:30 A.M. until 1:00/1:30 P.M. or until the last resident in the main dining room had completed eating and that left the unit with less staff. The Nurse said it had been very difficult to work and felt it was not safe for the residents who live on the unit. The Nurse said these concerns have been relayed by staff to administration and nothing changes. During an interview on 4/8/25 at 10:32 A.M., a CNA, who requested to remain anonymous, said when there are two and a half CNAs on each of the second floor units (F-Wing and D-Wing), it was not manageable. The CNA said the main resident dining room was not typically open on the weekends and there were staff call-outs on the weekend and there were not enough staff to have the main dining room open. The CNA said the resident's really enjoy the main dining room and were excited to have their meals there because the atmosphere was nice and the residents enjoy the socialization. During an interview on 4/9/25 at 4:40 P.M., the Administrator said the main dining room was not open during the weekends due to staffing shortages because a Nurse and a CNA need to observe the residents during that time. 37400 2. Resident #51 was admitted to the facility in February 2019 and resided on the F-Wing Unit. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the following for Resident #51: -he/she understands and was understood. -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of a possible 15 points. -had bilateral range of motion (ROM) impairments of his/her lower extremities. -was dependent on staff for toileting needs. During an interview on 4/7/25 at 8:07 A.M., Resident #51 said he/she had a horrible night last night (4/6/25). Resident #51 said he/she rang his/her call light on the Evening shift for assistance with toileting and a staff person came in and turned off the light, left the room and did not provide toileting assistance until two hours later. Resident #51 said he/she was so upset that he/she could not go to sleep until 4:00 A.M. the next morning. After the interview, the surveyor immediately notified the DON of the Resident's concern. On 4/7/25 from 10:40 A.M. through 11:01 A.M., the surveyor observed the following: -10:40 A.M.: a red blinking light was lit outside of Resident #51's room. Two CNAs were previously observed in other residents' room and there was no staff visible in the hallway. A light was observed blinking near the nurses station and there was an audible beeping coming from the nurses station. -10:58 A.M.: Resident #51's call light remained on and no staff were observed to enter the Resident's room. -11:00 A.M.: Resident #51's call light remained lit. The surveyor knocked and entered the Resident's room and observed the bathroom door to the room was open and Resident #51 was seated on the toilet. During an interview at the time, Resident #51 said he/she had been on the toilet and utilized the call light for assistance in the bathroom but no one had come to see him/her yet. -11:01 A.M.: CNA #2 entered the Resident's room at the time to provide assistance (21 minutes after the call light was initiated). During an inteview on 4/7/25 at 11:04 A.M., CNA #1 said Resident #51 required assistance of two staff with transfers and the Unit was scheduled with two and a half (2.5) CNAs today. CNA #1 said two CNAs on the hallway where Resident #51 resides was not enough. CNA #1 said she and CNA #2 were running around to get residents washed and dressed and up for the day, and they did not have time to take their scheduled breaks. CNA #1 said there are 11 residents on the F-Wing that required assistance of two staff. During an interview on 4/7/25 at 1:29 P.M., the DON said when a resident call light was initiated, it should be answered within five minutes. The DON said the staffing at the facility was a challenge, the facility was currently working on this concern, had hired nursing and understood the concern relative to CNAs. The DON said that the facility needed to work on the staffing. 3. Resident #45 was admitted to the facility in April 2024 and resided on the F-Wing Unit. Review of the Activities of Daily Living (ADL) Care Plan, initiated 4/4/24, indicated Resident #45 had an alteration in ability to care for him/herself and required assistance. The ADL Care Plan included the following interventions: -requires mechanical lift with two staff assistance with transfers, initiated 4/4/24. Review of the Nursing Progress Note dated 4/5/25, indicated Resident #45: -was lowered to the floor during a transfer from the wheelchair to the bed. -said his/her legs gave out and he/she was lowered to the floor by the CNA who was assisting him/her. -was in stable condition and vital signs were stable. -reported no pain to the Nurse and no injuries were sustained. Review of the CNA Care Card on 4/7/25 at 12:03 P.M., indicated the following: -Resident transfers with assistance of two staff with mechanical lift. On 4/6/25 at 10:16 A.M., the surveyor observed Resident #45 dressed and seated in a wheelchair in the common room located on the unit. During an interview at the time, Resident #45 said he/she had a fall last night (4/5/25) because there were not enough staff to assist in transferring him/her from the wheelchair to the bed. Resident #45 said one CNA assisted him/her and two staff were supposed to assist with transfers. Resident #45 said four to five staff had to assist him/her off the floor and to the bed, and his/her elbow hurt from the fall. Review of the facility schedule on 4/5/25 for the 3:00 P.M. to 11:00 P.M. shift on Resident #45's unit (F-Wing) indicated that two CNAs were scheduled. During an interview on 4/7/25 at 4:00 P.M., the Director of Rehabilitation (DOR) said staff should provide assistance of two staff for all transfers for Resident #45. 4. Resident #13 was admitted to the facility in November 2023 and resided on the C-Wing. Review of the person-centered Integumentary (skin) Care Plan, initiated 5/15/24, indicated Resident #13: -had an alteration in the integumentary system due to cerebrovascular accident (CVA: stroke), Left hemiparesis, Dementia, use of anticoagulation, neuropathy, wound on left ischium, right 1st metatarsal head, and right heel. The Integumentary Care Plan included the following intervention: >will be monitored for a change in condition and the Physician will be notified, initiated 5/15/24. Review of the MDS Assessment, dated 3/7/25, indicated Resident #13: -had severe cognitive impairment as evidenced by a BIMS score of four out of a total of 15 points. -was at risk for developing Pressure injuries. -had no unhealed Pressure Injuries. During an interview on 4/9/25 at 10:18 A.M., CNA #8 said Resident #13 had a right heel wound that had a black area in the center for a long time. CNA #8 said that while working on 3/23/25, she and CNA #7 identified that the Resident had right foot swelling and redness, and that the Resident's right heel wound looked different. CNA #8 said she had also noticed the Resident was acting differently and was quiet, which was not the Resident's usual behavior. CNA #8 said both she and CNA #7 were concerned, and that CNA #7 reported the concern about the Resident's change in condition to Nurse #5 and the Assistant Director of Nurses (ADON). During an interview on 4/9/25 at 10:50 A.M., the ADON said she had worked on 3/23/25 from 7:00 A.M. to 7:00 P.M. but did not recall hearing anything about Resident #13's change in condition relative to his/her right heel. The ADON said she may have been unable to recall hearing anything because she had worked 27 hours that weekend, after working her regular 40-hour schedule, due to a staffing shortage. During an interview on 4/9/25 at 2:52 P.M., the DON said that weekend (3/22/25 and 3/23/25) was hell weekend due to staffing. The DON said he also had to work on the Units during that time.

Based on record review, and interview, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required for five Residents (#29, #23, #48, #84 and #32), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #29, ensure that a MRR was reviewed by the Physician for the month of December 2024 when recommendations had been made by the Consultant Pharmacist. 2. For Resident #23, ensure MRRs were reviewed and responded to by the Physician when recommendations were made by the Consultant Pharmacist on 9/19/24, 11/20/24, 12/18/24, and 1/23/25. 3. For Resident #48, ensure MRRs were reviewed and responded to timely by the Physician when recommendations were made by the Consultant Pharmacist on 12/13/24, 1/21/25, and 2/24/25. 4. For Resident #84, ensure MRRs were reviewed and responded to by the Physician when recommendations were made by the Consultant Pharmacist on 4/17/24, 7/24/24, and 9/19/24. 5. For Resident #32, ensure the Physician reviewed and responded to the MRR completed by the Consultant Pharmacist. Findings include: Review of the facility policy Medication Regimen Review, revised on 11/5/24, indicated the following: -Any irregularities will be communicated to the physician utilizing a written recommendation and report for consideration -Copies of the medication regimen review and written recommendations will be maintained as a part of the permanent medical record -Information on the medical regimen reviews and written recommendations will be reviewed by the Director of Nursing (DON). 1. Resident #29 was admitted to the facility in October 2023 with diagnoses including Cerebral Infarction (stroke), Type II Diabetes Mellitus, Depression, Mood Disorder, and Orthostatic Hypotension. Review of Resident #29's medical record indicated a MRR had been conducted on 12/17/24 and indicated to see the report for details. Further review of the medical record failed to indicate any documented evidence of the MRR report for 12/17/24. During an interview on 4/7/25 at 1:59 P.M., the DON said that at this time he was unable to locate the report for the December 2024 MRR. 37400 2. Resident #23 was admitted to the facility in October 2023 with diagnoses including Dementia and Type 2 Diabetes. Review of the Resident's clinical record indicated the Consultant Pharmacist had recommendations for the following dates and noted to refer to the report for details on: -9/19/24 -11/20/24 -12/18/24 -1/23/25 Further review of the Resident's clinical record failed to indicate documented evidence on what the Consultant Pharmacist recommendations were or that the recommendations were addressed by the facility and/or the Physician. On 4/9/25 at 2:21 P.M., the surveyor requested the Consultant Pharmacy Recommendations for Resident #23 from the DON. During an interview on 4/9/25 at 5:20 P.M., the Administrator said he was unable to find evidence of the Consultant Pharmacist's Recommendations made on 9/19/24, 11/20/24, 12/18/24 and on 1/23/25 and whether the recommendations were addressed by the facility and/or the Physician. 3. Resident #48 was admitted to the facility in November 2024 with diagnoses including Parkinson's Disease, Depression and Dementia. Review of the Resident's clinical record indicated the Consultant Pharmacist made recommendations for the following dates and noted to refer to the report for details on: -12/13/24 -1/21/25 -2/24/25 Further review of the Resident's clinical record failed to indicate documented evidence on what the Consultant Pharmacist Recommendations were or indication that the recommendations were addressed by the facility and/or the Physician. During an interview on 4/9/25 at 11:33 A.M., the DON said he receives the recommendations from the Consultant Pharmacist and they are given to the Unit Managers (UM) to address with the Physician. The DON said when the Consultant Pharmacist Recommendations are responded to by the facility and/or the Physician, the DON would keep the original recommendation in his/office. The surveyor requested the Consultant Pharmacist Recommendations from the DON for Resident #48. On 4/9/25 at 12:35 P.M., the DON provided Resident #48's Consultant Pharmacy Recommendations as requested. The DON said the recommendation from 12/13/24 was not addressed until 2/28/25, after the Consultant Pharmacist made the recommendation again on 2/24/25. The DON said he was unable to see that the recommendation from 1/21/25 was addressed by the Physician. 45429 4. Resident #84 was admitted to the facility in October 2023 with diagnoses including Hemiplegia and Dementia. Review of Resident #84's Consultant Pharmacist Progress Notes indicated the following: -4/17/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations. -7/24/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations. -9/19/24: MRR completed Medications reviewed. Please see the Consultant Pharmacist Report for the Recommendations. Review of Resident #84's medical record failed to provide any evidence of the Pharmacy Recommendations and Clinical Pharmacy Reports indicated in the Pharmacist Progress Notes on 4/17/24, 7/24/24, and 9/19/24. Further review of Resident #84's medical record failed to indicate that the Physician had reviewed the 4/17/24, 7/24/24, and 4/17/24, Pharmacy Recommendations. During an interview on 4/9/25 at 2:30 P.M., the DON said that he was unable to locate the Pharmacy Recommendations for the requested dates and was also unable to provide evidence that the Clinical Pharmacy Reports had been reviewed by the Physician as required. The facility was unable to provide any additional information pertaining to the Clinical Pharmacy Reports and Physician Review of the Pharmacy Recommendations to the survey team at the time of survey exit. 50563 5. Resident #32 was admitted to the facility in October 2024 with diagnoses including Cerebral Infarction. Review of Resident #32's medical record indicated a Consultant Pharmacist MRR Recommendation, undated, printed on 1/29/25, that had not been reviewed by the Physician as evidenced by an incomplete/blank Physician/Prescriber response section. During an interview on 4/9/25 at 2:34 P.M., the surveyor and the DON reviewed the undated Pharmacy Recommendation printed on 1/29/25. The DON said that there was no evidence that the Physician had reviewed and addressed the MRR printed on 1/29/25.

Based on observations, interviews and records reviewed, the facility failed to provide a dignified existence for two Resident's (#9 and #17), out of a total sample of 23 residents. Specifically, the facility failed to: 1. ensure that Resident #9 had appropriate clothing to wear while out of his/her room. 2. For Resident #17, ensure dressing assistance was provided in accordance with the Resident's preference to be washed and fully dressed by 6:00 A.M., when the Resident required assistance from staff with dressing needs. Findings include: Review of the facility policy titled Resident Rights, revised 11/5/24, indicated it was the policy of the facility to respect the rights of the residents by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents . The policy also included the following: -the facility supports the resident's right to knowledgeably participate in decisions concerning their healthcare and medical treatment . Review of the facility policy titled Your Rights and Protections As a Nursing Home Resident, undated, indicated the following: -You have the right to be treated with dignity . 1. Resident #9 was admitted to the facility in December 2024, with diagnoses including Cerebral Palsy, suicidal ideation, and Depression. Review of the Minimum Data Set (MDS) Assessment, dated 12/23/24, indicated Resident #9 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Personal Effects Inventory, undated, labeled with Resident #9's name, indicated the following: -List how many items in each box with a small descriptor . -Make sure the resident's name is on all belongings. -When a new item is received list it on the inventory sheet and if something is discarded from the inventory, list it also. -How many shirts -1x -Visual Appliances -1x -Cell Phone -1x Further review of the Residnt's Personal Effects Inventory indicated all other areas/items, including clothing with a zero next to them, indicating no items in that category. On 4/6/25 at 10:05 A.M., Resident #9 was observed seated in his/her room, in his/her wheelchair, wearing a hospital gown. During an interview at the time, Resident #9 said that he/she has had no clothes since his/her admission to the facility. Resident #9 said the facility donated a couple of items of clothing, however those items were never returned to him/her after being brought to the laundry. Resident #9 said he/she was not sure if the facility staff labeled the donated items or not. Resident #9 said that when he/she goes to the rehabilitation gym for physical and occupational therapy, he/she does not have many clothing options and would often wear a hospital gown. On 4/7/25 at 8:15 A.M., the surveyor observed the following: -Resident #9's was lying on his/her bed, wearing a hospital gown. -The Resident's dresser and closet was empty of clothing. During an interview at the time, Resident #9 said that his/her dresser and closet has looked that way for a long time. During an interview on 4/7/25 at 8:21 A.M., Nurse #3 said Resident #9 often did not have any clothing. Nurse #3 said the staff had brought the Resident clothing from lost and found or clothes that had been donated in the past but Nurse #3 could not speak to where those items had gone to. During an interview on 4/7/25 at 3:17 P.M., the Administrator said the facility typically gave donations to a Resident when they were admitted to the facility with minimal or no clothing. The Administrator said the facility staff label the donated clothing with the receiving Resident's name to ensure that the items would be returned to the Resident which the clothing items had been donated to. On 4/8/25 at 7:57 A.M., the surveyor observed the following: -A T-shirt and sweatpants draped over the foot of Resident #9's bed. -Multiple items of clothing hanging in the Resident's closet. -Resident #9 was lying in bed wearing a hospital gown. During an interview at the time, when the surveyor asked how Resident #9 felt about having clothes to put on today, the Resident said, I am looking forward to getting up and dressed after I have breakfast. I feel good about having something to wear other than a hospital gown. On 4/8/25 at 11:26 A.M., Resident #9 was observed in the second-floor center day room, talking with another resident. Resident #9's was observed to be relaxed and smiling while talking to other residents. During an interview at the time, Resident #9 said he/she was happy to have clothes on and to not be wearing a hospital gown. On 4/9/25 at 10:28 A.M., Resident #9 was observed in the second-floor center day room, dressed, smiling and talking with other residents. 37400 2. Resident #17 was admitted to the facility in November 2010 with diagnoses including Cerebral Palsy, contractures of unspecified wrist and hand, contractures of the right and left knee, Torticollis (condition in which the neck muscles contract causing the head to twist to one side), and muscle weakness. Review of the Activity of Daily Living (ADL) Care Plan, initiated 10/12/24, indicated Resident #17 required the following: -extensive assistance of one staff for dressing. Allow sufficient time for dressing and undressing ., revised 10/12/24 -extensive assistance of one staff for personal hygiene/oral care . revised 10/16/24 -encourage Resident to participate to the fullest extent possible with each interaction, revised 10/12/24 Review of the MDS assessment dated [DATE], indicated Resident #17: -was understood and understands -was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points. -had no behaviors. -had range of motion (ROM) impairments on both upper and lower extremities. -was dependent on staff for bathing, dressing, toileting and personal hygiene/grooming needs. Review of the Certified Nurses Aide (CNA) Care Card, indicated for Resident #17: -requires extensive assist of one for personal hygiene. -please have Resident toileted, washed and dressed daily around 6:00 A.M. -respect Resident preferences at all times. -requires extensive assist of one staff to dress. -allow sufficient time for dressing and undressing. On 4/6/25 at 11:17 A.M., the surveyor observed Resident #17 lying in bed dressed in a shirt. A blanket was observed covering the Resident's lower body. During an interview at the time, Resident #17 said one of the CNAs on the 11:00 P.M. to 7:00 A.M.(night) shift would wash and only dress his/her upper body and would usually leave the bottom half for the next shift (7:00 A.M. to 3:00 P.M.- day shift). Resident #17 said this had been occurring with one specific CNA for one to two months, that he/she had reported this concern to multiple staff, and it continued to occur where the CNA refused to wash/dress his/her lower half. Resident #17 said he/she preferred to be fully washed and dressed and could not understand why this continued to occur with the specific CNA and he/she had filed a grievance relative to this. After the observation and interview, the surveyor reported Resident #17's concerns to the Director of Nursing (DON) and Assistant Director of Nurses (ADON). On 4/6/25 at 11:34 A.M., the surveyor observed the DON knock and enter Resident #17's room. Shortly after, the DON exited the Resident's room and told the surveyor that he spoke with Resident #17 about his/her concern. On 4/9/25 at 8:43 A.M., the surveyor observed Resident #17 lying in bed with a regular shirt on and a blanket covering his/her lower half. During an interview at the time, Resident #17 said he/she was washed on the 11:00 P.M. to 7:00 A.M. shift by the CNA and the CNA put a shirt on him/her but did not dress his/her lower half even when he/she requested to be fully dressed. Resident #17 proceeded to show the surveyor that he/she had on underwear and no pants at the time and said he/she liked to be fully dressed because he/she got cold. Resident #17 said it was the same CNA as previously reported on 4/6/25 and he/she could not understand why this continued to occur. Resident #17 said CNA #3, who worked 7:00 A.M. to 3:00 P.M. shift was aware of his/her concerns about getting dressed. During an interview on 4/9/25 at 8:46 A.M., CNA #3 said she regularly worked the 7:00 A.M. to 3:00 P.M. shift, and Resident #17 required total assistance from staff with bathing, dressing, and personal hygiene needs. CNA #3 said Resident #17 was supposed to get washed and dressed for 6:00 A.M., and that the Resident had a routine in the morning and would ring for staff assistance with bathroom needs. CNA #3 said certain CNAs would not fully wash and dress Resident #17, and when this occurred, she encouraged Resident #17 to tell administration. CNA #3 said Resident #17 wanted to be fully washed and dressed including having his/her shoes on in the morning because he/she gets cold. CNA #3 said she had been aware of Resident #17's concern for about a year and that it has been a specific CNA on the 11:00 P.M. to 7:00 A.M. shift that did not fully wash and dress the Resident as preferred. CNA #3 further said Resident #17 deserved to have the care he/she requests and could not understand why this continued. CNA #3 said she has provided Resident #17 with the morning care routine which included toileting, washing and dressing and it took a total of 15 to 20 minutes to provide the care the Resident wanted which was not a long time, so staff should be able to do as he/she requests/prefers. Please refer to F677

Based on interview, and record review, the facility failed to act upon, provide timely responses, and document written responses and rationale to grievances of resident care and services brought to facility administration by the Resident Council. Specifically, the facility failed to promptly respond to resident grievances relative to laundry delays, loss and errors. Findings include: Review of the facility policy titled Resident and Family Concerns and Grievances, revised on 10/5/24, indicated the following in part: -Residents or their family members, guardian, or representative may voice a grievance to the facility staff in person, by telephone or via written communication. -The facility shall provide a grievance report form to facilitate the voicing of a grievance if requested by a resident or family member the facility compliance and ethics officer or a designated staff will document and keep a log of all grievances expressed either orally and or in writing on the day that it is received or as soon as possible after the event or events that precipitated the grievance. -The facility will follow up with the resident, or their family members, guardian or representative within 72 hours of filing the grievance. -The facility will make a reasonable effort to ensure that all grievances are adequately resolved within 30 calendar days from the day the grievance was received -The facility will advise the resident of the outcome of the grievance investigation and shall make reasonable efforts to contact the resident's family members to advise them of the outcome of the grievance investigation. -The facility will provide the residents with a written grievance decision which shall include the date the grievance was received, a summary statement of the residents grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed or not confirmed, any action taken or to be taken by the facility as a result of the grievance and the date the written decision was issued. -In the event the facility cannot resolve the grievance within 30 calendar days, the facility will notify the resident, their family members, guardian or representative of the status and estimated completion date with the grievance resolution. -The facility will document all steps of the grievance resolution and the facility's records including whether or not the resident/family was satisfied with the grievance. -The documentation will be kept for a minimum of three years. Review of the Grievance Log provided by the facility indicated: -a grievance was filed by three residents on 9/16/24, and 9/18/24 relative to laundry concerns. -these laundry concerns had not been resolved. -no grievance forms corresponding to the 9/16/24 and 9/18/24 dates were available to review. Review of the Resident Council Meeting Minutes, dated 12/18/24, indicated the following: -Laundry/Housekeeping concern: --Reports of residents' clothing missing and not returned from the laundry department. Review of the Resident Council Meeting Minutes, dated 1/15/25, indicated the following: -Laundry/Housekeeping concern: --Laundry delays/loss/errors. Review of the Resident Council Meeting Minutes, dated 2/19/25, indicated the following: -Laundry/Housekeeping concern: --Laundry delays/loss/errors. Review of the Resident Council Meeting Minutes, dated 3/26/25, indicated the following: - Laundry/Housekeeping/Maintenance concern: --Laundry delays/loss/errors. -- Action - Improve laundry process. During a Resident Council Meeting held on 4/7/25 from 10:00 until 10:50 A.M., the following was discussed: -Resident #5 said that he/she was missing five pairs of pants that were labeled with his/her name. -Resident #14 said when he/she received his/her clothing after a long wait, the clothes were so wrinkled that he/she did not want to wear them. -Resident #6 said that he/she waited nearly four weeks to get clothes back from the laundry. -Resident #11 said that he/she sometimes never received his/her items back from the laundry. With a show of hands, eight out of 22 Residents indicated they had experienced waiting long periods of time to have their clothing returned to them, and said this concern has been going on for a long time. During an interview on 4/7/25 at 3:17 P.M., the Administrator said the facility had been experiencing laundry challenges due to a high turnover in laundry managers, a total of four managers in the last six months. The Administrator said that the facility now has a new laundry manager, but he had been at the facility for less than 30 days. During a follow-up interview on 4/9/25 at 10:20 A.M., the Administrator said he was unable to locate at this time the three missing grievances that had been filed on 9/16/24 and 9/18/24. The Administrator further said they have been aware of the ongoing laundry concerns but due to the turnover in that department, the laundry concerns continued to be an issue.

Based on interview, and record review, the facility failed to uphold resident rights for one Resident (#13), out of a total sample of 23 residents, relative to rights exercised by the Resident's Representative (RR #1). Specifically, the facility failed to provide Resident #13's Representative with a copy of the Resident's medical record when RR #1 was exercising the Resident's right to review a copy of the medical records, and the medical records were requested through the appropriate process from the facility by RR #1. Findings include: Review of the facility's HIPPA Notice of Privacy Practices, undated, from the Office of Civil Rights, indicated the following: -Rights that you have regarding your protected health information: >Access to your protected health information- you have the right to copy and/or inspect much of the protected health information that we retain on your behalf. >For protected health information that we maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. >Requests for access must be made in writing and signed by you or your legal representative. Resident #13 was admitted to the facility in November 2023 with diagnoses including Unspecified Dementia. Review of Resident #13's clinical record indicated a Health Care Proxy (HCP) Invocation form, dated 6/12/24, to have the Resident Representative make decisions due to the Resident's cognitive impairment. Review of the facility's Authorization for Release of Information, dated and signed by the Resident's Representative on 5/24/24, indicated that a copy of all Resident #13's medical records for personal reasons was requested. Review of the Comprehensive Minimum Data Set (MDS) Assessment, dated 12/7/24 indicated Resident #13 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a total of 15 possible points. During an interview on 4/8/25 at 1:08 P.M., with Resident #13 and his/her Resident Representative (RR) #1, RR #1 said he/she had requested a copy of the Resident's medical record on 5/24/24, after the Resident developed a wound in the facility. Resident #13 said he/she knew RR #1 requested the medical records at that time and was not surprised they were not received. RR #1 said a form was completed and submitted to the facility Administrator who told him/her that it could take three to six months to obtain the records from facility headquarters. RR #1 said he/she followed-up with the facility Administrator a few times since the request on 5/24/24, and was told the facility was still working on obtaining the medical records. RR #1 said when he/she visited Resident #13 on 4/6/25, he/she told the Administrator that he/she was still waiting for the requested medical records. RR #1 said he/she was told that the Medical Records staff would get them for him/her. RR #1 said the next day (4/7/24), the Medical Records Staff told RR #1 that she was told by the Administrator to obtain Resident #13's medical record and the Medical Records Staff was working on it. RR#1 said he/she had not yet received the requested medical records as requested. During an interview on 4/8/25 at 1:14 P.M., Medical Record Staff said she was told on 4/7/25 by the Administrator that RR#1 had requested Resident #13's medical record. Medical Records Staff said she was unsure of the original date the medical records was requested because the Administrator had that information. On 4/8/25 at 2:03 P.M., Medical Records Staff provided the surveyor a copy of the Authorization for Release of Information Medical Request Form for all Medical Records, completed by RR #1, and dated 5/24/24. The Medical Records Staff said she was unaware of the 5/24/24 request. During an interview on 4/8/25 at 2:37 P.M., with the Administrator and Medical Records Staff, the Administrator said he received the request for Resident #13's medical records on 5/24/24 and thought he had told Medical Records to mail the records because the Resident was in the hospital. The Medical Records Staff said that she had not received a request from the Administrator to gather Resident #13's medical records prior to 4/7/25 and had not mailed any medical records to RR#1. The Administrator said that the facility policy was to provide medical records upon written request within 48 hours, but this did not happen. The Administrator said that the facility had a miscommunication and did not provide the medical records documents that were requested when they should have. The Medical Records Staff said that she would not mail a medical record unless she was instructed to do so by the Administrator and if she did mail anything, it would be sent by certified mail. The Medical Records Staff was unable to show evidence that the medical records certified mail had been sent to RR #1.

Based on observation, interview and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice relative to monitoring and assessing skin conditions for two Residents (#30 and #45), out of a total of 23 sampled residents. Specifically, the facility failed to: 1. For Resident #30, identify, assess and implement interventions timely when skin areas developed on his/her inner and outer left lower leg. 2. For Resident #45, perform weekly skin assessments as per the comprehensive plan of care. Findings include: Review of the facility policy titled Skin Prevention, Assessment and Treatment, revised October 2024, indicated the following: - purpose of the policy was to identify factors that place the residents at risk for the development of pressure ulcers - implement appropriate interventions to prevent the development of clinically avoidable wounds - all residents should have their skin integrity examined thoroughly at least weekly by the licensed nurse . - findings from the weekly skin assessment should be documented by the licensed nurse - Certified Nurse Aides (CNAs) should observe skin integrity during the daily provision of routine cares and report any impairments to the Charge Nurse for appropriate follow-up. - any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, in the medical record. - documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining. - upon identification of the development of a wound, the wound assessments/treatments will be documented in the medical record and start the weekly Wound Log. - Nursing staff should keep the attending physician aware of the progress of all ulcers 1. Resident #30 was admitted to the facility in September 2023 with diagnoses including Type 2 Diabetes Mellitus with neuropathy and Hemiplegia and Hemipararesis following a Cerebral Infarction affecting the Left Non-Dominant side. Review of the Minimum Data Set (MDS) Assessment, dated 2/8/25, indicated the following for Resident #30: - he/she understood and understands - was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 points - had no behaviors or rejections of care - had bilateral lower extremity range of motion (ROM) impairments - utilized a wheelchair - required substantial/maximum assistance from staff with bathing and upper and lower body dressing - was dependent on staff for personal hygiene and putting on shoes - was at risk for pressure ulcers, had no pressure ulcers and had no arterial and venous ulcers - had application of medications/ointments other than to feet Review of the Weekly Wound Log, dated 3/7/25, indicated Resident #30 had a left lower leg blister that was resolved (healed) at that time. Review of the April 2025 Physician's orders included the following: - Diabetic foot care/check daily, observation of feet, toes, ankles, soles noting any alteration in skin integrity, color, temperature, and cleanliness. Inspect shoes for proper fit and excessive wear, check pedal pulses every evening shift, initiated on 9/4/23 - Follow initial wound care dressing guidelines if provider was not in office. May utilize until the provider examines or other orders are obtained. Place order individually for documentation of the wound as needed ., initiated 12/28/23 - May be followed by the in-house wound provider for wound evaluation and treatment, initiated 12/28/24 - Weekly skin check on Tuesdays, 7:00 A.M. to 3:00 P.M. shift. Please complete weekly skin assessments in charting under assessments, initiated 2/27/25 - Weekly shower on Tuesdays, 7:00 A.M. to 3:00 P.M. shift, initiated on 2/27/25 Review of the March 2025 through April 6th 2025 Treatment Administration Records indicated: - Diabetic foot care was performed daily with the exception of on 3/27/25 and on 3/28/25 where if was marked NA - received weekly showers and skin checks as ordered - the Resident had no documented refusals of care - there was no documented evidence of treatments for the Resident's left lower extremity areas Review of the Weekly Skin Check form, completed on 4/1/25, indicated Resident #30's skin had redness present on his/her left and right front lower legs and the skin was intact. On 4/6/25 at 9:59 A.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair in his/her room. The Resident was wearing a sock and shoe on his/her right foot and had on a non-skid sock on his/her left foot. The Resident's left lower extremity was observed to be swollen and the left calf was pink and had peeling skin. Two round quarter-sized areas with yellow centers were observed on the outer and inner middle left calf. During an interview, Resident #30 said the open areas on the outer and inner left calf were caused from his/her brace and pointed to a leg brace which was near his/her dresser. Resident #30 said he/she had a dermatology appointment on 4/1/25 for removal of skin tags and the skin doctor also looked at his/her left lower leg. On 4/06/25 at 3:32 P.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair in his/her room. The areas remained on his/her left lower extremity. Shortly after the observation, the Resident was observed to self propel out of the room, down the hallway and off the unit passing several staff. Review of Resident #30's clinical record included the following: - Provider Visit Note, dated 3/19/25, that indicated Resident #30 had a dermatology appointment on 4/1/25 at 2:00 P.M. for skin tags - Provider Visit Note, dated 4/4/25, that indicated the Resident had a follow-up appointment with dermatology on 8/5/25 at 2:15 P.M. - there was no documented evidence of identification, assessment or that interventions were in place for the Resident's areas located on his/her inner and outer middle lower left leg. - no documented evidence of the Resident's results from the dermatology consult that occurred on 4/1/25. On 4/7/25 at 11:27 A.M., the surveyor observed Resident #30 dressed in shorts and seated in a wheelchair in his/her room. The Resident's left lower leg remained swollen, was pink in color and had peeling skin. The two round quarter-sized areas on the Resident's middle left outer and inner calf were visible and remained with a yellow center. During an interview, Resident #30 said he/she was going out of the facility for a bit with a friend in the afternoon. Review of a Nurse's Note, dated 4/7/25, indicated the dermatology office contacted the facility at 3:50 P.M. to report results from a culture that was obtained from Resident #30 at his/her appointment last week (on 4/1/25). The Resident was positive for Methicillin Resistant Staphylococcus Aureus (MRSA: type of bacteria that can cause a serious infection and was difficult to treat with antibiotics) in his/her left lower extremity. The facility requested a copy of the laboratory results and the on-call provider was contacted regarding the results and requested the dermatology provider write the order for antibiotics and the dermatology office was closed at that time. The on-call provider gave an order for one time dose of antibiotic and requested the facility staff contact the dermatology office on 4/8/25 to obtain additional orders for antibiotics and wound care treatment orders. Review of the April 2025 Physician's orders indicated the following: - Infection Precautions- Contact Isolation: Resident is isolated in room, without a roommate or cohort with like pathogen, due to active infection with transmissible significant pathogens. Above standard transmission precautions maintained, with activities and all services brought to the resident, every shift, initiated 4/7/25 - Bactrim DS (antibiotic) 800-160 milligrams (mg), twice daily for one day pending dermatology recommendations on 4/8/25, initiated 4/7/25 - Doxycycline Monohydrate (antibiotic), 100 mg twice daily for ten days for MRSA infection in left lower leg, initiated 4/8/25 - Wound- left lower leg: cleanse with wound cleanser, xeroform/ABD/rolled gauze daily. Elevate legs as tolerated every day shift, initiated 4/8/25 Review of the Wound Logs, dated 4/7/25 indicated the following: - left shin lateral aspect (outer), acquired on 4/7/25, quarter-sized blister caused by leg brace and was 50% yellow slough and 50% epithelial tissue which measured 2.5 centimeters (cm) length by 2.5 cm width by 0.1 cm depth. The peri-wound was red, inflammation was present and infection was suspected, positive MRSA. - left shin medial aspect (inner), acquired on 4/7/25, quarter-sized blister caused by leg brace and was 50% yellow slough and 50% epithelial tissue which measured 2.5 centimeters (cm) length by 2.5 cm width by 0.1 cm depth. The peri-wound was red, inflammation was present and infection was suspected, positive MRSA During an interview, on 4/8/25 at 10:55 A.M., Medical Records Staff said she was responsible for coordinating resident medical appointments. She said resident information including the medication list, physician notes, most recent laboratory work and a blank consult sheet would be sent with the resident for the appointment. Medical Records Staff said when the resident returned to the facility, the completed consult sheet would be given to the nursing staff and they would review it for orders/recommendations and ensure the provider was aware. Medical Records Staff said if a resident returned from a medical appointment without a completed consult sheet, the nurses would notify her and she would contact the outside provider for information regarding the appointment. Medical Records Staff said she was not notified that consult information was not obtained when Resident #30 returned from the dermatology appointment on 4/1/25. During an interview, on 4/8/25 at 10:58 A.M., Nurse #3 said when Resident #30 returned from the dermatology appointment on 4/1/25 without consult information, the nurse should have contacted the dermatology office to obtain information about the appointment and receive any orders if any. During an interview, on 4/8/25 at 11:10 A.M., Unit Manager (UM) #1 said when a resident returns from an outside medical appointment, the nurse would receive the information from the resident regarding the visit and any instructions that would need to be relayed to the provider. UM #1 said if a resident returns without information from an appointment, the facility would contact the outside provider for information regarding the visit, and she was not sure this was done for Resident #30. UM #1 said she was unaware Resident #30 had left leg wounds or that a culture was obtained until the dermatology office contacted the facility on 4/7/25 (six days after the appointment). UM #1 said the Resident had skin checks that were performed weekly, but said there were times when he/she refused them. UM #1 said the Resident required assistance from staff with ADL care and that the Certified Nurse Aides (CNAs) also would report skin changes. The surveyor relayed observations of the Resident's left lower extremity from 4/6/25 which was swollen, pink with peeling skin and the presence of two round quarter-sized areas with yellow centers located on the outer and inner middle left calf. UM #1 said she was unaware of these areas and said the Resident did wear a brace on his/her left leg when he/she was out of the facility and that she observed him/her wearing the brace on 4/7/25. Review of the Weekly Skin Check, dated 4/8/25, indicated the Resident's skin was warm and dry, had no skin or foot problems and also indicated the Resident refused to be assessed. During an interview, on 4/8/25 at 11:54 A.M. and at 1:51 P.M., the Director of Nurses (DON) said the Resident's left lower leg areas were obviously missed by facility staff and should have been identified prior to 4/7/25. The DON said Resident #30 had an appointment on 4/1/25 to remove skin tags, but the facility was not aware that a lower extremity skin culture was obtained on that day. The DON said when a resident had a medical appointment outside of the facility and returns with no information, the facility should contact the outside provider to obtain information on what transpired at the appointment and this did not occur for Resident #30. The DON said had the facility known a culture of the Resident's left lower extremity was pending, contact precautions would have been initiated (on 4/1/25) pending the result of the culture. During a follow-up interview on 4/08/25 at 3:17 P.M., with the DON, UM #1 and the Director of Rehabilitation (DOR), the DOR said the therapy department was not made aware that Resident #30 was wearing a left leg brace, that there was no Physician's order for the Resident to use the brace and that it had been discontinued for quite some time. UM #1 said she was aware the Resident wore the brace at times when he/she was going out of the facility but was not aware Resident #30 had two areas on his/her left lower legs that he/she said were caused by the brace. On 4/09/25 at 4:03 P.M., the surveyor observed Resident #30's wound with UM #1. Resident #30 was observed dressed in shorts and seated in a wheelchair in his/her room. The Resident's left foot remained swollen and the Resident had a non-skid sock in place. A gauze wrap was observed dated 4/9/25 around the Resident's middle left lower leg. UM #1 removed the dressing and two quarter-sized circular areas were observed on the Resident's inner and outer left middle calf. The open area on the left inner leg was clean and no yellow discoloration was observed. The open area on the outer left calf had a yellow center. The Resident's left lower leg remained pink and had some flaking skin. During an interview following the observation, UM #1 said the Resident's left lower extremity wounds were not identified by the facility until the surveyor brought it to their attention on 4/7/25. UM #1 said Resident #30 had a history of lower extremity wounds, but the current wounds were not previously identified. Please refer to F880. 2. Resident #45 was admitted to the facility in April 2024 with diagnoses including Chronic Kidney Disease (CKD), Dementia and heart failure. Review of the Resident's At Risk for Skin Alteration Care Plan, initiated 4/4/24 indicated Resident #45 was at risk for skin concerns related to possible shearing due to sliding down in bed, impaired mobility and incontinence, and included the following interventions initiated 4/4/25: - weekly nurse skin review, - lotion to dry skin, and - skin checks weekly Review of the MDS Assessment, dated 3/25/25 indicated the following for Resident #45: - he/she understands and was understood - was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points. - required assistance of staff with dressing, toileting and personal hygiene - was at risk for pressure ulcers and had none at the time of the assessment. Review of the clinical record indicated no documented evidence that weekly skin checks were performed on after 1/14/25 until 3/4/25. On 4/6/25 at 10:16 A.M., the surveyor observed Resident #45 dressed and seated in a wheelchair. A bruise was observed on the top of the Resident's left hand and the Resident's bilateral lower extremities were observed to be swollen and had very dry, flaky skin. During an interview at this time, Resident #45 said the bruise on his/her left top hand was from an intravenous (IV) line from a recent hospitalization . Resident #45 said the edema in his/her lower legs had improved and that staff were supposed to apply lotion to his/her lower extremities daily but this rarely happened because the staff are too busy and running around. During an interview, on 4/9/25 at 10:34 A.M., the Assistant Director of Nurses (ADON) said skin checks for all residents were to be performed weekly and the nurses would be completing a head to toe entire body assessment weekly to identify any new skin areas or changes. The ADON said this information would be documented in the resident's electronic medical record. At this time, the surveyor reviewed Resident #45's clinical record with the ADON and she said weekly skin checks should have been completed between 1/14/25 through 3/4/25. The ADON further said Resident #45 was not a person who would refuse care or a skin assessment. On 4/9/25 at 2:40 P.M., the DON said he was unable to provide documented evidence that weekly skin checks had been performed during the week of 1/21/25, 1/28/25, 2/11/25 and 2/18/25. The DON said monthly skin assessments were completed on 2/2/25 and on 3/2/25 by the nurses and the CNAs observe the Resident's skin during care but the CNA's were not able to assess the Resident's skin.

Based on observations, interviews, and record review, the facility failed to ensure that three Residents (#2, #17, and #88), were provided activity of daily living (ADL) care in accordance with their needs/preferences, out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #2, ensure grooming assistance relative to facial hair removal was provided when the Resident was dependent on staff for personal hygiene needs. 2. For Resident #17, ensure dressing assistance was provided in accordance with his/her preferences when the Resident required assistance from staff with dressing needs. 3. For Resident #88, provide grooming assistance when the Resident required extensive physical assistance with grooming and had a preference for facial hair removal daily. Findings include: Review of the facility policy titled Resident Rights, revised 11/5/24, indicated it was the policy of the facility to respect the rights of the residents by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents . The policy also included the following: -the facility supports the resident's right to knowledgeably participate in decisions concerning their healthcare and medical treatment . 1. Resident #2 was admitted to the facility in November 2022 with diagnoses including Dementia, Adult Failure to Thrive and need for assistance with personal care. Review of the ADL Care Plan, initiated 10/25/22, indicated Resident #2 required assistance with ADL care and included the following interventions: -provide two staff with all care, initiated 9/23/23 -provide extensive assistance for personal hygiene (grooming). Resident was dependent on staff when fatigued, revised 10/16/23 Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated the following relative to Resident #2: -he/she was understood and understands. -has moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 points. -was dependent on staff for personal hygiene (including grooming/hair removal). Review of Resident #2's April 2025 Physician's orders included the following: -monitor for rejection of care every shift, dated 10/8/24 -weekly shower on evenings (3:00 P.M. to 11:00 P.M. shift) on Fridays, dated 2/28/25 Review of Resident #2's April 2025 Medication and Treatment Administration Record (MAR and TAR) indicated no refusals of care. Review of the Certified Nurses Aide (CNA) Care Card (resident specific information to assist with care) included the following relative to Resident #2: -two staff for all care -extensive assistance with personal care for grooming -dependent for care when the Resident was fatigued Review of the CNA documentation for March 2025 and April 2025 indicated Resident #2 required assistance from staff with grooming needs, accepted care and had no refusals of care. Further review of the CNA documentation failed to indicate documented evidence that shaving (facial hair removal) assistance was provided to Resident #2. The surveyor observed Resident #2 dressed and lying in bed with numerous long facial hairs measuring approximately 1/2 inch to one inch in length on the Resident's upper lip and chin on the following occasions: -4/6/25 at 10:42 A.M. -4/7/25 at 11:39 A.M. and 2:04 P.M. On 4/8/25 at 10:37 A.M., the surveyor observed Resident #2 lying in bed and dressed in a hospital gown. The surveyor observed numerous long facial hairs remained on the Resident's upper lip and chin. During an interview at the time, Resident #2 said he/she had not been washed/dressed yet and that he/she waited for staff to come in to assist him/her when staff were able. Resident #2 said he/she did not like to have facial hair and would like to have staff remove it but no one had offered to remove the facial hair for him/her. During an interview on 4/8/25 at 11:45 A.M., CNA # 4 and #5 were observed entering Resident #2's room to provide morning care. During an interview at the time, CNA #5 said Resident #2 required assistance from staff with all personal care including grooming and hygiene. During an interview on 4/8/25 at 12:18 P.M., CNA #4 said Resident #2 required assistance from staff with ADL care. On 4/8/25 at 12:22 P.M., the surveyor and Nurse #3 observed that Resident #2 was dressed and lying in bed. During an interview at the time, Resident #2 said he/she would like to have his/her facial hair removed and did not like having hair on his/her face. During an interview on 4/8/25 at 12:25 P.M., Nurse #3 said he observed the facial hair on the Resident's upper lip and chin and would alert the CNA's to assist in removing the facial hair for him/her. 2. Resident #17 was admitted to the facility in November 2010 with diagnoses including Cerebral Palsy, contractures of unspecified wrist and hand, contractures of the right and left knee, Torticollis (condition in which the neck muscles contract causing the head to twist to one side), and muscle weakness. Review of the ADL Care Plan, initiated 10/12/24, indicated Resident #17 required the following: -extensive assistance of one staff for dressing. Allow sufficient time for dressing and undressing ., revised 10/12/24 -extensive assistance of one staff for personal hygiene/oral care . revised 10/16/24 -encourage Resident to participate to the fullest extent possible with each interaction, revised 10/12/24 Review of the MDS assessment dated [DATE], indicated the following relative to Resident #17: -was understood and understands -was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15 points. -had no behaviors -had range of motion (ROM) impairments on both upper and lower extremities -was dependent on staff for bathing, dressing, toileting and personal hygiene/grooming needs Review of the CNA Care Card, indicated the following for Resident #17: -required extensive assist of one for personal hygiene -please have Resident toileted, washed and dressed daily around 6:00 A.M. -respect Resident preferences at all times -required extensive assist of one staff to dress. Allow sufficient time for dressing and undressing. On 4/6/25 at 11:17 A.M., the surveyor observed Resident #17 lying in bed dressed in a shirt. A blanket was observed covering the Resident's lower half. During an interview at the time, Resident #17 said one of the CNAs on the 11:00 P.M. to 7:00 A.M. (night) shift would wash and dress only his/her upper half and leave the lower body for the next shift (7:00 A.M. to 3:00 P.M. [day]). Resident #17 said this had been occurring with this specific CNA for one to two months, that he/she had reported the concern to multiple staff, and the CNA refusing to wash/dress his/her lower half continued. Resident #17 said he/she preferred to be fully washed and dressed and could not understand why this continued to occur with this CNA. Resident #17 said he/she had filed a grievance relative to this concern. After the observation and interview, the surveyor notified Resident #17's concerns to the Director of Nursing (DON) and Assistant Director of Nurses (ADON). On 4/6/25 at 11:34 A.M., the surveyor observed the DON knock and enter Resident #17's room. Shortly after, the DON was observed exiting the Resident's room and told the surveyor he spoke to the Resident about the concerns he/she had relative to the 11:00 P.M. to 7:00 A.M. CNA who provided personal care. On 4/9/25 at 8:43 A.M., the surveyor observed Resident #17 lying in bed with shirt on and a blanket covering his/her lower body. During an interview at the time, Resident #17 said he/she was washed on the 11:00 P.M. to 7:00 A.M. shift by the CNA and the CNA put a shirt on him/her but did not dress his/her lower half even when the Resident requested to be fully dressed. Resident #17 showed the surveyor that he/she had on underwear and no pants at the time. Resident #17 said that he/she liked to be fully dressed because he/she got cold. Resident #17 said it was the same CNA who was previously reported on 4/6/25, and he/she could not understand why this continued to occur. Resident #17 said CNA #3, who worked on the 7:00 A.M. to 3:00 P.M. shift was aware of his/her concerns. During an interview on 4/9/25 at 8:46 A.M., CNA #3 said she regularly worked the 7:00 A.M. to 3:00 P.M. shift, and that Resident #17 required total assist of staff with bathing, dressing, and personal hygiene. CNA #3 said because there were more residents on the unit and they were short staffed, there were times when residents had to wait. CNA #3 said Resident #17 was supposed to get washed and dressed for 6:00 A.M., that the Resident had a routine in the morning, and would ring for staff assistance with bathroom needs. CNA #3 said certain CNAs would not fully wash/dress Resident #17, and when this occurred, she encouraged Resident #17 to tell administration. CNA #3 said Resident #17 wanted to be fully washed and dressed including having his/her shoes on in the morning because he/she would get cold. CNA #3 said she was aware of Resident #17's concern for about a year and that it was a particular CNA on the 11:00 P.M. to 7:00 A.M. shift who did not fully wash/dress the Resident on that shift. CNA #3 further said Resident #17 deserved to have the care he/she requested and could not understand why this continued. CNA #3 said she had provided Resident #17 with the morning routine which included toileting, washing and dressing and it took a total of 15 to 20 minutes to provide the care the Resident wanted which was not a long time, so staff should be able to do as he/she requests/prefers. 51466 2. Resident #88 was admitted to the facility in September 2023 with diagnoses including Parkinson's Disease, muscle weakness and Adult Failure to Thrive. Review of the MDS assessment dated [DATE], indicated Resident #88: -was cognitively intact, as evidenced by a BIMS score of 14 out of 15. -required maximum assistance from staff for personal hygiene, including facial hair removal. -exhibited no behaviors or refusals of care. During an interview on 4/6/25 at 4:30 P.M., Resident #88 said that he/she has not had his/her facial hair removed in over a week. The surveyor observed facial hair about 1/4 inch in length on the Resident's neck, cheeks and chin. Resident #88 said he/she had always preferred to have no facial hair and prior to admission at the facility he/she used to remove his/her facial hair daily. Resident #88 said he/she had asked to have his/her facial hair removed that morning and was told it could happen after suppertime. On 4/7/25 at 8:22 A.M., the surveyor observed that facial hair about 1/4 inch in length remained on the Resident's neck, cheeks, and chin. During an interview at the time, Resident #88 said staff did not offer to remove his/her facial hair last night after suppertime and when he/she asked again this morning, he/she was told the staff would do it that night. During an interview on 4/7/25 at 2:25 P.M., CNA #6 said residents should have their facial hair removed every week on their shower day unless they requested or wanted their facial hair removed in between the shower days. CNA #6 said residents should not have unwanted facial hair. During an interview on 4/8/25 at 7:36 A.M., Resident #88 said his/her facial hair was not removed when care was provided the previous night. Resident #88 said the CNA was going to come back to provide assistance with removing his/her facial hair if they had time but the CNA never came back. Resident #88 said the staff helped him/her get washed and out of bed this morning, but facial hair removal was not offered. The surveyor observed that the Resident remained with hair about 1/4 inch in length on the cheeks, upper lip, neck and chin. Resident #88 said he/she has always preferred to have no facial hair. During an interview on 4/8/25 at 8:43 A.M., CNA #8 said Resident #88 was assigned to her, but she did not offer facial hair removal because the Resident was provided morning care on the 11:00 P.M. to 7:00 A.M. shift. CNA #8 said that a few weeks prior, Resident #88 told her that he/she preferred to not have facial hair and had removed his/her facial hair every day prior to coming to the facility. CNA #8 said she provided facial grooming to the Resident on the assigned shower day on 3/27/25 and was unsure if he/she has had his/her facial hair removed since. CNA #8 said that CNAs were expected to remove residents' facial hair weekly on their shower day but that CNAs' should also ask residents if they wanted to have their facial hair removed daily. CNA #8 said sometimes when staffing was lower (two CNAs versus three or three and half CNA's) the facial hair removal did not always happen. During an interview on 4/8/25 at 11:45 A.M., Unit Manager (UM) #4 said CNAs should be offering residents facial hair removal daily. UM #4 said facial hair removal for residents has been an ongoing issue in the building and that staff have been educated on this concern but it continued to be a problem.

Based on record reviews, and interviews, the facility failed to ensure a comprehensive care plan was initiated for the care and services of one Resident (#9), out of a total sample of 23 residents. Specifically, the facility failed to develop a comprehensive care plan for Resident #9 relative to Suicidal Ideations (SI) that the Resident experienced in the hospital, prior to his/her admission to the facility, which continued after his/her admission to the facility. Findings include: Resident #9 was admitted to the facility in December 2024 with diagnoses including Cerebral Palsy, Type II Diabetes and Depression. Review of a Hospital Consultation Note, dated 12/8/24, indicated the following for Resident #9: -was seen for a safety consult as he/she alluded to passive SI, expressed frustration with being in the hospital and his/her overall health. -was withdrawn, reporting he/she did not want to continue medication or procedures. -said he/she wished he/she would go to sleep and not wake up. -had a history of Depression with outpatient psychiatry and psychotherapy support. -reported feeling depressed at the time of the assessment. Review of the Provider Encounter Note, dated 3/3/25, indicated Resident #9: -endorsed passive SI with plans to stop taking his/her insulin and medication. -was visibly distressed and appeared depressed. Review of Resident #9's Alteration in Mood Care Plan, initiated on 2/27/25 (greater than two months after the Resident's admission to the facility) failed to indicate any documented evidence relative to the Resident's history of SI. During an interview on 4/8/25 at 10:54 A.M., with Minimum Data Set (MDS) Nurse #1 and MDS Nurse #2, the following was discussed relative to Resident #9: -MDS Nurse #1 said she added the SI diagnosis on 4/7/25, when she learned about the diagnosis while completing the Resident's quarterly review, which was in progress now. -MDS Nurse #2 said this was new information to them and did not know that Resident #9 had been seen by Psychiatry while at the hospital for SI. -MDS Nurse #1 said an Alteration in Mood Care Plan had been developed for Resident #9, however she would have expected a care plan to have been developed upon admission for a Resident with history of SI, but one had not been developed. -MDS Nurse #1 and MDS Nurse #2 said based on the Resident's history, comprehensive care plans for both mood and SI should have been developed upon admission and sooner than the 2/27/25 care plan.

Based on record review, and interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing, of a transfer or discharge for three Residents (#58, #13 and #47), out of a total sample of 23 residents. Specifically, the facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman: 1. For Resident #58, when the Resident was transferred out of the facility to the hospital on 3/11/25. 2. For Resident #13, when the Resident was transferred out of the facility to the hospital on 3/27/25. 3. For Resident #47, when the Resident was transferred out of the facility to the hospital on 3/8/25. Findings include: During an interview on 4/3/25 at 2:35 P.M. (prior to the start of survey), the Ombudsman said that she did not receive Discharge/Transfer notices from the facility. 1. Resident #58 was admitted to the facility in December 2024 with diagnoses including Alzheimer's Disease, Congestive Heart Failure and Cerebrovascular Accident (CVA -Stroke). Review of Resident #58's medical record indicated the Resident was sent to the hospital on 3/11/25. Review of Resident #58's clinical record failed to indicate documented evidence that the Ombudsman was notified of the Resident's transfer to the hospital on 3/11/25. 2. Resident #13 was admitted to the facility in November 2023 with diagnoses including Dementia. Review of Resident #13's medical record indicated the Resident was sent to the hospital on 3/27/25. Review of Resident #13's clinical record failed to indicate documented evidence that the Ombudsman was notified of Resident #13's transfer to the hospital on 3/27/25. 3. Resident #47 was admitted to the facility in February 2025 with diagnoses including Respiratory Failure and Pneumonia. Review of Resident #47's medical record indicated the Resident was sent to the hospital on 3/11/25. During an interview on 4/7/25 at 3:38 P.M., the Social Worker Assistant said the facility had been setting aside the required resident transfer documentation that was needed to be provided to the Ombudsman and when the Ombudsman comes into the facility, they would stop at the office and pick up the documentation. The Social Worker Assistant said to the best of her knowledge this was the previous process as well. During a follow-up interview on 4/8/25 at 3:33 P.M., the Ombudsman said that prior to the change in the Social Service Department, the facility would send the required transfer documents via fax, but she had not received any notifications from the facility since 2/3/25. The Ombudsman said that the fax she received on 2/3/25 was for the residents' that had transferred or discharged for the month of January 2025. The Ombudsman said it was her expectation and agreement with the facility that the resident transfer notices were to be sent to her monthly. The Ombudsman said anything a resident could appeal or had the right to appeal, she expected to be notified of. The Ombudsman further said she had not received any notifications of transfers or discharges for the months of February 2025 and March 2025, including Resident's #58, #13, and #47.

Based on interview and record review, the facility failed to ensure that advanced directives were honored for one Resident (#2), out of a total sample of 23 residents. Specifically, for Resident #2, the facility failed to ensure that the Medical Orders for Life-Sustaining Treatment (MOLST: legal document that allows individuals to communicate their preferences for life-sustaining treatment to healthcare providers) form and Physician's orders accurately reflected the Resident/Resident Representative's wishes putting the Resident at risk for being resuscitated (perform full measures including cardiopulmonary resuscitation and intubation) when the advanced directive wishes were for no resuscitation (do not resuscitate [DNR] and intubate [DNI]). Findings include: Review of the facility policy titled Advanced Directives, dated 10/16/23, indicated it was the policy for the facility to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate or refuse in experimental research and to formulate an advance directive. The policy also included the following: -the MOLST form is designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. -upon admission, the facility should determine whether the resident has an advance directive, and, if not, determine whether the resident wishes to formulate an advance directive. -the Advanced Directive shall be reviewed and updated upon resident request, with the comprehensive care plan, and with significant changes in resident condition. -if the resident or the resident's representative has executed an advance directive, or executes one upon admission, copies of these documents must be obtained and maintained in the same section of the resident's medical record readily retrievable by facility staff. Facility staff must document in a prominent part of the resident's current medical record whether or not the resident has executed an advance directive and what those wishes are. -The facility shall: >not be required to provide care that conflicts with an advance directive. >not be required to implement an advance directive if, as a matter of conscience, the facility cannot implement an advance directive and state law allows any health care provider or any agent of such provider to conscientiously object. -the facility will implement the instructions outlined in the Advanced Directive. To ensure appropriate implementation, the facility will: >periodically assess the resident for decision-making capacity and invoke health care agent or representative if the resident is determined not to have decision-making capacity. >identify the primary decision-maker (assessing the resident's decision-making capacity and identifying or arranging for an appropriate representative for the resident assessed as unable to make relevant health care decisions). >define and clarify medical issues and present the information regarding relevant health care issues to the resident or his or her representative, as appropriate. >identify situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition. -to be legally binding, the advanced directive must be signed by the resident or legal guardian as recognized by the state. If utilizing a MOLST form, the order will take effect after signatures of the resident/resident representative AND order is signed by the Provider (Physician or designee), or two Nurses receive the order and place the order on the form. Resident #2 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF), Dementia and Adult Failure to Thrive. Review of Resident #2's clinical record indicated a MOLST form which included: -full code status (attempt resuscitation, intubate and ventilate, transfer to the hospital and provide all other life saving measures). -the form was signed and dated by Resident #2 on 10/26/22. -the form was signed and dated by the Provider on 10/28/22. Review of the Advanced Directive Care Plan, initiated 10/26/22, indicated Resident #2 had an established advanced directive and included the following: -Health Care Proxy (HCP: representative designated to make medical decisions when a person was no longer able) was invoked. -MOLST- see document for details. -Activate Resident's advanced directive as indicated. Review of the HCP Invocation Form, signed and dated by the Provider on 5/29/24, indicated the Resident's designated HCP was invoked indefinitely. Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated the following for Resident #2: -he/she had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 points. -HCP was invoked. -do not resuscitate (DNR), do not hospitalize (DNH), do not intubate (DNI) and feeding and other treatment restrictions were in place. Review of the April 2025 Physician's orders included the following relative to advanced directives for Resident #2: -DNR, DNI, DNH, no dialysis, no artificial nutrition, use artificial hydration but short term only, invoked (HCP), dated 3/27/25. On 4/8/25 at 3:27 P.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #2's clinical record. UM #1 said the Resident's wishes for advanced directives were located in the electronic medical record (EMR) under the Physician's orders and a copy of the MOLST form should also be scanned into the system. UM #1 reviewed Resident #2 current advanced directives orders and said Resident #2 was a DNR, DNI, DNH, no dialysis, no artificial nutrition and artificial hydration for short term only. The surveyor and UM #1 reviewed the MOLST form located in Resident #2's clinical record which indicated he/she was a full code status. UM #1 said the Resident's HCP had updated the Resident's advanced directives recently, but the HCP updates did not appear to be in the Resident's record. During an interview on 4/8/25 at 3:29 P.M., Nurse #2 said if Resident #2 was found unresponsive and not breathing, she would refer to the Resident's MOLST Form to determine what measures the Resident wanted for advanced directives. Nurse #2 said the current MOLST Form for Resident #2 indicated he/she was a full code status so she would attempt to resuscitate Resident #2. Nurse #2 said regardless of what the electronic health record indicated under the April 2025 Physician's orders, she would refer to the MOLST form for advanced directives. During a follow-up interview on 4/8/25 at 3:30 P.M., UM #1 said she would have to clarify Resident #2's advanced directives. UM #1 said she could recall a new MOLST Form being completed by the HCP but was not sure where the updated MOLST Form was. UM #1 said at this time, Resident #2 was considered a full code status.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required emergent transfer to the Hospital Emergency Department (ED) on 04/18/22, for evaluation of an acute change in medical status, was medically cleared by the ED later that same day, and was returned to the Facility via ambulance, the Facility failed to ensure Resident #1 was permitted to return, and denied him/her re-entry. Resident #1 was not told why he/she was abruptly being discharged , said he/she had no where to go in the community to live, was quite upset of the situation, and subsequently required transfer back to the Hospital. Findings include: Review of the Facility's Policy titled, Discharge and Transfer, dated 02/01/19, indicated that copies of all discharge and/or transfer documentation would be maintained in the Medical Record. The Policy indicated the following for unplanned, acute transfers where the Center does not plan to take the resident back from the Hospital: - The resident would be notified verbally, followed by written notification. - A Discharge Transition Plan would be given to the Resident. - A copy of the Notice of Intent to Discharge and Discharge Transition Plan would be kept in the Medical Record. Resident #1 was admitted to the Facility in March 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated 03/30/22 indicated Resident #1's cognitive patterns were intact and that he/she required extensive assistance for transfers, toileting, and personal care. Review of a Nurse's Note, dated 04/18/22, indicated Resident #1 was sent to the Hospital for an emergent vascular consult because he/she was coughing up blood and there was also concern for a possible occlusion (blockage). Review of Resident #1's Medical Record indicated there was no documentation to support that a discharge plan had been made or discussed with Resident #1, or that verbal or written discharge notices, other than an Intent to Transfer Notice, had been issued to Resident #1. Review of Resident #1's Medical Record indicated there was no documentation to support a Physician's Discharge order was obtained, a Discharge Summary had been written, or that the Attending Physician was notified of his/her discharge from the Facility. Review of a Hospital Emergency Medicine Note, dated 04/19/22, indicated the following: - Per the Facility Nursing Staff, Resident #1 had been transferred to the Hospital to assess his/her right lower extremity pulse and when Resident #1 was returned to the Facility, the Nursing Staff said that per Corporate, Resident #1 was no longer a resident at the Facility. - Per Fire Department and Emergency Services, Resident #1 was discharged from the Hospital and brought back to the Facility by Ambulance Staff. - Resident #1 was refused admission back to the Facility and not given a reason why. - Per Emergency medical Services (EMS), Resident #1 sat in the Facility lobby and was refused care by Facility Staff. Review of a Police Report, dated 04/18/22, indicated the following: -Two Officers (#1 and #2) arrived and spoke with Resident #1, who said he/she was mad because he/she had been kicked out of the Facility. - Officer #1 asked the Assistant Director of Nurses (ADON) what was happening, and the ADON said Resident #1 had been kicked out of the Facility and was no longer a Resident. - Officer #1 asked the ADON why the Resident had been kicked out, and the ADON said she did not know and no one else knew why either. The ADON said Director of Nurses (DON) #1 made the decision, but she was not in the Facility at the time. -The ADON asked Officer #1 to bring Resident #1 outside because DON #1 said Resident #1 was not a Resident in the Facility anymore. - Officer #1 told the ADON he would not bring Resident #1 outside until she figured out what was going on, and until Resident #1 had a place to go where he/she could get care. - Resident #1 signed a refusal for the Ambulance Staff to transport him/her anywhere because he/she did not want to go anywhere else. - Resident #1 was alert and coherent, and there was no reason to force him/her to go anywhere. - Resident #1 said he/she was not given discharge paperwork from the Facility. - Resident #1 made some phone calls to family to see if they could pick him/her up, but they were unable to provide adequate care and had multiple flights of stairs. - Resident #1 thought someone might come get him/her, but after quite a while, no one came. - Resident #1 agreed to return to the Hospital. - Ambulance Staff reported to Officer #1 that Resident #1 was upset that he/she had been kicked out. Review of the Facility's Investigation, undated, indicated that upon return to the Facility after a medical work-up, the ADON told Resident #1 that she had been instructed to inform Resident #1 that he/she was no longer a resident of the Facility and that he/she been discharged . During an interview on 05/11/22 at 9:44 A.M., Resident #1 said he/she had been sent to the Hospital for an evaluation on 04/18/22 because he/she was coughing up blood and that staff were concerned that he/she may also have a circulation problem in one of his/her legs. Resident #1 said he/she thought the plan was for him/her to return to the Facility upon discharge from the Hospital and that he/she had not received any written or verbal discharge notices. Resident #1 said the Ambulance Staff brought him/her back to the facility on the night of 04/18/22, and the ADON said he/she had been discharged from the Facility and was not allowed back in. Resident #1 said the ADON refused to tell him/her why he/she was not allowed to return. Resident #1 said he/she got very upset because he/she could not understand why the Facility would not take him/her back. Resident #1 said he/she needed personal care, but Facility Staff had refused to help him/her and told the Police Officers to take care of him/her. Resident #1 said he/she was so upset because he/she had not been treated like a human being. Resident #1 said he/she was sent back to the Hospital on 04/18/22, and then discharged to a different facility on 04/19/22. Resident #1 said he/she agreed to go back to the Hospital since he/she had nowhere else to go, and required help with care. During an interview on 05/05/22 at 1:40 P.M., Nurse #1 said she was told by DON #1 that Resident #1 was not returning to the Facility, but then sometime around 9:00 P.M. or 9:30 P.M., Ambulance Staff brought Resident #1 back. Nurse #1 said she called DON #1 and was told not to allow Resident #1 back into the Facility. Nurse #1 said the ADON took over the situation. During an interview on 05/03/22 at 1:00 P.M. the Assistant Director of Nurses (ADON) said on 04/18/22 at approximately 9:00 P.M., Resident #1 returned to the Facility with Ambulance Staff. The ADON said she had been told by DON #1 that Resident #1 had been sent to the Hospital for a medical work-up and had been discharged from the Facility. During an interview on 05/03/22, Director of Nurses (DON) #1 said Resident #1 had been transferred to the Hospital on 04/18/22 for a vascular consultation. DON #1 said there were rumors that Resident #1 was involved with drugs, so while Resident #1 was at the Hospital, she contacted the Regional Nurse to let her know and was told to contact the Market President. DON #1 said the Market President told her if that Resident #1 was out of the building, they should keep him/her out of the building and not allow him/her back. DON #1 said the Market President said that he would take care of it. DON #1 said she followed her directive from the Market President and told the ADON not to allow Resident #1 back into the Facility when he/she returned from the Hospital. During an interview on 05/05/22 at 1:39 P.M., the Market President said he had not been made aware of any drug-related issues with Resident #1 prior to his/her discharge to the Hospital, and said he did not give the directive to not permit Resident #1 back to the Facility. The Market President said the Facility should have permitted Resident #1 to return to the Facility after he/she was discharged , but they refused to.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required assist of one staff member for personal hygiene, transfers, and ambulation, and who was undergoing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . - On 4/18/22 after being transferred to and evaluated in the Hospital Emergency Department for an acute change in his/her medical status, Resident #1 was medically cleared by the Hospital and transferred back to the Facility via Ambulance the same day. However, upon return to the Facility he/she was denied entry and was informed by staff that Administration said he/she was discharged . Resident #1 remained in the Facility lobby, was denied assistance with incontinence care when requested, and was not administered any of his/her medications. Resident #1 required transfer back to and admission the Hospital in order to ensure his/her care needs were met. Resident #1 said the situation was very upsetting to him/her and said Facility staff treated him/her like he/she did not matter. Findings include: Review of the Facility's Policy titled, Discharge and Transfer, dated 02/01/19, indicated that copies of all discharge and/or transfer documentation would be maintained in the Medical Record. The Policy indicated the following for unplanned, acute transfers where the Center does not plan to take the resident back from the Hospital: - The resident would be notified verbally, followed by written notification. - A Discharge Transition Plan would be given to the Resident. - A copy of the Notice of Intent to Discharge and Discharge Transition Plan would be kept in the Medical Record. Review of the Facility's Policy titled, Abuse Prohibition, dated 04/09/21, indicated that the Center (Facility) prohibits abuse, mistreatment, neglect, misappropriation of patient (resident) property, and exploitation for all patients (residents). The Policy included the following Federal definitions: - Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. - Abuse includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental or psychosocial well-being. Instances of abuse of all patients (residents), irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. - Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient (resident) to experience humiliation, intimidation, fear, shame, agitation, or degradation. - Neglect is defined as the failure of the Center (Facility), its employees, or service providers to provide goods and services to a patient (resident) that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #1 was admitted to the Facility in March 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Comprehensive Care Plan, dated as revised on 3/26/22 and 3/27/22, indicated he/she required an assist of one staff member with all Activities of Daily Living, including personal hygiene, dressing, transfers, toileting, and locomotion, and that he/she was receiving treatments for wounds to his/her bilateral buttocks. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated 03/30/22, indicated Resident #1's cognitive patterns were intact and that he/she required extensive assistance for transfers, toileting, and personal care. Review of a Nurse's Note, dated 04/18/22, indicated Resident #1 was sent to the Hospital for an emergent vascular consult because he/she was coughing up blood and there was also concern for a possible occlusion (blockage). Review of Resident #1's Medical Record indicated there was no documentation to support that a discharge plan had been prepared or discussed with Resident #1, or that verbal or written discharge notices were provided at the time of his/her Hospital transfer other than the Facility's Intent to Transfer Notice. Review of Resident #1's Medical Record indicated there was no documentation to support a Physician's Discharge order was obtained, a Discharge Summary had been written, or that the Attending Physician was notified of his/her discharged from the Facility. During an interview on 05/11/22 at 9:44 A.M., Resident #1 said he/she had been sent to the Hospital Emergency Department for an evaluation on 04/18/22 because he/she was coughing up blood and that staff were concerned that he/she may also have a circulation problem in one of his/her legs. Resident #1 said he/she thought the plan was for him/her to return to the Facility upon discharge from the Hospital. Resident #1 said the Ambulance Staff brought him/her back to the facility on the night of 04/18/22, and said the Assistant Director of Nursing (ADON) told Ambulance staff he/she had been discharged from the Facility and was not allowed back in. Resident #1 said the ADON refused to tell him/her why he/she was not allowed to return. Resident #1 said he/she got very upset because he/she could not understand why the Facility would not take him/her back. Resident #1 said the Police came and tried to figure out why the Facility would not allow him/her to return. Resident #1 said he/she had been so messed up because of this incident and said the Facility Staff treated him/her like he/she did not matter. Resident #1 said he/she needed personal care, but Facility Staff had refused to help him/her and told the Police Officers to take care of him/her. Resident #1 said he/she was so upset because he/she was not being treated like a human being. Resident #1 said he/she was sent back to the Hospital on 04/18/22, and then discharged to a different facility on 04/19/22. Resident #1 said he/she agreed to go to the Hospital since he/she had nowhere else to go, and needed assistance with care. Review of a Police Report, dated 04/18/22, indicated the following: - Two Officers (#1 and #2) arrived and spoke with Resident #1, who said he/she was mad because he/she had been kicked out of the Facility. - Officer #1 asked the ADON what was happening, and the ADON said Resident #1 had been kicked out of the Facility and was no longer a Resident. - Officer #1 asked the ADON why the Resident had been kicked out, and the ADON said she did not know and no one else knew why either. The ADON said Director of Nurses (DON) #1 made the decision, but she (DON #1) was not in the Facility at the time. - Officer #1 requested the ADON call DON #1, which she did several times, but DON #1 did not answer. - The ADON asked Officer #1 to bring Resident #1 (who was in the Facility lobby) outside because DON #1 said Resident #1 was not a resident in the Facility anymore. - Officer #1 informed the ADON he would not bring Resident #1 outside until she figured out what was going on, and until Resident #1 had a place to go where he/she could get care. - Resident #1 signed a refusal for the Ambulance Staff to transport him/her anywhere because he/she did not want to go anywhere else. - Resident #1 was alert and coherent, and there was no reason to force him/her to go anywhere. - Resident #1 requested his/her medications from the Facility Staff and they refused to give them to him/her, even though he/she would need it since he/she was kicked out for no reason. - Resident #1 said he/she was not given discharge paperwork from the Facility. - Officers #1 and #2 took Resident #1 to the lobby to calm him/her down. - Resident #1 told Officers #1 and #2 that his/her brief was soiled. - Resident #1 asked the ADON for assistance because he/she had open sores on his/her buttocks. The ADON said she could not give Resident #1 extra briefs or provide assistance because Resident #1 had been kicked out of the Facility. - The ADON suggested that Officers #1 and #2 take Resident #1 to the bathroom and assist him/her themselves since they are concerned citizens. - Resident #1 made some phone calls to family to see if they could pick him/her up, but they were unable to provide adequate care and had multiple flights of stairs. - Resident #1 thought someone might come get him/her, but after quite a while, no one came and he/she was in the lobby still sitting in his/her own filth. - Resident #1 agreed to return to the Hospital. - Ambulance Staff reported to Officer #1 that Resident #1 was upset that he/she had been kicked out, and any rational person would have been, but at no time had Resident #1 become violent. - Officer #1 did not observe Resident #1 to be under the influence of any illicit drugs. Review of a Hospital Emergency Medicine Note, dated 04/19/22 indicated the following: - Per the Facility Nursing Staff, Resident #1 had been transferred to the Hospital to assess right lower extremity pulse and when Resident #1 was returned to the Facility, the Nursing Staff said that per Corporate, Resident #1 was no longer a resident at the Facility. - Per the Fire Department and Emergency Services, Resident #1 was discharged from the Hospital and brought back to the Facility by Ambulance Staff. - Resident #1 was refused admission back to the Facility and not given a reason why. - Per Emergency Medical Services (EMS), Resident #1 sat in the Facility lobby and was refused care by Facility Staff . - Resident #1 was alert and oriented. Review of the Facility's Internal Investigation, undated, indicated that upon return to the Facility after medical work-up, the ADON told Resident #1 that she had been instructed to inform Resident #1 that he/she was no longer a Resident of the Facility and that he/she been discharged . During an interview on 05/05/22 at 1:40 P.M., Nurse #1 said she was told by DON #1 that Resident #1 was not returning to the Facility, but then sometime around 9:00 P.M. or 9:30 P.M., Ambulance Staff brought Resident #1 back, and someone had let Resident #1 and Ambulance Staff in. Nurse #1 said she was the first nurse to speak with Resident #1. Nurse #1 said she called DON #1 and was told not to allow Resident #1 back into the Facility. Nurse #1 said the ADON took over and she went back to her medication pass. During an interview on 05/03/22 at 1:00 P.M. the Assistant Director of Nurses (ADON) said on 04/18/22 at approximately 9:00 P.M., Resident #1 returned to the Facility with Ambulance Staff. The ADON said she had been told by DON #1 that Resident #1 had been sent to the Hospital for a medical work-up and had been discharged from the Facility. During an interview on 05/03/22, Director of Nurses (DON) #1 said Resident #1 had been transferred to the Hospital on 04/18/22 for a vascular consultation. DON #1 said there were rumors that Resident #1 was involved with drugs, so while Resident #1 was at the Hospital, she contacted the Regional Nurse to let her know and said she was told to contact the Market President. DON #1 said the Market President told her if that Resident #1 was out of the building, they should keep him/her out of the building and not allow him/her back. DON #1 said the Market President said he would take care of it. DON #1 said she followed her directive from the Market President and told the ADON to discharge Resident #1 and not allow him/her back into the Facility when he/she returned from the Hospital. DON #1 said there was no evidence that Resident #1 had engaged in drug activity at the Facility prior to his/her transfer to the Hospital, but she said she had to follow the directive given to her by the Market President. During an interview on 05/05/22 at 1:39 P.M., the Market President said he had not been made aware of any drug-related issues with Resident #1 prior to his/her discharge to the Hospital, and said he did not give the directive to not permit Resident #1 back to the Facility. The Market President said the Facility should have permitted Resident #1 to return to the Facility after he/she was cleared and discharged from the Hospital, but they refused to.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was in a wheelchair and being transported by Facility staff in a Facility owned transportation van, the Facility failed to ensure he/she was properly secured, in order to maintain his/her safety to prevent an accident resulting in an injury. - On 4/06/22 at 4:00 P.M., during the return trip to the Facility from an outside appointment, although Resident #1's wheelchair had been secured inside the van by staff, Resident #1 had not been secured with the trunk shoulder seatbelt by staff. The Van Driver suddenly swerved the vehicle to avoid hitting a car that pulled out in front of him, and Resident #1 fell forward partially out of the wheelchair. Resident #1's right ankle hit the Van Driver's seat, and twisted. Resident #1's body was suspended forward in the wheelchair by his/her waist seatbelt, which was still attached to the wheelchair, but had moved up to his/her mid chest area. Resident #1 was repositioned by the Van Driver, brought back to the Facility, and then transferred to the Hospital Emergency Department for evaluation. Resident #1 was diagnosed with a sternal (breastbone) fracture with anterior mediastinal hemorrhage (bleeding by the breastbone), a displaced right ankle fracture, and was admitted to the Hospital for surgical repair for the ankle fracture. Findings include: The Facility's Policy, titled, Vehicle Safety, dated 9/26/19, indicated: -Seat belt use is mandatory in all vehicles. -Authorized drivers who accompany residents will be provided education of vehicle safety. -The Facility will provide safe and reliable transportation for residents. -Prior to each use of the vehicle, the driver will perform a pre-trip vehicle safety inspection checklist. -Any items not met on the inspection must be corrected prior to the use of the vehicle. -Employees are required to immediately report all accidents or moving violations that occur while driving a company vehicle. Resident #1 was admitted to the Facility in March 2022, diagnoses included [CONDITION(S)], generalized muscle weakness, and arthritis. Review of the Situation Background Analysis and Recommendation (SBAR), dated 4/06/22, indicated that Resident #1 had been a passenger in the Facility's transport van, his/her wheelchair tipped, he/she complained of right ankle pain, was brought back to the Facility, evaluated, and a physician's order was obtained to send Resident #1 emergently to the Hospital. Review of the Facility's Internal Investigation, dated 4/06/22, indicated that on 4/06/22 at 4:00 P.M., during the return trip back to the Facility from an outside appointment in a transport van, the driver swerved to miss another vehicle, and when he did, Resident #1 fell forward from the wheelchair. The Driver bought Resident #1 back to the Facility, he/she was assessed by nursing, 911 was activated, and he/she was transferred to the Hospital Emergency Department for evaluation and treatment. During an interview on 4/27/22 at 11:50 A.M., Resident #1 said at the time of his/her fall from the wheelchair, he/she only had a waist restraint on, and did not have the shoulder trunk seatbelt, but should have. Resident #1 said he/she fell forward in the wheelchair, and said his/her whole body fell out of the wheelchair. Resident #1 said he/she told Van Driver #1, I think I broke my foot. Review of Van Driver #1's Written Witness Statement, dated 4/12/22, indicated after he swerved to avoid hitting a car, and then heard Resident #1 cry out, I have fallen. The Statement indicated when he turned around, he saw Resident #1 suspended (forward) by the waist seatbelt which was around his/her mid chest from the wheelchair secured to the floor, and he/she was halfway off the floor. The Statement indicated Van Driver #1 repositioned Resident #1 and called the Facility. During an interview on 4/27/22 at 1:05 P.M. and review of the Driver Training Acknowledgement Form, Van Driver #1 said he did not apply the trunk shoulder seatbelt to secure Resident #1 in his/her wheelchair. Van Driver #1 said he only attached the four-point wheelchair straps and the waist seatbelt. Van Driver #1 said that although he did have wheelchair seatbelt education from 2/16/22 through 2/18/22, he said it did not include the trunk shoulder seatbelt. During an interview and observation in the transport van on 4/27/22 at 12:15 P.M., Van Driver #2 said there are four safety straps in the van to secure the wheelchair and two safety belts in the van to secure a resident for transport. Van Driver #2 said there are multiple components for the driver to complete when securing a wheelchair and a resident in the van. Van Driver #2 demonstrated to the Surveyor how the four-point wheelchair floor hooks are secured to the wheelchair frame in four places, demonstrated how to secure the attachment for the waist seatbelt, and demonstrated how and where to secure the attachment for the trunk shoulder seatbelt. Van Driver #2 said the purpose of the trunk shoulder seatbelt was to prevent the resident from falling forward. During an interview on 4/27/22 at 8:20 A.M., the Administrator said that Van Driver #1 did not apply the shoulder trunk seatbelt to Resident #1, as required. Review of the Hospital History and Physical Report, dated 4/06/22, indicated Resident #1 was admitted to the Hospital after he/she was a passenger in a transport van, when the van he/she was riding in swerved and Resident #1 fell forward out of the wheelchair, striking his/her chest, resulting in a sternal fracture with anterior mediastinal hemorrhage. The Report indicated Resident #1 was also found to have a right ankle fracture requiring an open reduction with internal fixation to correct the right ankle fracture, and was admitted .

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission his/her skin was assessed and documented by nursing as being intact with no open areas, and was at high risk for skin breakdown, the Facility failed to ensure it implemented and that Resident #1 received adequate preventative skin care interventions to prevent the development of pressure injuries. - Upon admission to the facility, Resident #1's skin was assessed and documented by nursing as being intact with no open areas. Approximately 10 days after admission documentation indicated, Resident #1 had developed unstageable pressure injuries (tissue damage that is full-thickness skin and tissue loss, obscured by dead tissue but if the dead tissue is removed it would be a stage 3 or stage 4 pressure injury) to his/her sacrum and left heel and deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration, which results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to his/her sacral area. Findings include: The Facility's Protocol titled, Skin Integrity Care Delivery Process, dated 6/1/16, indicated to evaluate for the presence of specific risk factors and to develop a plan of care to address the individual risk factors: - Impaired or decreased mobility of function - Bed mobility problem, bed fast or chair fast - Co-morbid conditions: [MEDICAL CONDITION] disease, end stage [MEDICAL CONDITION], diabetes mellitus and [MEDICAL CONDITION]. - Repositioning Guide: Provide turning and repositioning to residents at risk for pressure ulcers, specifically those who have impaired mobility and or impaired sensation. Turning and repositioning plans are implemented regardless of the bed surface (type of bed). Schedules are based on individual needs, risks, tissue tolerance. Schedules may be more or less than every 2 hours in bed and more or less frequent than every hour in a chair. The National Pressure Ulcer Advisory Panel (NPUAP) announced a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury, dated (MONTH) 13, (YEAR). Pressure injuries are staged to indicate the extent of tissue damage. The NPUAP article indicated the the following definitions: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead tissue, usually cream or yellow in color) or eschar (dry black, hard necrotic/dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Resident #1 was admitted in 2/2018, [DIAGNOSES REDACTED]. The Initial Admission Nursing Assessment, dated 2/12/18, indicated Resident #1 had rashes to his/her groin and buttocks, with no open areas. The Norton Plus Pressure Ulcer Scale, dated 2/12/18, indicated Resident #1 was assessed as being at high risk for the development of pressure injuries. The Assessment indicated Resident #1's risk factors included; baseline confusion, chair bound, mobility was very limited, occasional incontinence, and abnormal blood laboratory work. The Activities of Daily Living Care Plan, dated 2/13/18, indicated Resident #1 required the assistance of two staff persons with activities of daily living, including bathing, dressing, ambulation, toilet use and transfers, due to a decline in function after a hospitalization . The Skin Care Plan, dated 2/13/2018, indicated Resident #1 was at risk for skin breakdown due to limited mobility, and that Resident #1 will show no signs of skin breakdown. The interventions included to assist him/her with repositioning, to float heels while in bed and pressure redistribution surface to bed as per facility protocol. The Nutritional Assessment, dated 2/15/18, indicated Resident #1 did not have a pressure injury. Resident #1's Certified Nurse's Aide Care Card, indicated to assist resident in repositioning, he/she was a two assist with bed mobility, observe skin condition with activities of daily living and to report abnormalities. The Documentation Survey Report for CNAs, dated, 2/2018, indicated on 2/17/18 at 9:41 P.M. and on 2/20/18 at 12:43 P.M., during bathing, reddened areas were observed on Resident #1's skin that did not go away. Review of the Nurse Progress Notes, dated 2/17/18 and 2/20/18, indicated there was no further documentation of the new reddened areas. Review of Resident #1's medical record indicated he/she was assessed and identified as being at increased risk for skin breakdown upon admission and a schedule for turning and repositioning Resident #1 was not started until 2/20/18 during the 3:00 P.M. to 11:00 P.M. shift. The Change in Condition Note for Resident #1, dated 2/21/18, indicated the following; - in the morning there were pressure injuries noted; The description of the pressure sores were left blank, for a new onset of a grade 2 or higher pressure injury or progression of pressure ulcer despite interventions. The location and details of the pressure sores indicated they were located on the coccyx, right buttocks and left buttocks, with the following descriptions; - A Stage one linear pressure injury in the center of the coccyx area measuring 6 centimeters (approximately 2 inches) in length at 12:00 o'clock and increasing to 3 cm (approximately 1 inch) at 6:00 o'clock, with a scant amount of bloody drainage with granulated edges. - An unstageable pressure injury on the right buttocks measuring 2.5 cm (approximately 1 inch length by 5 cm (approximately 2 inches) in width, and 5 cm by 1 cm of an unstageable black pressure injury from 2:00 o'clock to 7:00 o'clock. The Change in Condition Note, dated 2/21/18, also indicated that the Nurse Aide reported that Resident #1 did not have this wound on yesterday's day shift. - However, this was not consistent with findings reported on the Documentation of Survey Report for CNAs on 2/17/18 and 2/19/18, where it was documented that there were reddened areas observed on Resident #1 that were not going away, (which are an indicator of a stage one pressure injury). The Physician's Progress Note for Resident #1, dated 2/22/18, indicated that there were (two pressure injuries); - An unstageable sacral pressure injury with deep tissue trauma measuring 5 cm in length by 7 cm in width that was deep purple in areas and fading to somewhat reddened in other areas. - An unstageable left heel pressure injury, eschar noted at 6 cm by 5 cm. Review of Resident #1's Treatment Administration Record, for (MONTH) (YEAR), indicated a turning and repositioning schedule was not started until 2/20/18 during the 3:00 P.M. to 11:00 P.M. shift (more than one week after his/her admission to the Facility). This was not consistent with the Facility's Policy Skin Integrity Care Delivery Process and Repositioning Guide, which indicated residents at high risk for skin breakdown should be placed on a turning and repositioning schedule. The Treatment Administration Record, dated 2/22/18 at 3:00 P.M., indicated for the Nurse to ensure that Resident #1 was repositioned every two hours every shift. The Surveyor interviewed the Director of Nurses (DON) on 9/5/18 at 2:15 P.M. The DON said that she checked with the staff and even though Resident #1 was at high risk for developing a pressure injury and required a 2 person staff assist with bed mobility, he/she did not have a schedule for repositioning in bed as per their protocol, prior to the development of the sacral and left heel pressure sores. The Hospital Admission, dated 2/22/18, indicated Resident #1 had left foot pain for the past week and was found to have a left foot pressure injury with [MEDICAL CONDITION] and a sacral pressure injury.

Based on records reviewed and interviews, for one of three residents (Resident #1), who was assessed as being at high risk for skin breakdown, the Facility failed to ensure it developed and implemented an adequate plan of care to maintain his/her skin integrity to prevent the development of pressure injuries. - Upon admission to the facility, Resident #1's skin was assessed and documented by nursing as being intact with no open areas. Within approximately two weeks of his/her admission to the Facility, Resident #1 developed unstageable pressure injuries (tissue damage that is full-thickness skin and tissue loss, obscured by dead tissue but if the dead tissue is removed it would be a stage 3 or stage 4 pressure injury) to his/her sacrum and left heel and deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration, which results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to his/her sacral area. Findings include: The Facility Protocol titled, Skin Integrity Care Delivery Process, dated 6/1/16, indicated the following; - Evaluate for the presence of specific risk factors - Develop a plan of care to address the individual risk factors: - Impaired or decreased mobility of function - Bed mobility problem, bed fast or chair fast - Co-morbid conditions: [MEDICAL CONDITION] disease, end stage [MEDICAL CONDITION], diabetes mellitus and [MEDICAL CONDITION]. - Repositioning Guide: Provide turning and repositioning to residents at risk for pressure ulcers, specifically those who have impaired mobility and or impaired sensation. Turning and repositioning plans are implemented regardless of the bed surface (type of bed). Schedules are based on individual needs, risks, tissue tolerance. Schedules may be more or less than every 2 hours in bed and more or less frequent than every hour in a chair. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Initial Admission Nursing Assessment, dated 2/12/18, indicated Resident #1 had rashes to his/her groin and buttocks, with no open areas. The Norton Plus Pressure Ulcer Scale, dated 2/12/18, indicated Resident #1 was assessed as being at high risk for the development of pressure injuries. The Assessment indicated Resident #1's risk factors included; baseline confusion, chair bound, mobility was very limited, occasional incontinence, and abnormal blood laboratory work. The Activities of Daily Living Care Plan, dated 2/13/18, indicated Resident #1 required the assistance of two staff persons with activities of daily living, including bathing, dressing, ambulation, toilet use and transfers, due to a decline in function after a hospitalization . The Skin Care Plan, dated 2/13/2018, indicated Resident #1 was at risk for skin breakdown due to limited mobility, and that Resident #1 will show no signs of skin breakdown. The interventions included to assist him/her with repositioning, to float heels while in bed and pressure redistribution surface to bed as per facility protocol. Resident #1's Certified Nurse's Aide Care Card, indicated to assist resident with repositioning, he/she required the assistance of two staff with bed mobility, observe skin condition with activity of daily living and to report abnormalities. A Change in Condition Note for Resident #1, dated 2/21/18, indicated the following: - Nurse Aide reported in the morning there were pressure injuries on Resident #1, and that he/she did not have pressure injuries on yesterday's day shift. - The location and details of the pressure injuries indicated they were located on the coccyx, right buttocks and left buttocks, with the descriptions: - A Stage one linear pressure injury in the center of the coccyx area measuring 6 centimeters (approximately 2 inches) in length at 12:00 o'clock and increasing to 3 cm (approximately 1 inch) at 6:00 o'clock, with a scant amount of bloody drainage with granulated edges. - An unstageable pressure injury on the right buttocks measuring 2.5 cm (approximately 1 inch length by 5 cm (approximately 2 inches) in width, and 5 cm by 1 cm of an unstageable black pressure injury from 2:00 o'clock to 7:00 o'clock. - Since the change in condition occurred, the signs or symptoms had gotten worse and this condition, signs or symptoms had not occurred before. The Physician's Progress Note, dated 2/22/18, indicated that there were (2 pressure injuries); - An unstageable sacral pressure injury with deep tissue trauma measuring 5 cm in length by 7 cm in width with a deep purple in areas and fading to somewhat reddened in other areas. - An unstageable left heel had a pressure injury, eschar noted at 6 cm by 5 cm. Review of Resident #1's Treatment Administration Record, for (MONTH) (YEAR), indicated a turning and repositioning schedule was not started until 2/20/18 during the 3:00 P.M. to 11:00 P.M. shift (more than one week after his/her admission to the Facility). This was not consistent with the Facility's Policy Skin Integrity Care Delivery Process and Repositioning Guide, which indicated residents at high risk for skin breakdown should be placed on a turning and repositioning schedule. The Treatment Administration Record, dated 2/22/18 at 3:00 P.M., indicated for the Nurse to ensure that Resident #1 was repositioned every two hours every shift. The Hospital Admission, dated 2/22/18, indicated Resident #1 had left foot pain for the past week and was found to have a left foot pressure injury with [MEDICAL CONDITION] and a sacral pressure injury. The Surveyor interviewed the Director of Nurses (DON) on 9/5/18 at 2:15 P.M. The DON said that she checked with the staff and even though Resident #1 was at high risk for developing a pressure injury and required a two person staff assist with bed mobility, he/she did not have care plan interventions for scheduled repositioning in bed as per their protocol, prior to the development of the sacral and left heel pressure sores. The Hospital Admission, dated 2/22/18, indicated Resident #1 had left foot pain for the past week and was found to have a left foot pressure injury with [MEDICAL CONDITION] and a sacral pressure injury.

Based on record review and interview for 1 of 3 sampled residents (Resident #1), the facility failed to ensure the necessary services were provided for assessing and monitoring weight loss and insufficient fluid intake. After Resident #1 was found to be lethargic (leaning to the side while sitting in a chair) and was in respiratory distress and was hospitalized . In addition, there was a delay of 3 hours in transferring to the hospital. Findings include: Resident #1 was admitted to the facility in ,[DATE] with the following [DIAGNOSES REDACTED]. 1. Resident #1's admission weight on [DATE] was 152 pounds (lbs). The plan of care, dated [DATE], indicated Resident #1 was a nutritional risk due to inadequate intake and due to [MEDICATION NAME] (diuretic); staff were to monitor for changes in nutritional status, unplanned weight loss/gain and report to the Physician as indicated. The Nutrition Assessment of [DATE] indicated Resident #1's usually oral intake was poor on admission 0 to 25 % but was improving the 3 days prior to [DATE] (ranged between 50 to 100 %). The dietary plan of care starting on ,[DATE] was for weekly weights for 4 weeks. Review of the Activity of Daily Living Record for meal percent intake indicated: Resident #1's intake started to decline on [DATE]. The intake records indicated the following: From [DATE] through [DATE] breakfast, lunch, and dinner was documented as ranging from - 0% to 50%. Review of Resident #1's weights indicated the following weights: [DATE] - 150 lbs, (not done on [DATE], resulting in a 13 day delay) [DATE] - 151 lbs [DATE] - 150 lbs [DATE] - 150 lbs [DATE] - 140 lbs The Nursing Note of [DATE] at 3:48 P.M., indicated that Resident #1 had a 10 pound (lb) 7.9% weight loss (over 5 days) and the Physician will be notified. The Surveyor interviewed Unit Manager #1 at 2:30 P.M. on [DATE], Unit Manager #1 said that the 10 lb weight loss that Unit Manger #1 found on [DATE] was not reported to the Physician. Unit Manger #1 was not aware of Resident #1's oral food intake decline on [DATE] through [DATE]. 2. For Resident #1, the facility failed to ensure Resident #1 received an adequate fluid intake in the setting of diuretic use, a urinary tract infection and the administration of Bactrim (an oral antibiotic). The facility policy for Fluid Balance, dated [DATE], stated that the facility will provide residents with sufficient amounts of fluids based on individual needs. Resident's hydration will be determined through routine nursing evaluation. Intake and output will be monitored and documented for those at risk for dehydration; monitor intake and output as indicated (when a Resident is on an antibiotic). Resident #1 was diagnosed with [REDACTED]. The Geriatric Dosage Handbook, 12 edition, for Bactrim it stated that under warnings/precautions to maintain adequate hydration to prevent crystalluria (crystal formation in the kidneys) which can cause kidney damage. For [MEDICATION NAME] it stated under the warning and precautions to monitor fluid status and renal function in an attempt to prevent oliguria (decreased urinary output) and azotemia (increased amounts of nitrogenous waste products in the blood). The Dietician's Nutrition Assessment of [DATE] indicated that Resident #1 required 2,045 cubic centimeters (cc) of fluid per day to maintain proper hydration. The Fluid intake documentation indicated staff documented that Resident #1 consumed 1440 cc/24 hours (605 below the daily requirement) on [DATE], 1280 cc (765 cc below the daily requirement) on [DATE], 1200 cc (845 cc below the daily requirement) on [DATE], 1560 cc (485 cc below the daily requirement) on [DATE], 1640 cc (405 cc below the daily requirement) on [DATE], 1120 cc (925 cc below the daily requirement) on [DATE]. There is no documentation that staff documented Resident #1's intake for [DATE] or [DATE]. The Medication Record of ,[DATE], indicated that Resident #1 received [MEDICATION NAME] 20 milligrams twice a day, from [DATE] to [DATE] at 8:00 A.M. The Surveyor interviewed Unit Manager #1 at 2:20 P.M. on [DATE]. Unit Manager #1 said Resident #1 required 2045 cubic centimeters (cc) per day to maintain proper hydration. Unit Manager #1 said that Resident #1 was at risk for dehydration due to a urinary tract infection which was treated with an antibiotic. Unit Manager #1 also said that Resident #1's intake and output should be monitored and documented until the antibiotic which was started on [DATE], was discontinued. Unit Manger #1 said there was no documentation of intake and output for [DATE] or [DATE] and there should have been. Unit Manger #1 said that Resident #1's fluid intake was below the daily requirements (which included fluids with the medication pass fluids on the intake and output sheets), and the Physician was not notified of insufficient fluid intake and that Resident #1 was also on a diuretic with an insufficient fluid intake. 3. For Resident #1, the facility failed to ensure timely transfer of Resident #1 to the hospital on [DATE] at approximately 9:30 A.M. Resident #1 was noted to be in respiratory distress but was not transferred to the hospital until 3 hours later. The facility documentation policy, dated [DATE], stated that the purpose of documentation is to communicate the Resident's status and provide accurate accounting of care and monitoring provided. The facility vital signs policy, dated ,[DATE], stated that vital signs (blood pressure, pulse, respirations, temperature) will be monitored more frequently than monthly, based on the Resident's condition and additional monitoring may be done based on nursing judgment. The Surveyor interviewed Unit Manager #1 at 2:30 P.M. on [DATE]. Unit Manger #1 said that she worked on [DATE] and Resident #1 was leaning to the side while seated in the Common Room, and she asked Nurse Practitioner #1 to assess Resident #1. The Nurse Practitioner's note dated [DATE] (which was started on at 9:23 A.M.), indicated that Resident #1 had a change in condition and the Nurse Practitioner was called to evaluate Resident #1. Resident #1 had a diffuse [MEDICATION NAME] rash encompassing the entire torso, and was hypoxic (decreased oxygen levels). The vital signs were last monitored at 9:43 A.M. on [DATE]. The temperature was 97.4 degrees Fahrenheit, (normal 98.6 degrees Fahrenheit), heart rate was 90 beats per minute (bpm) normal 60 to 100, elevated from this Resident's baseline, and blood pressure was ,[DATE] (normal ,[DATE]) and pulse oximetry was 90 % (normal is 95 to 100 %). The Nurse Practitioner's order, dated [DATE], (untimed) indicated to transfer Resident #1 to the Community Hospital for evaluation and treatment. The Surveyor interviewed Unit Manager #1 at 2:30 P.M. Unit Manager #1 said that there were no Nursing Notes to indicate Resident #1 was monitored after Resident #1's decline (approximately 3 hours in which there was no monitoring). In addition, the ambulance was not called for 3 hours after this Resident had an acute decline and was in respiratory distress, and the Nurse Practitioner ordered Resident #1 to be evaluated at the hospital. The Surveyor interviewed the Nurse Practitioner at 3:50 P.M. on [DATE]; the Nurse Practitioner stated that Resident #1 had an acute decline with Respiratory distress with an pulse oximetry of 90 % on room air (normal is 95 to 100 %) and a body rash due to a drug reaction. The Nurse Practitioner said that Resident #1 required transport to the Hospital right away, but not an emergent 911 call. There was no indication that Resident #1's oxygen saturation levels, breathing, or medical condition (an indication to the degree of respiratory distress) was monitored after Resident #1 was found in respiratory distress until he/she was transferred to the Hospital. After Resident #1's acute decline on [DATE] at 9:43 A.M., there was no nursing documentation of Resident #1's initial condition and continuing status, nor of care provided or monitoring performed, while waiting approximately 3 hours before EMS was called to transport Resident #1 to the hospital. The Nurse Practitioner's order of [DATE], untimed indicated to start oxygen at 2 liters via a nasal cannula, there was no documentation to indicate this occurred. The Ambulance Run Report of [DATE] indicated the Ambulance was not called for transport until 12:19 P.M. (almost 3 hours later). EMS (Emergency Medical Service) arrived at 12:23 P.M. on [DATE] and found Resident #1 gasping, and in apparent distress. Resident #1 had a pulse rate of 80 bpm (normal 60 to 100 bpm), respiratory rate of 40 bpm (breaths per minute) (normal 12 to 20 bpm), and blood pressure ,[DATE] (normal ,[DATE]). The EMS determined Resident had an oxygen saturation of 94% on 4 litters of oxygen via nasal annular. The primary clinical impression was difficulty breathing, [MEDICAL CONDITION] (a blood infection), and respiratory acidosis. The Surveyor interviewed the Director of Nursing at 3:30 P.M. on [DATE], she said that there was no indication that Resident #1 had been monitored by the nursing staff for approximately 3 hours, prior to the EMS arrival. Resident #1 was admitted to the Community Hospital on [DATE]. The Hospital's Discharge Summary of [DATE] indicated that Resident #1 was admitted on [DATE] with acute septic shock and multi-organ heart failure. Resident #1 was treated with intravenous antibiotics, fluids for [MEDICAL CONDITION]. Resident #1's code status was changed from full code to comfort care, and Resident #1 died on [DATE].